Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Manor Methodist Nsg C during CMS and state inspections, most recent first.
Incomplete Oxygen Therapy Care Plan: A resident with asthma had a physician order for oxygen at 2 LPM via NC, but the comprehensive care plan did not include individualized interventions tied to the prescribed flow rate. The MDS Coordinator confirmed the plan lacked specific oxygen-related guidance for staff, including following the ordered rate.
Aerosol containers were found at the bedside in two residents’ rooms, including one air freshener on a nightstand and five aerosol items such as deodorant spray and dry shampoo hairspray in another room. Staff, including an LPN, CNAs, the IP, DON, ADON, and Administrator, confirmed the items were present and stated aerosol containers were not permitted in resident rooms because of safety concerns for residents who wander.
A resident with asthma and a BIMS score of 00 had a physician order for oxygen at 2 LPM via nasal cannula, but repeated observations showed the concentrator set at 3 LPM. The DON confirmed the mismatch, and an RN admitted she completed med pass without verifying the oxygen setting matched the order.
The facility failed to implement DPH-recommended diagnostic testing during a GI outbreak that affected all units, involving 33 residents and 13 staff with nausea, vomiting, diarrhea, and some fevers. Although DPH advised testing individuals with diarrhea and the facility had a standing order to document and fax such recommendations to the physician, the physician was not informed and therefore did not order stool samples, while the NP, though aware of the recommendation, declined testing for residents under her care. The DON was unaware that the Infection Preventionist had reported a diagnosis instead of symptoms to DPH and acknowledged the physician should have been notified of the recommendation, and the Administrator reported not knowing the specific virus involved and confirmed the DPH report should have focused on symptoms and prescribed treatment.
A resident with severe cognitive impairment and multiple chronic conditions was found to have been restrained in a wheelchair with a gait belt, contrary to facility policy prohibiting restraints for discipline or staff convenience. Progress notes and staff interviews revealed that the resident, who had been repeatedly getting out of bed, was placed in a wheelchair, and a gait belt was wrapped around the upper body and the back of the wheelchair, effectively tying the resident in place. A CNA discovered the restraint while preparing a Hoyer lift transfer, removed the gait belt, and assisted the resident to bed. The incident was documented in the medical record, and the resident’s responsible party was notified.
A resident at risk for intracranial hematomas did not receive timely medical evaluation after a fall with a head injury. Despite a Nurse Practitioner's recommendation for a CT scan, the resident was not transferred to the hospital due to the responsible party's refusal. The resident's condition declined, with increased confusion and garbled speech, yet the facility chose to monitor in-house, contributing to the deficiency.
The facility failed to maintain food safety and sanitary conditions, with a walk-in freezer consistently above the required temperature, leading to thawed and potentially unsafe food. Staff did not adhere to proper hand hygiene and sanitation practices, resulting in chemical contamination of food. Raw chicken was left unrefrigerated for hours before being returned to the malfunctioning freezer, further compromising food safety.
A facility failed to refer a resident with newly identified mental disorders for a PASARR Level II evaluation. The resident, admitted with multiple diagnoses, was later diagnosed with mood, depressive, anxiety, and bipolar disorders, requiring a Level II review. Despite policy requirements, the facility did not make the necessary referrals, and the Administrator could not find documentation of a Level II screening.
A facility failed to conduct required smoking assessments for a resident with multiple health conditions, including cerebral infarction and COPD. The facility's policy mandates initial, annual, and quarterly assessments to ensure safe smoking practices, but these were not completed. The care plan was updated without an assessment, and the absence of these assessments was confirmed by the Administrator and staff.
Incomplete Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to implement appropriate individualized interventions on the comprehensive care plan for a resident who required oxygen therapy management. Review of the electronic medical record showed diagnoses including unspecified asthma, uncomplicated, and physician orders dated 03/24/2026 for oxygen at 2 liters per minute via nasal cannula. The resident’s care plan identified the need for oxygen therapy related to respiratory disease, but the interventions did not include individualized or specific care measures tied to the physician order or the prescribed oxygen flow rate. During interview on 04/30/2026 at 12:30 PM, the MDS Coordinator stated that the oxygen care plan should have included individualized medical interventions related to the flow rate so staff would know the prescribed rate and be able to monitor for hypoxia and the resident’s drive to breathe. She confirmed the care plan lacked specific interventions related to oxygen, including following the physician order for the flow rate. She also stated that after she was notified the resident’s flow rate was on the wrong setting during the survey, she reviewed and updated the care plan to include oxygen interventions, including administering oxygen at the rate prescribed by the medical provider.
Aerosol Containers Left at Residents’ Bedsides
Penalty
Summary
The facility failed to ensure an environment free from potential hazards by allowing aerosol containers to remain in resident rooms at the bedside for two sampled residents, R34 and R37. Observations showed an aerosol air freshener on top of the nightstand next to R37's bed during multiple checks, and staff later confirmed it was present in the room. The Nurse Supervisor LPN and CNA stated aerosol containers were not permitted in resident rooms because of safety concerns for residents who wander, and they removed the item during the interview. The Administrator, DON, and ADON also confirmed the aerosol container had been present in R37's room and stated aerosol items were not permitted in resident rooms. In R34's room, observations during multiple checks revealed five aerosol containers, including deodorant spray and dry shampoo hairspray, placed on a nightstand at the bedside. An LPN and CNA confirmed the aerosol containers were present and stated they were not permitted in resident rooms, particularly because of safety concerns for residents who wander. The CNA and LPN removed the aerosol containers during the interview. The IP later confirmed aerosol containers were present in R34's room and stated they were not permitted in resident rooms, and the Administrator, DON, and ADON also confirmed the items had been present in the resident's room.
Oxygen Rate Not Set Per Physician Order
Penalty
Summary
The facility failed to ensure the physician’s order for oxygen administration was followed for one resident who had diagnoses including unspecified asthma, uncomplicated. The resident’s quarterly MDS showed a BIMS score of 00, indicating the resident was unable to complete the assessment, and also noted respiratory therapy under special treatments and programs. The physician order dated 03/24/2026 specified oxygen at 2 liters per minute via nasal cannula. Observations on 04/28/2026 at 11:18 AM and 3:08 PM, and on 04/29/2026 at 9:04 AM, showed the resident’s oxygen rate set at 3 LPM. During a rounding observation on 04/29/2026 at 10:08 AM, the DON confirmed the oxygen order was for 2 LPM and verified the concentrator was set at 3 LPM instead of 2 LPM. The DON stated nurses should check the oxygen rate to match the physician order at least once per shift, usually during medication pass. An RN assigned to the resident on 04/29/2026 stated she completed medication pass earlier and admitted she did not verify the concentrator to confirm the oxygen rate was on the prescribed setting, and confirmed the order was for 2 LPM.
Failure to Implement DPH-Recommended Diagnostic Testing During GI Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to follow Department of Public Health (DPH) recommendations for diagnostic testing during a gastrointestinal (GI) outbreak affecting all six units. The facility’s infection surveillance policy states that the Infection Preventionist and the attending physician will determine if laboratory tests are indicated. A GI outbreak with symptoms of nausea, vomiting, diarrhea, and some fevers occurred among 33 residents and 13 staff, and DPH was contacted for guidance regarding a possible Norovirus outbreak. DPH later recommended that individuals experiencing diarrhea receive testing and inquired whether the facility had a contract with a commercial lab. However, the physician was not informed of this recommendation and therefore did not order stool samples, stating he routinely does not order stool cultures and was unaware of DPH’s guidance. The NP reported she was aware of the recommendation to test for Norovirus but declined testing for residents under her care, stating the treatment plan would be the same and that residents were already receiving treatment. Interviews revealed multiple communication and implementation failures related to the DPH recommendations. The Infection Preventionist/Quality Assurance LPN confirmed the scope of the outbreak, but the DON stated she was not aware that the Infection Preventionist had listed a diagnosis for DPH instead of only symptoms and confirmed that the physician should have been informed of the DPH recommendation. The physician standing order required that any treatment or testing recommendations from the health department be documented, faxed to the physician, and a copy retained at the facility, but this process was not followed. The NP indicated that by the time the DPH recommendation was communicated, there were no longer residents with active GI symptoms under her care. The Administrator stated she did not know the type of virus present and confirmed that the report to DPH should have described the symptoms and treatment prescribed according to the physician’s orders. These actions and inactions resulted in the facility not implementing DPH’s recommended diagnostic testing for symptomatic residents during the outbreak.
Improper Use of Gait Belt as Physical Restraint in Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints, as required by its policy titled "Restraints/Bed Rails" and regulatory standards. The facility’s policy states that residents have the right to be free from any physical restraints imposed for discipline or staff convenience and not required to treat medical symptoms. The resident involved, identified as R6, had multiple diagnoses including type 2 diabetes mellitus, mood disorder, hypertension, chronic obstructive pulmonary disease, and benign prostatic hyperplasia. A quarterly MDS with an ARD of 11/19/2025 documented a BIMS score of 1, indicating severe cognitive impairment. The care plan noted cognitive decline and emphasized respecting the resident’s right to make decisions. Progress notes from 11/10/2025 through 1/11/2026 documented a situation in which staff used a gait belt to restrain R6 to his wheelchair. During an interview, an LPN reported receiving a call from a CNA who informed her that the resident was tied to a wheelchair with a gait belt. Another CNA described that the resident had been getting out of bed despite bedside mats and was placed in a wheelchair; when preparing to use a Hoyer lift to transfer the resident to bed, the CNA observed a gait belt wrapped around the resident’s upper body and the outer back of the wheelchair, effectively restraining the resident. The CNA immediately removed the gait belt and transferred the resident to bed. The report notes that the responsible party was notified and that the resident did not sustain injuries. The DON later stated that a CNA was terminated for substantiated abuse, and the Administrator stated that her expectation is that no residents be restrained.
Failure to Ensure Timely Medical Evaluation After Resident Fall
Penalty
Summary
Facility staff failed to ensure the appropriate medical evaluation of a resident who sustained a head injury during a fall. The resident, who was at increased risk for intracranial hematomas due to advanced age and the use of antiplatelet agents, did not receive timely follow-up care after the injury. Despite a recommendation from the Nurse Practitioner for a CT scan to rule out bleeding, the resident was not transferred to the hospital because the responsible party declined the transfer. The resident's medical record indicated a history of dementia and repeated falls, with a recent admission assessment showing no cognitive impairment. However, after the fall, the resident exhibited significant changes in condition, including confusion, garbled speech, and a decline in cognitive abilities. These changes were documented in various progress notes and observed by multiple staff members, including the Social Worker and MDS Nurse. Despite the resident's progressive decline and the strong recommendation for a CT scan, the facility decided to monitor the resident in-house. The DON and other staff members stood by this decision, even though the resident's condition continued to worsen. The facility's failure to act on the Nurse Practitioner's recommendation and the responsible party's initial refusal to transfer the resident contributed to the deficiency identified in the report.
Food Safety and Sanitation Failures in Dietary Department
Penalty
Summary
The facility failed to maintain food safety and sanitary conditions, leading to a significant risk of foodborne illness. The walk-in freezer was observed to have internal temperatures consistently above the required 0 degrees Fahrenheit, with readings between 20 to 30 degrees Fahrenheit over several days. This resulted in food items such as ice cream, hamburger patties, and other frozen goods thawing and becoming potentially unsafe for consumption. The Dietary Manager and staff were unaware of the temperature discrepancies, and no corrective actions were taken despite the obvious signs of thawed and discolored food. Additionally, the facility's dietary staff did not adhere to proper hand hygiene and sanitation practices. During meal service, a staff member was observed using improperly sanitized pan covers, which were dipped in a sanitation solution and immediately placed over food without allowing the solution to dry. This led to the sanitation solution dripping into the food, posing a risk of chemical contamination. The staff member did not recognize the need for corrective action, and the Dietary Manager instructed the staff to continue serving the contaminated food. Further observations revealed that raw chicken was left unrefrigerated for over four hours in the kitchen's frying area before being returned to the malfunctioning freezer. The chicken, along with other thawed food items, was stored in unsanitary conditions, with liquids draining onto the freezer floor. The Dietary Manager did not express concern over the improper handling and storage of the chicken, nor did she report the freezer's malfunction to maintenance. These actions and inactions contributed to the facility's failure to ensure food safety and prevent potential foodborne illnesses among residents.
Failure to Refer Resident for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with newly identified mental disorders to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation. This deficiency was identified during a review of the facility's compliance with PASARR requirements. The facility's policy mandates that assessments should be coordinated with the PASARR program, and any significant change in a resident's mental condition should be reported to the state mental health authority for a resident review. However, the facility did not adhere to this policy for one resident who had been diagnosed with several mental disorders after admission. The resident in question was admitted with multiple diagnoses, including cerebral infarction, heart disease, and mood disorders. After admission, the resident was diagnosed with unspecified mood disorder, major depressive disorder, anxiety disorder, and bipolar disorder, all of which required a PASARR Level II review. Despite these diagnoses, the facility did not make the necessary referrals for a Level II screening. The Administrator acknowledged the oversight and attempted to locate any additional referrals but was unable to find any documentation of a Level II screening related to the resident's subsequent diagnoses.
Failure to Complete Smoking Assessments for Resident
Penalty
Summary
The facility failed to complete necessary assessments to determine the ability of a resident, identified as R#22, to smoke safely. According to the facility's Resident Smoking Guidelines, assessments should be conducted initially, annually, with significant changes, and quarterly in accordance with the OBRA MDS schedule. However, the clinical record for R#22, who was admitted with multiple diagnoses including cerebral infarction and chronic obstructive pulmonary disease, did not contain a smoking assessment for the annual evaluation period. Interviews with the Social Services Assistants and the MDS Coordinator revealed that the smoking assessments were not completed as required, and the care plan was updated without an assessment. The Administrator confirmed the absence of quarterly smoking assessments and the lack of an assessment for the annual evaluation. The facility's policy assigns the responsibility of completing smoking assessments to the Social Services department, which was reiterated in an in-service training conducted in November 2024. Despite this, the assessments were not performed, leaving the facility unable to determine if R#22 continued to be safe to smoke.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lillian Carter Health Center By Harborview | 9.9 mi | ★★★★★ | 9 | 0 |
| Montezuma Health And Rehabilitation | 20.5 mi | ★★★★★ | 2 | 0 |
| 4angels Of Byromville Healthcare Center | 21.3 mi | ★★★★★ | 15 | 0 |
| Lee County Health And Rehabilitation | 22 mi | ★★★★★ | 0 | 0 |
| Miona Geriatric & Dementia Center | 22.5 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.