Magnolia Creek Nursing And Rehabilitation
MAGNOLIA CREEK NURSING AND REHABILITATION in COVINGTON, TN — inspection on August 12, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a
position. CNA A stated Resident #1 would get out of bed at times and wander around the Memory Care
because there were 15-16 other residents on the Memory Care Unit. CNA A was asked if she had received education on abuse which included recognizing and reporting an injury of unknown origin.
CNA A confirmed she was not aware a head injury could be a sign of abuse.
During an interview on [DATE] at 3:56 PM, Registered Nurse (RN) S stated her last abuse in-service was more than a year ago as she had just worked a minimal schedule while attending school. RN S stated she did not recall being given education related to reporting an injury of unknown origin as suspected abuse.
During an interview on [DATE] at 4:49 PM, LPN U stated the last in-service training she received was within the past 3 months. LPN U did not recall specific training on injury of unknown origin being included in the reporting requirements for abuse.
During an interview on [DATE] at 5:16 PM, RN N stated the last in-service on abuse was within the past year. RN N acknowledged she was not aware of the requirement to report an injury of unknown origin within a specified time frame.
During a telephone interview on [DATE] at 11:00 AM, RN C stated on [DATE] she worked 6:00 AM to 6:00 PM on the Memory Care Unit. RN C stated Resident #1 did not have a raised area on his left forehead when she left work on [DATE]. RN C stated during morning (6:00 AM) report on [DATE], LPN B reported Resident #1 had a raised area on his left forehead. LPN B reported Resident #1 had not had a fall and she didn't know what caused the raised area on his forehead. RN C stated LPN B did not complete an event report and did not ask her to complete the event report for the raised area. RN C was asked if she had reported the injury to Administration. RN C replied, No. RN C was asked if she had been educated on recognizing abuse and reporting abuse. RN C acknowledged she had received abuse education, and she had provided abuse education during her employment in the facility. RN C was asked what she was required to do if a resident had an injury no one had witnessed happening and the resident was unable to explain how the injury occurred. RN C replied, .If the injury needed treatment, I would call the doctor.I would fill out an incident report and give it to the Unit Manager.
During an interview on [DATE] at 1:45 PM, the Director of Nursing (DON) acknowledged she was aware Resident #1 was sent to the hospital on [DATE] for evaluation of a raised area on his left forehead and she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff.
The DON was asked if the facility had determined the cause of Resident #1's injury to his forehead.
The DON stated there was not an injury or fall and staff concluded the raised area was probably an allergic reaction to a mosquito bite.
The DON was asked if staff provided monitoring for Resident #1 at all times during the night of [DATE]-[DATE].
The DON stated staff did not monitor at all times.
The DON was asked if Resident #1's injury of unknown cause had been reported to the SSA within two hours and the facility investigation results reported to the SSA within 5 business days.
The DON confirmed the injury had not been reported to the SSA and investigated.
During an interview on [DATE] at 2:42 PM, the Administrator stated as the Administrator and Abuse Coordinator she was responsible to ensure allegations of abuse, known or suspected, are reported to the SSA in the required time frame.
Refer to F-F684
445461 08/12/2025
Magnolia Creek Nursing and Rehabilitation 1992 Hwy 51 S Covington, TN 38019
During an interview on [DATE] at 1:45 PM, the DON stated the Staff Development Coordinator (SDC) was in the building on [DATE] and told her about Resident #1 getting sent out per family request.
The DON concluded she did not have any concerns with the assessment and intervention provided to Resident #1 by nursing staff.
The DON was asked if Resident #1 had an injury of unknown origin which required investigation.
The DON stated Resident #1's injury (hematoma) was not caused by an injury or fall and was thought to be a mosquito bite.
The DON acknowledged Resident #1 was not monitored at all times during the night of [DATE]-[DATE].
The DON stated the facility started an investigation after APS (Adult Protective Services) came to the facility and told them about the investigation ([DATE]).
The DON was asked if the facility was required to investigate injuries of unknown origin.
The DON put her head down for a minute and then got up from the table and left the room.
During an interview on [DATE] at 2:42 PM, the Administrator stated when a resident has an injury that cannot be explained the facility would be required to investigate.
Refer to F-F684
445461 08/12/2025
Magnolia Creek Nursing and Rehabilitation 1992 Hwy 51 S Covington, TN 38019
During an interview on [DATE] at 3:20 PM, RN M stated, .On [DATE] [Named RN C] called and asked
jeopardy to resident health or #1] was normally alert, oriented to self and recognizes his wife. usually up and walking around, hard safety to get him to stay in one spot, anxious.I never actually went back to memory care and looked at [Resident #1].helped by documenting [Named Resident #1]'s vital signs, a progress note and printing
transfer out, I would press on to get the order to send out.at times you have to press a little harder with the on-call doctors.
During an interview on [DATE] at 3:56 PM, RN S stated she documented Resident #1's Skilled Observation Note on [DATE]. RN S acknowledged she had not actually observed Resident #1 on [DATE] and documented the information provided by RN C. RN S confirmed a resident with a head injury or possible head injury and on blood thinning medications would need to be sent out for evaluation for a brain bleed. RN S stated, .if the telehealth physician did not order the transfer, I would request the order due to the risk of brain bleed.getting evaluation and treatment could prevent death to the resident.I would complete neuro checks in the computer under the event note.if you are performing neuro checks there was a reason to open an event note.wouldn't document in progress note only.
During an interview on [DATE] at 4:49 PM, LPN U confirmed residents who present with a raised area or swelling on the forehead need to be evaluated for head injury and if they are taking anticoagulants, they should be sent to the emergency room for evaluation. LPN U concluded she would call the on-call and request the transfer order due to risk of brain bleed.
During an interview on [DATE] at 4:55 PM, LPN P was asked what steps she would take for a resident who presented with a raised area to their head, and she was unaware of how the injury occurred. LPN P stated, .the resident could have had a fall or accident.risk of blood clot or brain bleed.need to call someone and get him sent out even if the resident appeared fine, I would be more concerned if the resident was taking Eliquis.could be something more serious.neuro checks are done in the computer system, and they include a blood pressure check.
During an interview on [DATE] at 5:16 PM, RN N stated when
445461 08/12/2025
Magnolia Creek Nursing and Rehabilitation 1992 Hwy 51 S Covington, TN 38019
During a telephone interview on 7/25/2025 at 4:15 PM, LPN T stated she had worked with RN C on occasion and had to help RN C with documenting in the electronic health record. LPN T concluded, .[Named RN C] has lots of trouble on the computer.she forgets how to get in and how to complete documentation. LPN T confirmed she has documented assessments completed by RN C without performing the assessment herself.
During a telephone interview on 7/25/2025 at 6:09 PM, the NP stated the facility had not called her on 5/25/2025 to discuss Resident #1's change of condition or request an order to transfer the resident to the ER.
Refer to F-F684
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.