Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Pruitthealth - Magnolia Manor during CMS and state inspections, most recent first.
The facility failed to properly label, date, and discard expired food items, as observed in the dietary department. Additionally, a CNA was seen feeding a resident with her fingers and placing the plate on her lap, contrary to sanitary practices. These actions were confirmed by staff and had the potential to affect the sanitary delivery of food to residents.
The facility failed to submit Level II PASARR applications for five residents with significant mental health diagnoses, as revealed through staff interviews and record reviews. Despite being on psychiatric medications and displaying behaviors warranting further assessment, these residents did not receive the necessary evaluations. The Social Service Director admitted to not making any Level II referrals and was unclear about the criteria, contributing to the deficiency.
The facility failed to conduct necessary nutrition assessments for three residents, leading to significant weight loss and inadequate nutritional care. A resident with severe cognitive impairment lost 10 lbs without an admission assessment, while another with heart failure lost 41 lbs without being assessed for weight changes. A third resident experienced a 51 lbs weight loss with minimal RD oversight. Staffing shortages and lack of RD coverage contributed to these deficiencies.
The facility failed to maintain infection control during medication administration and dining. An LPN placed a glucometer and lancet on a bed without a barrier and pocketed a used needle. Another LPN did not sanitize hands after administering nasal spray, and medication was poured into bare hands. Staff did not sanitize hands between serving trays or offer residents hand hygiene before meals. A stained sheet was found on a PPE cart, and an old IV tubing was left in a resident's room.
A resident with little cognitive impairment requested the removal of facial hair, which was not addressed for two weeks, impacting her dignity. Despite being told to wait for shower days, the grooming was not performed, causing distress. A CNA confirmed the delay, and the DHS stated that such requests should be fulfilled promptly.
A resident with a BIMS score indicating little cognitive impairment was found with expired prescription medication at their bedside, which they occasionally used without being assessed for self-administration. The LPN confirmed the medication's presence, and the DHS was unaware of it, acknowledging the risk of expired medication use.
The facility failed to provide four residents with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. This deficiency was identified through record reviews and staff interviews, revealing that the required Advance Directive Checklist was not completed for these residents, denying them the opportunity to make informed healthcare decisions.
The facility failed to maintain a safe and clean environment, with issues such as a stained pillow for a resident, trip hazards from electrical sockets, a cracked toilet, and unsanitary water fountains. These deficiencies were observed across multiple halls, and staff were unaware of these conditions until they were pointed out.
The facility failed to inform residents about the grievance process, including the identity of the Grievance Official and how to file a grievance. During a Resident Council meeting, several residents were unaware of these details, and there was confusion among staff about the Grievance Official's identity. Meeting minutes from the past year showed that resident rights and grievance procedures were not discussed, leading to the deficiency.
The facility failed to implement comprehensive care plans for several residents, resulting in missed showers, inadequate incontinence care, and lack of psychiatric and vision services. Observations revealed residents left in soiled conditions and without necessary services, despite care plans outlining these needs. Staff interviews confirmed a lack of adherence to care plans, highlighting communication gaps and oversight in resident care.
The facility failed to provide adequate ADL care for six residents, resulting in deficiencies in personal hygiene and care. One resident missed scheduled showers and was not assisted with facial hair removal, while another was left soiled in bed without timely incontinence care. Additionally, four residents had long and dirty fingernails, indicating a lack of personal hygiene care. Staff interviews revealed confusion about responsibilities and a lack of a clear policy on ADL care.
The facility failed to provide vision services to two residents, one with moderate cognitive impairment and another with worsening vision due to cataracts. Despite recommendations for eyeglasses and reports of vision issues, there was a lack of follow-up and communication, resulting in delays in obtaining necessary vision care.
A resident with a left-hand contracture did not receive the prescribed application of a resting hand splint, as staff failed to follow the OT Restorative Nursing Program recommendation. Despite a physician's order and care plan, the resident was observed without the splint on multiple occasions. Interviews revealed that CNAs were either unaware or not trained to apply the splint daily, and the resident confirmed the lack of assistance. The Therapy Director and OT highlighted the risk of further contractures without the splint, while the DHS expected staff to adhere to the orders.
The facility failed to maintain a safe environment by not securing an oxygen tank, allowing aerosol cans in a resident's room, and not providing adequate supervision for high fall-risk residents. An unsecured oxygen tank posed a risk, aerosol cans were against policy, and fall prevention measures were inconsistently applied, leading to falls and injuries.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. One resident had oxygen masks uncovered and on the floor, and an oxygen cylinder was left free-standing in the room for almost a month despite requests for removal. Another resident's oxygen tubing was improperly stored and not labeled when changed. Staff interviews confirmed these issues, and the DHS acknowledged the risks and responsibilities involved.
The facility failed to provide necessary mental health services to three residents, despite their diagnoses of depression, PTSD, and other mental health conditions. One resident did not receive counseling or psychiatric services, another did not receive psychiatric services after admission, and a third was taking antipsychotic medications without a psychiatric consult. The Social Services Director and Director of Health Services confirmed the lack of follow-through on psychiatric referrals.
Deficiencies in Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its policy on labeling, dating, and storage of food items, as observed during a survey. In the dietary department, several items were found to be improperly labeled or expired. Specifically, a stand-up cooler contained two pitchers of liquid that were neither labeled nor dated, and a bottle of mayonnaise with an expired date. In the dry pantry area, a box of flour tortillas was found to be expired. Additionally, a walk-in cooler contained a large package of diced ham that had been opened but was not labeled with an open or use-by date. These observations were confirmed by the Dietary Aide and later by the Dietary Manager, who acknowledged the failure to follow the facility's policy. In the 500-hall dining room, a Certified Nursing Assistant (CNA) was observed assisting a resident with eating in an unsanitary manner. The CNA used her fingers instead of utensils to feed the resident and placed the resident's plate on her lap rather than on the table. This practice was confirmed by the CNA and was contrary to the expectations outlined by the Unit Manager/Registered Nurse and the Director of Health Services, who stated that utensils should be used and plates should remain on the table. These actions had the potential to affect the sanitary delivery of food to residents, increasing the risk of foodborne illnesses.
Failure to Conduct PASARR Level II Assessments
Penalty
Summary
The facility failed to submit applications for Level II PASARR (Pre Admission Screening and Resident Review) to the appropriate state designated mental health authority for evaluation and determination of the need for specialized services for five residents. This deficiency was identified through observations, staff interviews, and record reviews. The facility did not provide a policy on PASARR when requested, indicating a lack of procedural guidance. Resident 15 had multiple psychiatric diagnoses, including major depressive disorder and psychotic disorder with delusions, but only had a PASARR Level I assessment. The Social Service Director (SSD) acknowledged the absence of a Level II assessment despite the resident's significant mental health diagnoses. Similarly, Resident 16, who was admitted with anxiety and dementia, displayed irrational behaviors and was on psychiatric medications, yet did not have a PASARR Level II assessment. The SSD and other staff interviews confirmed the lack of a system to monitor and apply for Level II assessments when new psychiatric diagnoses were made post-admission. Residents 61, 65, and 23 also lacked PASARR Level II assessments despite having significant mental health diagnoses and being on psychotropic medications. Interviews with the SSD and medical records staff confirmed the absence of these assessments. The SSD admitted to not making any Level II referrals since working at the facility and was unsure of the criteria for such assessments, mistakenly believing only schizophrenia required a Level II assessment. This lack of knowledge and procedural oversight contributed to the deficiency, potentially impacting the residents' access to necessary mental health services.
Failure to Conduct Nutrition Assessments
Penalty
Summary
The facility failed to provide evidence of completed nutrition assessments by a Registered Dietitian (RD) for three residents, leading to deficiencies in nutritional care. Resident R66, admitted with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and heart disease, experienced a weight loss from 130 lbs to 120 lbs without an admission nutrition assessment being conducted. Despite being on a puree diet and Ensure supplement, the care plan noted hydration deficits, and the resident continued to decline with a poor appetite. The RD confirmed that R66 was not seen for an admission assessment. Resident R44, with diagnoses including heart failure and a history of stroke, was not assessed for weight changes despite a significant weight loss from 208 lbs to 167 lbs. The RD last saw R44 in February, and the care plan identified risks related to nutrition and hydration. Resident R46, with Alzheimer's and other conditions, was seen by the RD only twice, despite a significant weight loss from 181 lbs to 130 lbs. The RD noted the lack of coverage and the inability to perform necessary assessments due to staffing shortages, with the Dietary Manager filling in for some duties. The facility's failure to conduct timely and adequate nutrition assessments contributed to the deficiencies identified by surveyors.
Infection Control Deficiencies in Medication Administration and Dining Practices
Penalty
Summary
The facility failed to maintain effective infection control practices during medication administration for three residents. For one resident, the LPN placed a glucometer and lancet on the bed without a barrier during a fingerstick blood sugar check and later put a used needle in his pocket before discarding it in the sharps container. Another resident received nasal spray medication without the LPN sanitizing his hands after glove removal, and the medication container was placed on the cart without a barrier or cleaning. A third resident's medication was poured into the LPN's bare hands without gloves. In the dining room, staff did not wash or sanitize their hands between serving trays or offer residents hand hygiene before meals. A CNA assisted a resident with eating without sanitizing her hands. The Unit Manager and other staff were unaware of the policy regarding hand hygiene during meal assistance, although it was expected that staff should sanitize hands before assisting residents or handling food. Additionally, a PPE cart was found with a stained sheet lying uncovered next to PPE items, and an IV tubing coated with brown substances was left in a resident's room, despite the resident not requiring an IV. The tubing was identified as belonging to a previous resident and was removed after being reported by the current resident.
Failure to Honor Resident's Grooming Request
Penalty
Summary
The facility failed to honor a resident's request for personal grooming, specifically the removal of facial hair, which impacted the resident's dignity and self-determination. The resident, who had a BIMS score indicating little to no cognitive impairment, required moderate assistance with personal hygiene. Despite her requests, the staff did not remove the facial hair on her chin for approximately two weeks, telling her to wait until her designated shower days. However, even on those days, the grooming was not performed, leading the resident to stop requesting assistance, which caused her distress. Observations confirmed the presence of thick facial hair on the resident's chin over several days. Interviews with the resident and a CNA corroborated the resident's account, with the CNA acknowledging the delay in addressing the resident's request. The Director of Health Services stated that the expectation was for such requests to be fulfilled promptly, without the resident having to wait for specific days. This deficiency highlights a failure in the facility's care practices, as the resident's right to dignity and respect was not upheld.
Unauthorized and Expired Medication Found at Resident's Bedside
Penalty
Summary
The facility failed to ensure that unauthorized and expired medications were not stored at the bedside of a resident, identified as R16. During an observation, a bottle of expired prescription medication, labeled as premium saline moisturizing nasal spray, was found on R16's bedside table. The medication had a discard date of 10/28/2023, and the resident was not assessed to self-administer medications. The facility did not provide a policy on self-administering medications when requested. R16 had a BIMS score of 15, indicating little to no cognitive impairment, and had diagnoses including unspecified dementia, paroxysmal atrial fibrillation, chronic kidney disease stage 4, and pulmonary hypertension. During an interview, R16 acknowledged using the medication occasionally and was unaware of its expiration. The LPN confirmed that residents are not allowed to have medications in their rooms unless assessed. The Director of Health Services was unaware of the medication in R16's room and acknowledged the risk of residents using expired medication.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide residents and/or their representatives with written information regarding their rights to accept or refuse medical or surgical treatment, as well as to formulate an advance directive. This deficiency was identified for four residents out of a sample of 28. The facility's policy, dated 2014, required that an Advance Directive Checklist be completed upon admission, but this was not adhered to for the residents in question. For Resident 52, the medical record lacked signed acknowledgment or evidence of receipt of information about their rights. Resident 65's record also did not contain an Advance Directive Checklist, and the Social Services Director confirmed this omission. Similarly, Resident 15's record showed a lack of proper documentation and acknowledgment of advance directive information, despite having a DNR order. The Social Services Director and Administrator acknowledged the absence of the checklist, noting that a revised version was in use. Resident 29's record also lacked evidence of providing written information about their rights, with the Social Services Director unaware of whether the facility currently provided such information. These failures collectively denied the residents the opportunity to make informed choices about their healthcare decisions.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment across three of its halls, specifically Halls 600, 700, and 800. Observations revealed several deficiencies, including a stained pillow for a resident identified as R53, trip hazards from electrical sockets on the floor in the common areas of the 700 and 800 halls, a cracked toilet in the 600 hall, and unsanitary conditions of three water fountains covered in a thick beige/white hard scale substance. These issues were confirmed through staff interviews and record reviews, indicating a lack of awareness and maintenance in these areas. The resident R53, who was admitted with conditions such as muscle weakness, dysphagia, and type 2 diabetes mellitus, was observed lying on a soiled, yellow-stained pillow without a pillowcase over several days. The Director of Health Services expressed that it was expected for staff to replace soiled pillows and provide clean pillowcases, highlighting a lapse in meeting these expectations. Additionally, the Maintenance Director and Administrator were unaware of the cracked toilet and the condition of the water fountains until the environmental tour, indicating a lack of regular monitoring and maintenance in the facility.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, including the identity of the Grievance Official and how to file a grievance. The facility's policy, titled 'Grievances: Healthcare Centers,' designates the Administrator as the Grievance Official responsible for overseeing the grievance process, maintaining confidentiality, and issuing written decisions. However, during a Resident Council review meeting, it was revealed that three out of seven residents did not know how to file a grievance or the name of the Grievance Official. Additionally, there was confusion among staff, as the Resident Council President incorrectly identified the Social Services Director as the Grievance Official, and the Activities Director, who was new to the position, did not confirm this information. The Activities Director admitted to not reviewing resident rights, the grievance filing process, or the name of the Grievance Official during previous meetings. A review of the Resident Council meeting minutes from the past year confirmed that these topics were not discussed. This lack of communication and education regarding the grievance process led to the deficiency, as residents were not adequately informed about their rights and the procedures for voicing grievances.
Deficiencies in Care Plan Implementation and Resident Care
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. For one resident, identified as R36, the facility did not adhere to the scheduled bathing preferences, resulting in missed showers and inadequate personal hygiene. Observations revealed that the resident was left in soiled bed linens with a strong odor of urine, indicating a lack of attention to incontinence care. The Unit Manager was unaware of these issues, highlighting a communication gap and failure to follow the care plan. Another resident, R52, experienced similar neglect in incontinence care. Despite being dependent on staff for toileting assistance, the resident was found in a soiled state multiple times, with staff failing to provide timely care. Interviews with staff revealed a lack of adherence to the care plan, which required checks every two hours and assistance with toileting. The Director of Health Services and other staff confirmed the expectation for regular incontinence care, yet it was not consistently provided. Additionally, the facility did not provide necessary psychiatric and vision services for residents R25, R65, and R56. R65 and R25 did not receive psychiatric consultations despite their diagnoses and care plan requirements. R56, who required vision services, did not receive prescribed eyeglasses following an eye exam. These oversights were confirmed through interviews with staff, including the Social Services Director and the Director of Health Services, who acknowledged the failure to implement the care plans as intended.
Deficiencies in ADL Care and Hygiene in LTC Facility
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for six residents, leading to deficiencies in personal hygiene and care. One resident, with a BIMS score indicating little to no cognitive impairment, reported not receiving assistance with facial hair removal and missed showers on scheduled days, particularly on weekends. Despite having a shower in her bathroom, the resident was told by staff that showers were only provided on weekdays, forcing her to wash at the sink, which she could not do thoroughly due to physical limitations. The Unit Manager was unaware of these missed showers, indicating a lack of communication and oversight. Another resident, with a BIMS score indicating cognitive impairment, was found lying in bed soiled with urine, with the room having a strong urine smell. The resident reported being left in this state since the previous night and expressed that this was a frequent occurrence. Despite being dependent on staff for toileting assistance, the resident was not checked for incontinence care until late in the morning. Interviews with staff revealed a failure to perform regular checks and provide necessary care, with the Director of Health Services acknowledging the need for more frequent rounds. Additionally, four residents were observed with long and dirty fingernails, indicating a lack of personal hygiene care. Interviews with staff revealed confusion and inconsistency regarding nail care responsibilities, with some staff believing it was not part of standard ADL care. The facility lacked a clear policy on ADL care, contributing to the oversight in maintaining residents' personal hygiene. The Director of Health Services confirmed that fingernails should be cleaned during baths and trimmed when needed, but this was not consistently documented or communicated among staff.
Failure to Provide Vision Services to Residents
Penalty
Summary
The facility failed to obtain vision services for two residents, R56 and R78, as required by their policy on specialty services. R56, who has moderate cognitive impairment and impaired vision, had an eye exam over four months ago, and glasses were recommended. However, the glasses were never ordered due to a lack of follow-up by the social worker, as confirmed by the Director of Health Services. R56 expressed concern about not receiving his eyeglasses, which were prescribed in May 2024. R78, who has little to no cognitive impairments, was observed using broken readers instead of prescription glasses. R78 reported worsening vision due to cataracts and difficulty with daily activities like watching television and completing word puzzles. Despite informing staff about his vision issues and broken glasses, no action was taken to arrange an eye examination. The social worker was unaware of R78's vision problems and had not made a referral for an eye exam, as the resident had not met the 90-day stay requirement for vision services. The facility's policy requires that all residents be screened for vision services, regardless of their status. However, the Director of Health Services was unaware of R78's vision problems, indicating a communication breakdown within the facility. Both residents experienced delays in receiving necessary vision care, highlighting a failure in the facility's process for managing specialty services and ensuring timely follow-up on physician recommendations.
Failure to Apply Splint Device as Ordered
Penalty
Summary
The facility failed to adhere to an Occupational Therapy Restorative Nursing Program recommendation for a resident with a left-hand contracture, which required the application of a progressive resting hand splint. The resident, who had a BIMS score indicating little to no cognitive impairment, was observed on multiple occasions without the splint device, despite a physician's order and care plan specifying its use for 6-7 hours daily. Interviews with the resident confirmed that staff were not assisting with the application of the splint, and the resident had ceased requesting help due to lack of assistance. Interviews with Certified Nursing Assistants (CNAs) revealed a lack of awareness and training regarding the splint application. CNA QQ admitted to not applying the splint during her shifts, while CNA NN was unaware of the requirement to apply the splint daily. The Therapy Director and Occupational Therapist confirmed the necessity of the splint to prevent further contractures, and the Director of Health Services expressed an expectation for staff to follow the physician's orders. The deficiency in care had the potential to result in the progression of the resident's contractures.
Deficiencies in Safety and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from potential accident hazards for its residents. One resident receiving oxygen therapy had an unsecured oxygen tank in their room, which posed a risk of tipping over and potentially exploding. Despite the resident's awareness of the risk and requests for staff to secure the tank, it remained free-standing for nearly a month. The Director of Health Services acknowledged the risk and confirmed that staff are expected to monitor rooms for safety. Another resident was found with numerous aerosol cans in their room, which is against the facility's policy. The resident was unaware of the policy, and staff interviews confirmed that aerosol cans are not permitted in resident rooms. The Director of Health Services stated that staff should remove such items and have family members retrieve them. The facility also failed to provide adequate supervision for residents at high risk for falls. One resident had a fall mat ordered but it was found leaning against the wall instead of on the floor. Another resident, who had a history of falls, was found without fall mats at the bedside. A third resident fell while attempting to use the bathroom because they could not reach the call light, and there was no indication of neuro checks being conducted post-fall. Staff interviews revealed that fall prevention measures were not consistently implemented, and the Director of Health Services expected adherence to the facility's fall protocol.
Improper Respiratory Care and Equipment Handling
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents receiving oxygen therapy, leading to potential infection risks. For one resident, oxygen masks were found uncovered and resting on the floor, and an oxygen cylinder was left free-standing in the room, posing a safety hazard. Despite the resident's awareness of the risk and requests for removal, the oxygen cylinder remained in the room for almost a month. Interviews with staff confirmed the presence of the cylinder and acknowledged the associated risks. For another resident, the oxygen tubing was not stored properly, as it was found laying across the oxygen concentrator without being bagged. The resident did not use the oxygen equipment consistently, and the tubing was not labeled when changed. Interviews with staff revealed that nurses were responsible for changing the tubing, but there was a lack of clarity on the labeling process. The Director of Health Services confirmed that not all residents required humidified oxygen and that nurses were responsible for contacting doctors if issues arose.
Failure to Provide Mental Health Services to Residents
Penalty
Summary
The facility failed to provide necessary mental health services to three residents, as required by their policy. Resident 61, diagnosed with major depressive disorder, PTSD, and depression, did not receive counseling or psychiatric services despite experiencing periods of depression and confusion. The Social Services Director (SSD) was unaware of the resident's depression and did not follow up on counseling refusals, which were not documented. The resident's care plan included a referral for psychiatric evaluation, but no such evaluation was conducted. Resident 65, with diagnoses including bipolar disorder, major depressive disorder, anxiety disorder, PTSD, and dementia, also did not receive psychiatric services after admission to the facility. Despite the care plan indicating a need for psychotropic drug monitoring and psychiatric consultation, the SSD and Director of Health Services (DHS) confirmed that no psychiatric services were provided, which could have potentially benefited the resident's quality of life. Resident 25, admitted with conditions such as anxiety disorder and depression, was taking two antipsychotic medications but had not received a psychiatric consult. The care plan noted the need for a psychiatric consultation, but the SSD did not make the referral, and the DHS confirmed that the SSD should have followed through with the referral process. The resident expressed feelings of sadness and a desire to talk to someone, highlighting the lack of mental health support provided by the facility.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Moultrie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colquitt Regional Senior Care & Rehabilitation | 1 mi | ★★★★★ | 15 | 0 |
| Pruitthealth - Sunrise | 1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Moultrie | 1.1 mi | ★★★★★ | 0 | 0 |
| Southwell Health And Rehabilitation | 20.3 mi | ★★★★★ | 5 | 0 |
| Thomasville Vistas Of Journey Llc | 22.4 mi | ★★★★★ | 25 | 0 |
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