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 Magnolia Square Nursing And Rehab during CMS and state inspections, most recent first.
A resident with chronic pain and mobility limitations, dependent on staff for toileting and transfers, reported that a CNA provided rough and aggressive care during a nighttime bathroom trip, continued a transfer despite the resident’s repeated pain complaints and a foot being caught in the wheelchair, and then got close to the resident’s face and threatened that the resident would have to use a bed pan if not transferring independently. A roommate heard banging and saw the CNA yank back covers and observed the resident in apparent pain, while another CNA shadowing at the doorway described the CNA as rude and aggressive, continuing the transfer after the resident said "you are hurting me" and arguing about bed pan use. Several other CNAs and an LPN later received consistent reports from the resident about the rough treatment and bed pan threats, and the LPN characterized the interaction as abuse based on the resident’s upset and quivering voice. These actions and statements formed the basis of a cited abuse-related deficiency for failure to protect the resident from verbal and emotional abuse.
The facility failed to maintain safe hot water temperatures in resident rooms, with temperatures ranging from 123.2°F to 129.9°F, posing a scalding risk to cognitively impaired residents. Despite facility policy requiring safe water temperatures, the issue persisted due to inadequate monitoring by the Maintenance Director. Residents involved had severe cognitive impairments, making them unable to regulate water temperatures or recognize the danger.
A facility failed to maintain effective infection control when a CNA and WN did not perform proper hand hygiene during incontinent and wound care for a resident with multiple health conditions. The staff did not change gloves or wash hands between tasks, violating the facility's hand hygiene policy.
A resident with ALS was left on the toilet for six hours, leading to an allegation of neglect that was not reported to the SSA within the required two-hour timeframe. The DON believed the facility could investigate first, contrary to policy. Staff interviews confirmed the incident should have been reported immediately.
Failure to Protect Resident From Verbal and Emotional Abuse During Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from verbal and emotional abuse during toileting and transfer assistance. The resident, who had diagnoses including thoracic spondylosis, hyperlipidemia, and osteoporosis, required partial to moderate assistance with transfers and toileting and was totally dependent on one staff member for toilet use. During a night shift, the resident used the call light for assistance to the bathroom. CNA B responded, accompanied by CNA E, and assisted the resident out of bed and into a wheelchair. During this process and the subsequent transfer back to bed, the resident repeatedly reported pain, including when the resident’s leg and foot became caught in the wheelchair, but CNA B continued the transfer. The resident reported that CNA B was rough, rude, and loud, and that the aide “flopped” the resident into the chair and continued care despite the resident’s complaints of pain and statements that the foot was caught. The resident stated that after being returned to bed, CNA B squatted down between the resident’s bed and the roommate’s bed, got close to the resident’s face, and told the resident that if the resident did not transfer independently, the resident would be put on a bed pan. The resident refused the bed pan and later described feeling scared to use the call light again that night, remaining quiet and delaying further toileting needs until day shift staff were on duty. The resident also reported hearing other residents saying “you are hurting me” and “that hurts” after the incident and expressed not wanting CNA B to return to the room. Multiple witnesses corroborated aspects of the resident’s account. The roommate reported hearing banging during the transfer, seeing CNA B yank back the bed covers and throw pillows, and observing from the resident’s facial expression that the resident was in pain, as well as seeing CNA B squat between the beds. CNA E, who was shadowing CNA B and standing at the doorway, stated that CNA B was rude and aggressive, continued the transfer after the resident said “you are hurting me,” and argued with the resident about using a bed pan, prompting CNA E to suggest they leave the room due to discomfort with CNA B’s behavior. Other CNAs reported that the resident told them CNA B had been rough, hateful, and rude, had tried to make the resident use a bed pan, and had said the resident would have to use a bed pan if the resident did not get up independently. An LPN who witnessed the resident’s later report described the resident’s voice as quivering and characterized the interaction as abuse based on its impact on the resident. These actions and statements by CNA B, in the context of the resident’s dependence for toileting and transfers and repeated pain complaints, constitute the basis for the cited abuse-related deficiency. CNA B’s own written and verbal statements acknowledged that the resident complained of pain during transfers, that the resident’s foot became caught under or in the wheelchair, and that a bed pan was suggested as an alternative because the resident was not assisting with transfers. However, the resident’s and witnesses’ descriptions emphasized that CNA B continued the transfer despite the resident’s pain complaints and used threatening and demeaning language about forcing the resident to use a bed pan if the resident did not transfer independently. The facility’s own policies defined abuse as including intimidation and actions causing mental anguish and stated a goal of maintaining an abuse-free environment. The events described, including the aggressive manner of care, continuation of care despite pain complaints, and degrading statements about bed pan use, led surveyors to identify a failure to protect the resident’s right to be free from verbal and emotional abuse.
Unsafe Hot Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding the regulation of hot water temperatures at hand sinks in resident rooms. Observations revealed that the hot water temperatures at the sinks of seven residents in the Special Care Unit ranged from 123.2 degrees Fahrenheit to 129.9 degrees Fahrenheit. These temperatures exceed the safe range and pose a risk of scalding, particularly for residents who are cognitively impaired and unable to regulate water temperatures themselves. The residents involved in this deficiency were all diagnosed with severe cognitive impairments, including Alzheimer's disease and unspecified dementia. These conditions rendered them unable to recognize or respond to the danger of excessively hot water, increasing their risk of injury. The facility's policy mandates that tap water temperatures be maintained within a safe range to prevent scalding, but this was not adhered to, as evidenced by the recorded temperatures. Interviews with facility staff, including the Maintenance Director and Certified Nurse Aide Unit Director, confirmed that the residents would not be able to regulate the water temperatures and might not know to pull their hands away from hot water to avoid scalding. The Maintenance Director admitted to not increasing monitoring of water temperatures after a plumbing company serviced the facility's water system, which contributed to the ongoing issue of unsafe water temperatures.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices during incontinent and wound care for a resident. The incident involved a Certified Nursing Assistant (CNA) and a Wound Nurse (WN) who did not adhere to the facility's hand hygiene policy. The policy mandates hand hygiene before and after direct contact with residents, before handling clean or soiled dressings, and when moving from a contaminated body site to a clean body site. During the care of a resident with a history of congestive heart failure, respiratory failure, diabetes, and chronic kidney failure, the WN and CNA did not perform hand hygiene between glove changes and handled soiled materials improperly. The observation revealed that the WN and CNA performed incontinent care and wound care without changing gloves or performing hand hygiene as required. The WN handed soiled wipes across the resident's chest and cleaned the resident's buttocks and anal area towards an exposed wound without changing gloves. After removing the soiled brief, the WN applied new gloves without hand hygiene and continued to cleanse the wound. The CNA adjusted the resident's pillow and clothing without changing gloves or performing hand hygiene. Interviews with the WN, CNA, and Infection Preventionist confirmed the failure to follow proper hand hygiene protocols during the care process.
Failure to Report Alleged Neglect in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of possible neglect within the required two-hour timeframe to the State Survey Agency (SSA). A resident, who was diagnosed with amyotrophic lateral sclerosis (ALS) and had significant impairments in mobility and communication, was reportedly left on the toilet from approximately 2:00 A.M. until 8:00 A.M. The resident's durable power of attorney (DPOA) informed the Director of Nursing (DON) about the incident, expressing concern over the prolonged period the resident was left unattended and potential skin compromise. The facility's policy mandates that all allegations of neglect be reported promptly to the SSA, yet the DON did not report the incident, believing that the facility could conduct its own investigation first. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), confirmed that leaving a resident on the toilet for such an extended period would be considered neglect and should have been reported immediately. The facility's grievance log showed that the DPOA filed a grievance regarding the incident, but there was no documentation of the facility notifying the SSA. The Administrator acknowledged that all allegations of abuse or neglect should be reported to the SSA within two hours and that the DON should have reported the incident as neglect. The failure to report the incident in a timely manner was a clear violation of the facility's policy and state regulations, as confirmed by interviews with the DON and other staff members.
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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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springfield Rehabilitation & Health Care Center | 0.3 mi | ★★★★★ | 0 | 0 |
| Maples Health And Rehabilitation, The | 0.7 mi | ★★★★★ | 0 | 0 |
| Manor At Elfindale, The | 1.2 mi | ★★★★★ | 10 | 0 |
| Birch Pointe Health And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Springfield Villa | 1.8 mi | ★★★★★ | 10 | 1 |
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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.