Magnolia Creek Nursing And Rehabilitation

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for certain what caused the raised area due to staff was not monitoring Resident #1 at all times. LPN B confirmed she did not believe Resident #1 had fallen or caused an injury to himself. LPN B was asked if she had received training for abuse which included recognizing and reporting an injury of unknown origin. LPN B stated she had received training on abuse and did not recall reporting injuries as suspected signs of abuse. During a telephone interview on [DATE REDACTED] at 12:06 AM, CNA A stated on [DATE REDACTED]-[DATE REDACTED] she frequently observed Resident #1 in bed sleeping, and sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 would get out of bed at times and wander around the Memory Care Unit. CNA A confirmed she was not always monitoring him during the night ([DATE REDACTED]-[DATE REDACTED]) 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 REDACTED] 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 REDACTED] 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 REDACTED] 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 REDACTED] at 11:00 AM, RN C stated on [DATE REDACTED] 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 REDACTED]. RN C stated during morning (6:00 AM) report on [DATE REDACTED], 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 REDACTED] at 1:45 PM, the Director of Nursing (DON) acknowledged she was aware Resident #1 was sent to the hospital on [DATE REDACTED] 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 REDACTED]-[DATE REDACTED]. 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 REDACTED] 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Creek Nursing and Rehabilitation

1992 Hwy 51 S Covington, TN 38019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with him all the time that night [[DATE REDACTED]-[DATE REDACTED]].we did not have him 1 on 1 [monitoring] every minute. I guess he could have fallen and got himself up.I know there wasn't an injury. LPN B confirmed she did not ask Resident #1 if he fell or what had happened due to his level of cognitive impairment because it wasn't likely he could tell her what happened. LPN B confirmed she was asked to provide a statement related to

the [DATE REDACTED] incident on [DATE REDACTED], during the complaint survey. During a telephone interview on [DATE REDACTED] at 12:06 AM CNA A stated she observed Resident #1 in bed sleeping, and at times sitting on the side of the bed, which was in the lowest position. CNA A stated Resident #1 could get up with the bed in the low level and would wander around the Memory Care Unit. CNA A confirmed she checked on Resident #1 during the night and was not always monitoring him, because there were 15-16 other residents on the memory care unit. CNA A stated, .I didn't see the place [hematoma] on his head the night before. CNA A was asked if

she had received education on abuse which included injury of unknown origin, such as a knot on a resident's head with unknown cause. CNA A confirmed she was not aware a head injury could be a sign of abuse. CNA A confirmed she had not been asked to provide a statement about the incident with Resident #1 until [DATE REDACTED]. During an interview on [DATE REDACTED] at 1:45 PM, the DON stated the Staff Development Coordinator (SDC) was in the building on [DATE REDACTED] 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 REDACTED]-[DATE REDACTED]. The DON stated the facility started an investigation after APS (Adult Protective Services) came to the facility and told them about the investigation ([DATE REDACTED]). 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 REDACTED] 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Creek Nursing and Rehabilitation

1992 Hwy 51 S Covington, TN 38019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Immediate jeopardy to resident health or safety

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 REDACTED] at 5:16 PM, RN N stated when

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Magnolia Creek Nursing and Rehabilitation

1992 Hwy 51 S Covington, TN 38019

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

#1, and he did not respond verbally, open his eyes or grasp her hands during the neuro assessments. RN C concluded Resident #1 did not want to be bothered and she didn't find that unusual. RN C acknowledged LPN B did not initiate an event note related to the hematoma on Resident #1's forehead. RN C stated Resident #1 was asymptomatic (not showing symptoms) except for sleeping a lot during the day, which was not unusual for him. RN C was asked if Resident #1 had any oral intake including foods and medications on 5/25/2025. RN C responded, .I was about to give him his meds [medication] when his wife came in and demanded me to send him out.he didn't eat breakfast but that wasn't unusual for him, and he left before lunch was served. RN C was asked if she had documented Resident #1's neuro check assessments as normal. RN C stated on the Memory Care Unit it was impossible to have a normal neuro check assessment and confirmed she had documented Resident #1's neuro check assessments as normal. During an

interview on 7/25/2025 at 1:45 PM, the DON was asked if staff were required to complete an event note for abnormal skin issue findings or injuries. The DON confirmed staff were required to complete an event note if no one could explain the bruising or injury. The DON stated RN C notified the NP on 5/25/2025 and obtained an order to transfer Resident #1 to the hospital at the wife's request. The DON was asked if neuro checks should be documented as normal if the patient/resident does not wake up during the assessment and the patient/resident was unable to complete the assessment. The DON replied, .No, it would be documented as abnormal findings.the person's ability to complete the assessment could depend on their baseline. The DON was asked if she considered checking a patient's BP as part of the neuro check process was professional standards of practice. The DON replied, .yeah.BP is documented in the vital signs section of the record [EHR]. The DON confirmed nurses should not document an assessment on a resident using information provided to them by another nurse or staff member. The DON was asked to review the transfer form completed on 5/25/2025 and determine which provider was notified for orders to send Resident #1.

The DON stated the nurse documented notification to the NP. The DON confirmed notification to the provider should not be documented unless the provider was notified. 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

Event ID:

Facility ID:

If continuation sheet