Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Of Marion County during CMS and state inspections, most recent first.
The facility failed to develop and/or implement comprehensive care plans for two residents. One resident with dementia, impaired mobility, and repeated falls was supposed to have non-slip socks and proper footwear, but was repeatedly observed without them and had multiple falls documented. Another resident with severe cognitive impairment had a documented right hand contracture and prior splint use, but the care plan did not address the contracture and staff confirmed nothing was currently being done for it.
Medication Administration Not Held Per Ordered Parameters: A resident with HTN, dementia, DM, and PVD had a carvedilol order to hold for pulse less than 70 or SBP less than 120. Review of the MAR showed multiple doses were documented as given even when the resident’s pulse or SBP was below the ordered parameters. UM and DON stated the issue was related to staff selecting the wrong MAR completion button, causing meds that were held to appear as administered.
A resident with severe cognitive impairment and a documented risk for functional decline due to contractures had a right hand contracture that was not addressed in the care plan. Observation showed her fingers contracted into her palm, and she stated she could not open them or use them. Staff confirmed she previously had a splint but had not used one for about two years, no therapy services had been provided since then, and nothing was currently being done to assess or manage the contracture.
Failure to implement fall prevention interventions for a resident with dementia and a history of falls. The resident’s care plan called for non-slip socks and proper footwear, but staff observed her wearing regular socks or no shoes during multiple checks, and event reports documented repeated room falls when she was barefoot, in regular socks, or when floor grip strips had lost effectiveness. Staff confirmed the resident should have non-slip socks and shoes as part of her fall precautions.
The facility failed to ensure the nutritional value of pureed meat by not following recipe instructions. A staff member did not measure ingredients as required, pouring chicken base directly from the container. This was confirmed by the staff member, Certified Food Manager, and Registered Dietitian, who all emphasized the importance of following recipes to maintain nutritional value.
The facility failed to maintain a safe, clean, and homelike environment in six rooms, with issues such as leaking faucets, a broken dresser, a blown light bulb, and dirty blinds. The Maintenance Director was unaware of these issues, despite the use of the TELS system for monitoring maintenance tasks.
A facility failed to obtain a physician order for hand splints for a resident with contractures, leading to inconsistent application. The resident, with conditions such as cerebral palsy and intellectual disabilities, was observed with contracted hands and required staff assistance for daily activities. Despite the care plan indicating a risk for contractures, the splints were only applied nine out of 32 days, with no documentation of refusal. Staff interviews confirmed the inconsistency, resulting in a deficiency identified during a survey.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. An LPN administered furosemide and losartan to a resident with hypertensive chronic kidney disease and other conditions, despite the resident's systolic blood pressure being below the threshold specified in the physician's orders. The error was confirmed by the ADON after reviewing the MAR and discussing with the LPN.
The facility failed to follow infection control practices for four residents, including improper cleaning of a glucometer, lack of sanitization of shared equipment, and inadequate use of PPE during wound care. A resident with diabetes had their glucometer cleaned incorrectly, and shared equipment was not sanitized between uses on two residents. Additionally, a resident on Enhanced Barrier Precautions did not receive proper care as the LPN did not wear the required PPE.
Incomplete Care Planning for Falls and Contracture Management
Penalty
Summary
The facility failed to develop and/or implement a comprehensive care plan related to fall prevention for one resident and contracture management for another resident. R9 had diagnoses including dementia with agitation, diabetes, and peripheral vascular disease, and a quarterly MDS showed a BIMS score of 7, indicating moderate cognitive impairment. Her care plan identified her as a fall risk with impaired mobility, impaired cognition, and no safety awareness, and included interventions such as non-skid socks and proper footwear. However, event reports documented multiple falls over several months, including falls while wearing regular socks, bare feet, or with non-skid strips that had decreased grip, and one fall when she attempted to walk independently and her feet got tangled. Observations and interviews showed R9 was repeatedly not wearing non-slip socks or shoes as described in the care plan. She was observed in her room wearing regular socks without non-slip strips and without shoes, and she stated she needed non-slip socks so she would not fall. CNA and UM interviews confirmed her fall prevention measures were supposed to include non-slip socks and shoes when up in her wheelchair, and that the floor strips had limited grip. The facility policy stated residents at high risk would be placed on a fall management program with appropriate interventions based on assessment. R16 had diagnoses including chronic kidney disease and type 2 diabetes, and her annual MDS showed a BIMS score of 2, indicating severe cognitive impairment. Her annual CAA documented risk for functional decline because of contractures, but her care plan did not mention her right hand contracture. During observation, her right hand fingers were contracted tightly into her palm, and she stated she could not open them. CNA, RA, DOR, DON, and MDSC interviews confirmed she previously had a splint, was no longer using one, and that nothing was currently being done for the contracture or included on the care plan.
Medication Administration Not Held Per Ordered Parameters
Penalty
Summary
The facility failed to ensure carvedilol was held according to the physician’s ordered parameters for one resident with essential primary hypertension, dementia with agitation, diabetes, and peripheral vascular disease. The resident’s quarterly MDS showed a BIMS score of 7 out of 15, indicating moderate cognitive impairment. The physician’s order for carvedilol 12.5 mg twice daily directed staff to hold the medication for a pulse less than 70 or systolic blood pressure less than 120. Review of the MAR from 12/01/2025 through 01/26/2026 showed 25 doses of carvedilol were documented as given when the resident’s pulse or systolic blood pressure was below the ordered parameters. Examples included doses administered with pulse readings as low as 48 and 50, and systolic blood pressure readings as low as 98, 106, 109, 110, 111, 116, 118, and 109. During interviews, the UM stated the issue was related to staff documenting medications incorrectly on the MAR by selecting the wrong completion button, and the DON stated the same problem had occurred previously and reappeared in December 2025.
Failure to Address Resident’s Right Hand Contracture
Penalty
Summary
The facility failed to ensure one resident, R16, received appropriate services for a right hand contracture. R16 was admitted with diagnoses including chronic kidney disease and type 2 diabetes, and her annual MDS showed a BIMS score of 2, indicating severe cognitive impairment. Her annual CAA documented that she was at risk for functional decline because of contractures, but her care plan did not mention the right hand contracture. During observation, R16’s right index through little finger were contracted with the fingernails touching her palm, and she stated she could not open any finger and wished she could. R16 later stated she could not use any of the fingers on her right hand because they were “just stuck like that.” Staff interviews confirmed she previously had a splint but had not had one for about two years, and that nothing was currently being done for the contracture. The DOR stated therapy would only screen a resident if nursing made a referral and confirmed R16 had not received therapy services since she stopped using the splint. The DON, ADON, and MDSC all confirmed the contracture should have been on the care plan with interventions and reassessment, and that there was currently nothing in place to assess it.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure identified fall prevention interventions were implemented for one resident with a history of falls. R9 was admitted with diagnoses including dementia with agitation, diabetes, and peripheral vascular disease, and her quarterly MDS showed a BIMS score of 7 out of 15, indicating moderate cognitive impairment. Her care plan documented that she had a history of falling, was at risk for falls due to low blood pressure, impaired mobility, impaired cognition, and no safety awareness, and included interventions to replace non-skid socks with slip grip socks and provide proper, well-maintained footwear. Review of event reports showed multiple falls in R9’s room over the prior six months, including falls when she was wearing regular socks, bare feet, or when her non-slip socks were not on, and one fall when the grip strips on the floor had decreased grip. During observations on 01/27/2026 and 01/28/2026, R9 was seen in her room wearing regular socks without non-slip strips and without shoes, and she stated she needed non-slip socks so she would not fall. Staff interviews confirmed that R9’s fall prevention measures included proper footwear and/or non-slip socks, that she should have shoes on when up in her wheelchair and non-slip socks at other times, and that the floor strips did not have much grip. The facility’s fall management policy stated that residents at high risk would be placed on a fall management program with appropriate interventions based on assessment.
Failure to Follow Pureed Food Recipe
Penalty
Summary
The facility failed to ensure the nutritional value of meat during the pureed process by not following the recipe instructions. Specifically, the staff member responsible for preparing pureed food for 16 residents did not measure all ingredients as required. During an observation, it was noted that the staff member poured chicken base directly from the container without measuring it, which was against the facility's policy and the recipe instructions. This practice was confirmed by the staff member during an interview. Further interviews with the Certified Food Manager and the Registered Dietitian confirmed that the recipe instructions should be followed to maintain the nutritional value of the food. The Registered Dietitian emphasized that not following the recipe could affect the nutritional value of the food. The facility's Administrator also confirmed that the expectation is for the cooks to adhere to the policy and procedure by following the recipe for preparing pureed food.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in six out of forty-nine rooms. Specifically, rooms 112, 114, and 120 had leaking faucets on the hot water side, causing water to pool on the sink tops. Room 138b had a broken bedside dresser, room 109 had a blown light bulb, and room 139 had dirty blinds and a discolored air conditioning unit. These deficiencies were observed during multiple screenings and confirmed by the Maintenance Director during walking rounds. The Maintenance Director was unaware of the issues needing repair, despite the facility's use of the TELS system, an electronic system designed to monitor maintenance tasks. The Administrator, who has been working at the facility since December 2023, stated that all staff have access to the TELS system and are expected to report needed repairs. However, the system did not alert the Administrator or the Maintenance Director about the required repairs, indicating a lapse in communication or reporting within the facility's maintenance management process.
Failure to Obtain Physician Order for Splints in Resident with Contractures
Penalty
Summary
The facility failed to obtain a physician order for the application of hand splints for a resident with known contractures, which was identified during a survey. The resident, who has diagnoses including intellectual disabilities, cerebral palsy, and anxiety disorder, was observed with contracted hands and was dependent on staff for assistance with daily activities. The resident's care plan indicated a risk for contractures and included the use of splints and braces. However, there was no specific physician order for the splints until the survey date, despite the resident's condition and care needs. Documentation revealed that the splints were applied inconsistently, with records showing they were only applied nine out of 32 days in the month prior to the survey. Interviews with staff confirmed that the splints were not applied daily as required, and there was no documentation of the resident refusing the splints. The Restorative staff was responsible for ensuring the application of the splints, but the lack of documentation indicated that the splints were not consistently applied, leading to the deficiency identified by the surveyors.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration for one resident, resulting in a rate of 7.69%. This deficiency was identified through observation, staff interviews, and record reviews. The facility's policy on medication administration requires nurses to verify patient identity and medication details before administration. However, during an observation, a Licensed Practical Nurse (LPN) administered medications to a resident despite being informed that the resident's systolic blood pressure was below the threshold specified in the physician's orders. The resident involved had diagnoses including hypertensive chronic kidney disease, essential primary hypertension, and morbid obesity. The physician's orders specified that certain medications, furosemide and losartan, should be withheld if the resident's systolic blood pressure was below 110. Despite this, the LPN administered these medications after being informed of a blood pressure reading of 108/68. The Assistant Director of Nursing confirmed the error after reviewing the Medication Administration Record and discussing the incident with the LPN.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control practices for four residents, leading to deficiencies in the care provided. For one resident with Type 2 Diabetes Mellitus, the glucometer was not cleaned according to the manufacturer's guidelines. The LPN used an alcohol swab instead of the recommended disinfectant wipes, and the glucometer was placed on the medication cart without a barrier. This was confirmed by the LPN and the Infection Control Nurse, who both believed that using an alcohol swab was acceptable, contrary to the manufacturer's instructions. Additionally, shared equipment such as a blood pressure cuff was not sanitized between uses on two residents, as observed with a CNA who did not clean the equipment between residents. Furthermore, a resident on Enhanced Barrier Precautions due to a wound did not receive appropriate care, as the LPN performing wound care did not wear the required PPE, only donning gloves. The LPN was under the impression that the precautions were no longer necessary after the wound was downgraded, which was a misunderstanding of the facility's policy and CDC guidelines.
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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 Buena Vista
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four County Health And Rehabilitation | 19.3 mi | ★★★★★ | 0 | 0 |
| Miona Geriatric & Dementia Center | 19.7 mi | ★★★★★ | 8 | 0 |
| Lillian Carter Health Center By Harborview | 21.6 mi | ★★★★★ | 9 | 0 |
| Taylor County Health And Rehabilitation | 22.3 mi | ★★★★★ | 4 | 0 |
| Muscogee Manor & Rehabilitation Ctr | 23 mi | ★★★★★ | 12 | 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.