Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Staff entered resident rooms overnight and searched through personal belongings, removing items such as linens, medications, snacks, and personal grooming items without advance notice. Residents reported feeling violated and embarrassed, and staff acknowledged the rooms were being cleaned out to be "state-ready" and that some residents were not okay with it. A resident’s urinal containing urine was also repeatedly observed on the bedside table, and the resident said it was embarrassing and that the room smelled like urine.
Failure to Notify Representatives of Significant Weight Loss and New Wound: The facility did not notify a resident’s representative about significant wt loss after weekly weights showed a marked decline, and the RD acknowledged the son was not informed about the loss or dietary changes. The facility also did not document notifying another resident’s representative when a new chin wound from collar pressure was found; the LPN recalled seeing the wound and placing a wound care consult, but was unsure whether the family was called.
Inaccurate MDS assessments were completed for multiple residents when active diagnoses and care-related items did not match the medical record. One resident’s MDS omitted glaucoma, A-fib, and protein-calorie malnutrition; another resident’s MDS incorrectly coded weight loss and insulin injections and omitted BPH; and two other residents’ MDS assessments failed to include depression despite physician orders and admission records documenting it.
Failure to obtain physician orders for wound care and dressing changes affected two residents. One resident had multiple lower-extremity wounds with an undated, loose dressing and wound notes showing daily calcium alginate treatment, but the TAR did not show completed dressing documentation after one date. Another resident had an undated left arm dressing with drainage staining, no wound care order in the chart, and staff stated dressings require an order and should be dated and initialed.
A resident with multiple orthopedic and infectious diagnoses was observed in severe pain with grimacing, wincing, and moaning, and stated pain was 10 out of 10 while reporting no pain medication had been received after return from the hospital. Although oxycodone orders were in place and the ADC had inventory available, no oxycodone was accessed or administered before 9:00 AM, and staff acknowledged the resident had not received the ordered pain medication.
Staff failed to use PPE and hand hygiene when handling soiled linens and trash, and failed to follow contact precautions for two residents with ESBL in urine. A floor tech handled soiled waste and linen without gloves or hand hygiene, and staff entered residents' rooms without gowns and gloves despite isolation orders and signage issues. The facility also failed to keep a resident's suprapubic catheter bag from resting on the floor mat during care.
Failure to use EBP PPE during midline care: An LPN provided IV/midline care to a resident on EBP while wearing gloves but no gown. The LPN stated she did not normally wear a gown for midlines or IVs, while the DON stated EBP was expected for residents with wounds, IVs, PICC lines, G-tubes, and foley catheters. The resident’s order required EBP for wounds and IV care, and the facility policy called for gown and glove use for residents with chronic wounds or indwelling medical devices.
The facility failed to properly store food in the main kitchen and 700 Hall Nourishment Room, with unlabeled and undated food items found in both areas. The ice machine in the kitchen also had a brownish buildup. The Dietary Assistant confirmed these issues, which violated the facility's policies requiring food to be labeled, dated, and stored properly, and for ice machines to be regularly cleaned.
The facility failed to complete timely MDS assessments for several residents. Two residents did not have their Medicare 5-day assessments completed within the required timeframe, and two other residents were discharged without a completed discharge MDS. The Regional MDS Coordinator confirmed these deficiencies during interviews.
The facility failed to ensure accurate assessments for two residents. A resident's MDS inaccurately showed anticoagulant use without an active order, while another resident's MDS recorded an incorrect admission date from a previous stay. These inaccuracies were confirmed by the Regional MDS Coordinator.
A facility failed to verify the placement of a gastrostomy tube (G-tube) before administering water and medication to a resident, potentially leading to aspiration or vomiting. An LPN administered substances through the G-tube without aspirating stomach content to confirm correct placement, contrary to the facility's policy and standard procedures. The Director of Nursing outlined the correct procedure, which includes checking placement by listening for air and assessing residuals, but these steps were not followed.
The facility failed to follow infection prevention and control practices during medication administration via G-tube. A nurse placed medications on a table with a urinal without providing a barrier, and another nurse administered enteral feeding to a resident with a G-tube without using appropriate PPE, despite enhanced barrier precautions being required. The DON confirmed these actions were against facility policy and CDC guidelines.
Failure to Protect Resident Privacy and Dignity During Room Searches and Personal Care
Penalty
Summary
The facility failed to promote and maintain resident dignity and privacy when staff entered resident rooms during the night and went through personal belongings without advance notice. Residents reported that staff came into their rooms around 3:00 to 4:00 AM and removed items from drawers and belongings, including medications, snacks, a brush, and other personal items. One resident stated staff said they were getting medications out of the room because state was coming in the morning, and another resident said staff searched through all belongings and took personal items, describing it as a major violation of privacy. A cognitively intact resident also reported being awakened while two nurses searched through personal items and said they were waiting for surveyors. Staff interviews confirmed that room searches occurred on the night shift for reasons such as pulling excess linens, towels, washcloths, supplies, creams, lotions, and decluttering rooms to be "state-ready." Staff stated they went into resident rooms to look for extra linen, tidy rooms, and bag medications, and that some residents were okay with it while others were not. Staff also acknowledged that residents were not given advance notice that their rooms would be searched and that some residents woke up during the process. The Administrator stated routine room checks were done periodically on 11-7 shifts and acknowledged that residents may have been upset and that the practice needed to be reapproached. The facility also failed to maintain dignity for a resident whose urinal containing urine was observed on the bedside table. The urinal was seen on the bedside table with urine on multiple observations, and the resident stated the room smelled like urine and that it was embarrassing to have the urinal on the bedside table. The report also notes that the Administrator stated the facility did not have policies for personal property or resident rights, while the admission packet included a resident right to privacy in treatment and caring for personal needs, to close room doors and have staff knock before entering, and to security in storing and using personal possessions.
Failure to Notify Representatives of Significant Weight Loss and New Wound
Penalty
Summary
The facility failed to notify resident representatives of changes in condition for two residents. For Resident #7, the record showed diagnoses including displaced intertrochanteric fracture of the right femur, generalized muscle weakness, cognitive communication deficit, dysphasia, unspecified protein-calorie malnutrition, acute respiratory failure with hypoxia, hypokalemia, COPD, type 2 diabetes mellitus, and GERD. Physician orders dated 4/9/2026 directed weekly weights, and the documented weights showed 180.2 lbs on 4/9/2026, 180.0 lbs on 4/10/2026, and 163.5 lbs on 4/21/2026. A dietary note documented significant weight loss of 9.1% or 16.4 lbs in one month. The resident’s representative stated he was not notified about the weight loss or measures put in place, and the RD stated she did not notify the son about the weight loss or dietary changes. The DON stated the son should have been told about the weight loss and new measures. For Resident #161, a skin check note documented a new wound on the chin due to pressure from the collar, and a physician order was written for wound care consult. The resident representative stated staff told her at a meeting that the LPN had found the chin wound, and she questioned why the wound was not properly evaluated and the family notified. The progress notes contained no documentation that the representative was notified about the new chin wound on 4/24/2026. The LPN stated he saw the wound, made a wound care consult, and did not remember whether he called the family. The DON stated that when a resident has a new wound, the nurse is expected to complete a change of condition, notify the doctor, obtain orders, and notify the family.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure resident assessments were completed accurately to reflect resident status for 4 of 12 residents reviewed. For one resident, the admission MDS did not list active diagnoses of glaucoma, atrial fibrillation, and protein-calorie malnutrition even though the admission record documented those diagnoses. The MDS Lead RN stated that these diagnoses should have been included in Section I of the MDS. For another resident, the admission/5-day MDS coded weight loss in Section K even though the only documented weight in the current admission did not support that coding, and the RD stated she would have coded no because the resident did not appear to trigger weight loss parameters. The same resident’s MDS also coded 4 insulin injections in Section N, but the MAR showed 6 administrations, and Section I did not include BPH despite physician documentation of that diagnosis. For two additional residents, quarterly and annual MDS assessments did not include depression in Section I even though physician orders and admission records documented depression and related treatment with sertraline and trazodone; the MDS Lead RN stated depression should have been included.
Failure to Obtain Orders for Wound Care and Dressing Changes
Penalty
Summary
The facility failed to obtain physician orders to provide wound care for two residents reviewed for skin conditions. Resident #38 was observed sitting at bedside with a dressing on the right lower leg that was not dated and had loose gauze around the wound. The resident stated the dressing was not changed as often as it should be and said the last change was about one week earlier. Review of the physician orders did not show wound care dressing change orders, although wound care progress notes documented calcium alginate dressings and daily treatment for multiple wounds on the feet and lower legs. The resident’s TAR did not show active completed documentation for calcium alginate dressing treatments after 04/17/2026, despite later wound care notes continuing to reference daily dressing treatments. Resident #199 was observed with a 2 x 2 dressing on the left arm that was not dated and had lifting and drainage staining, and later the dressing was found with dried dark brown drainage. The resident stated the injury occurred at the facility and was not aware of daily dressing changes. Review of physician orders did not document wound care dressing change orders, and a progress note from the skin check stated no prior areas of skin impairment and no new areas noted. Staff stated that when there is a skin concern they should complete a change of condition, notify the MD, take a picture, and that dressings need an order and should be dated and initialed. The DON stated dressing changes should be based on doctor orders or PRN if soiled, and that staff should look under dressings during skin sweeps to see what is underneath.
Failure to Provide Ordered Pain Medication
Penalty
Summary
The facility failed to provide pain medications and follow physician orders for pain management for a resident admitted after joint replacement surgery with diagnoses including klebsiella pneumonia, urinary tract infection, presence of a right artificial knee joint, unilateral primary osteoarthritis of the left knee, and rheumatoid arthritis. The resident’s orders dated 5/5/2026 included oxycodone HCL 15 mg by mouth every 6 hours as needed for pain rated 6-10 and oxycodone HCL 15 mg by mouth four times a day for nonacute pain. On 5/5/2026, the resident was observed in bed with facial grimacing, wincing, and moaning when attempting to move the legs, and stated the pain was 10 out of 10 and that pain medication had not yet been received. A later observation showed the same signs of pain, and the resident again stated no pain medicine had been given since returning from the hospital the prior night. The automated medication dispensing system showed oxycodone 15 mg inventory available, but no medication was accessed from the machine on 5/4/2026 or 5/5/2026 before 9:00 AM, and the MAR showed no oxycodone administered during that period. An LPN stated the resident had been in pain and that there may have been a problem with the prescription, while the DON stated the oxycodone was not given and the nurse should have called pharmacy and obtained medication for the resident.
Failure to Follow PPE, Contact Precautions, and Catheter Care
Penalty
Summary
The facility failed to ensure staff used appropriate PPE and performed hand hygiene when handling soiled linens and trash in the memory care unit. During observation, a floor technician/housekeeping staff member picked up soiled trash behind the nurses station, held it against his body to remove excess air, twisted the bag several times, and placed it into a gray bin labeled for soiled linen only. He then went into the soiled utility room, handled soiled linen bags in the same manner, and added them to the same bin. Hand hygiene was not observed before or after the task, and the staff member touched access code buttons and doors when leaving the unit. In interview, the staff member stated he handled the soiled trash and linen without gloves or PPE and without completing hand hygiene before exiting the unit. Housekeeping leadership stated staff should not touch trash to their body and should use proper hand washing or disinfecting of hands, and that the behavior had been verbally addressed before. The facility also failed to ensure transmission-based precautions were followed for two residents on contact precautions for ESBL in urine. One resident had diagnoses including aftercare following joint replacement surgery, klebsiella pneumonia, and UTI, and had an order for contact precautions with verification of correct door signage and equipment present. Observations showed the room door without isolation signage or PPE near the doorway, and staff entered the room without gown or gloves while assisting the resident. Staff later stated they had not known the resident was on precautions and that PPE should have been worn every time the room was entered. Another resident had an order for contact precautions for ESBL in urine, yet observations showed enhanced barrier precautions signage on the doorway while a CNA entered the room without a gown and gloves to deliver breakfast and later returned without gown and gloves to remove the tray. The resident stated staff had not been using a gown or gloves when caring for them or changing the sheets, and staff stated they should have worn a gown and gloves every time they entered the room. The facility also failed to maintain proper urinary catheter care and maintenance for a resident with a suprapubic catheter. During observation, the resident was lying in bed with the bed in the lowest position, and the urinary catheter bag was resting on top of the floor mat and did not have a privacy cover. The resident had orders to check the catheter and tubing for kinks and flow of urine, secure tubing to prevent pulling out or trauma, and use enhanced barrier precautions for the suprapubic catheter during high-contact care activities. Staff stated the catheter bag should not be touching the floor for infection control purposes, but also stated it was difficult to keep the bag from touching the floor because the resident was a fall risk and the bed had to remain low. Leadership and the infection preventionist stated the bag should not be touching the ground and discussed using another type of barrier so it would not contact the floor.
Failure to Use EBP PPE During Midline Care
Penalty
Summary
The facility failed to ensure staff used appropriate personal protective equipment while performing midline care for a resident on enhanced barrier precautions (EBP). During an observation, an LPN entered the resident’s room, performed hand hygiene, donned gloves, turned off the IV pump, disconnected the IV tubing from the resident’s midline, wiped the midline port with alcohol, flushed it with 10 milliliters of normal saline, applied a green cap, removed the gloves, and performed hand hygiene while leaving the room. The LPN did not wear a gown during the midline care. During interview, the LPN stated she did not normally wear a gown for midlines or IVs and only wore gloves. The DON stated nurses were expected to use EBP every time they cared for residents with breaks in the skin, G-tubes, wounds, IVs, PICC lines, and foley catheters. The resident’s physician order dated 11/18/2025 indicated EBP for wounds and IV every shift, with gloves and a gown required for high-contact resident care activities. The facility policy stated EBP includes targeted gown and glove use for residents with chronic wounds or indwelling medical devices, regardless of MDRO colonization status.
Improper Food Storage and Sanitation in Kitchen and Nourishment Room
Penalty
Summary
The facility failed to ensure proper storage of food products in the main kitchen and one of the nourishment rooms, specifically the 700 Hall Nourishment Room. During an initial tour of the main kitchen, surveyors observed two unlabeled and undated bags of unidentified patties, with one bag open and unsealed, and one unlabeled and undated bag of mixed vegetables in the reach-in cooler. The Dietary Assistant confirmed that these food items should have been labeled, dated, and sealed. Additionally, the ice machine in the kitchen was found to have a brownish, soft buildup at the lip of the inside top rim, which the Dietary Assistant acknowledged. In the 700 Hall Nourishment Room, surveyors found plastic-wrapped burritos and an opened ice cream container in the freezer that were not labeled or dated. The Dietary Assistant stated that these food items should also have been labeled and dated. The facility's policies and procedures, last reviewed in July 2024, require that all food items be covered, labeled, and dated, and that ice machines and equipment be cleaned regularly to maintain sanitary conditions. These observations indicate a failure to adhere to the facility's established food storage and sanitation protocols.
Failure to Complete Timely MDS Assessments for Residents
Penalty
Summary
The facility failed to complete comprehensive assessments for the Admission Minimum Data Set (MDS) for four residents. Resident #41 and Resident #176 did not have their Medicare 5-day assessments completed or accepted, as their admission assessments were not opened within the required timeframe of days one to eight. The Regional MDS Coordinator confirmed that these assessments were not in compliance with the date requirements. Additionally, Resident #112 was admitted and later discharged home, but there was no discharge MDS completed within the required 21 days after discharge. Resident #57 was discharged home with his daughter, but the facility did not complete a discharge MDS for this resident either. During an interview, the Regional MDS Coordinator acknowledged the absence of the discharge MDS for Resident #57 and confirmed that it should have been completed. These deficiencies indicate a failure in the facility's process for timely and accurate completion of MDS assessments for residents upon admission and discharge.
Inaccurate Resident Assessments for Anticoagulant Use and Admission Dates
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. For Resident #90, the Quarterly Minimum Data Set (MDS) assessment inaccurately indicated the resident was receiving anticoagulant medication, despite there being no active order for such medication. The resident had a previous order for Eliquis, an anticoagulant, which had ended, but this was not reflected in the MDS assessment. The Regional MDS Coordinator confirmed the absence of an active order during an interview. For Resident #27, the Entry MDS inaccurately recorded the admission date as the date from a previous stay, rather than the current admission date. This error was acknowledged by the Regional MDS Coordinator during an interview, indicating a failure to update the resident's records accurately.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure the proper verification of gastrostomy tube (G-tube) placement before administering water and medication to a resident, which could lead to possible aspiration or vomiting. During an observation, a Licensed Practical Nurse (LPN) administered water and Guaifenesin Syrup through a resident's G-tube without aspirating the stomach content to verify the correct placement of the tube. The LPN allowed the substances to drain via gravity without performing the necessary checks for tube placement. The Director of Nursing (DON) explained that the standard procedure for administering medications through a G-tube includes checking for placement by putting air through the tube and listening with a stethoscope, as well as assessing for residual by pulling back with a syringe. The facility's policy, last reviewed in July 2024, also requires verification of tube placement by aspirating gastrointestinal content. However, the LPN did not follow these procedures, leading to a deficiency in the care provided to the resident.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration via gastrostomy (G-tube). During an observation, a registered nurse placed medications on an overbed table that also held a urinal half full of dark yellow liquid, without removing the urinal or providing a barrier or clean surface between the urinal and the medications. The nurse acknowledged the oversight during an interview, and the Director of Nursing (DON) confirmed that using a surface with bodily fluids for medication storage is an infection control issue. Additionally, a licensed practical nurse administered a bolus dose of enteral feeding to a resident with a G-tube while wearing only gloves, without using additional personal protective equipment (PPE) such as a gown or goggles, despite the resident being on enhanced barrier precautions. The facility's policy and the CDC guidelines require gown and glove use during high-contact resident care activities, including device care or use like feeding tubes, to prevent the transmission of multidrug-resistant organisms (MDROs). The DON confirmed that enhanced barrier precautions should have been followed for residents with G-tubes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At North Florida | 1.9 mi | ★★★★★ | 23 | 3 |
| Palm Garden Of Gainesville | 3 mi | ★★★★★ | 0 | 0 |
| Gainesville Health And Rehabilitation | 4.2 mi | ★★★★★ | 4 | 0 |
| Terrace Healthcare & Rehabilitation Center | 4.5 mi | ★★★★★ | 7 | 0 |
| Plaza Health And Rehab | 5.4 mi | ★★★★★ | 19 | 0 |
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