Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Gardens Center For Nursing And Rehabilita during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least 8 consecutive hours per day on multiple occasions, as confirmed by staffing records and staff interviews. Staffing challenges, including difficulties in hiring RNs and the absence of a Staffing Coordinator, contributed to the deficiency. The DON and Administrator acknowledged the issue and confirmed that agency staff were not used.
A resident with significant medical conditions had a physician-ordered change in advance directive status from Full Code to DNR, which was documented in multiple records but not updated in the care plan. Staff interviews and record reviews confirmed the care plan continued to reflect outdated information, and the DON acknowledged the care plan should have been revised to match the physician's order.
A resident with severe cognitive impairment and multiple medical conditions was admitted to hospice and received hospice care, but there was no physician order for hospice services found in either the electronic medical record or the hospice binder, as confirmed by staff interviews.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental risks and insufficient staff monitoring.
A resident reported inappropriate touching by a male staff member to a Nursing Assistant, who informed a Staff Nurse. However, the Staff Nurse did not investigate or report the allegation. The Occupational Therapist later documented the allegation, but the Administrator failed to read and act on the report promptly, delaying notification to authorities and protective measures. The alleged perpetrator was not suspended until police intervention.
A resident with a suprapubic urinary catheter did not receive the prescribed catheter flushes due to an error in transcribing the nephrology order. The order was incorrectly entered as a one-time flush instead of every 12 hours, resulting in only one flush being performed. Despite the oversight, the resident showed no signs of a UTI.
The facility failed to maintain the dignity of residents by not answering call bells in a timely manner. One resident reported waiting up to two hours, resulting in sitting in urine and bowel movements. Another resident with Parkinson's Disease and dementia experienced delays and expressed frustration. A third resident with heart failure and COPD also reported waiting 30 minutes for assistance. The DON was unaware of the wait times and emphasized that call lights should be answered promptly by all staff.
The facility failed to address and communicate efforts to resolve concerns raised during Resident Council meetings over eight consecutive months. Residents repeatedly complained about inadequate ADL care, slow call light response times, and cold food, but there was no evidence of follow-up or resolution. Interviews confirmed that these issues were not addressed, and the previous Activities Director responsible for communicating these concerns was no longer employed.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in Resident Rights and Reasonable Accommodation of Needs. Issues included not answering call bells for residents needing ADL assistance, not providing privacy cover for a urinary catheter, and failing to place call lights within reach. Additionally, a dependent resident was not provided with an appropriate wheelchair.
The facility failed to place call lights within reach for two residents, preventing them from requesting assistance. One resident with severe cognitive impairment and a history of falls had his call bell tied out of reach, while another resident with chronic osteomyelitis and difficulty walking found her call bell on the floor behind a box. Staff did not ensure proper call bell placement as required by their care plans.
A resident with severe cognitive impairment and a history of falls experienced a fall while attempting to move backward in her wheelchair. The facility failed to conduct a root cause analysis or an at-risk meeting to address the incident, as confirmed by the DON.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days per week, as required by federal regulations. Record reviews and staff interviews confirmed that on 13 out of 36 days reviewed, there was no RN coverage for the required duration. Staffing data from the CMS Payroll-Based Journal (PBJ) system and the facility's own nurse staffing sheets documented these lapses on specific dates. The Scheduling Coordinator, who had only recently started in her role, was unable to explain the lack of RN coverage for the listed dates and acknowledged awareness of the regulatory requirement. She also noted ongoing difficulties in hiring RNs. The Director of Nursing (DON) confirmed the accuracy of the PBJ report and the facility's staffing records, stating that the facility had been without a Staffing Coordinator for several months, during which time the DON managed the nursing schedule. The DON and the Administrator both cited challenges in recruiting RNs, particularly for weekend shifts, and confirmed that the facility did not use agency staff. The Administrator was not aware that the facility was not meeting the federal RN coverage requirement until the issue was brought to his attention.
Failure to Update Care Plan Following Change in Advance Directive Status
Penalty
Summary
The facility failed to revise the care plan for a resident after a change in advance directive status from Full Code to Do Not Resuscitate (DNR), as ordered by the physician. The resident, who had diagnoses including sequelae of cerebrovascular disease and malignant neoplasm of a urinary organ, had a MOST form and medical transfer form both indicating DNR status. However, the care plan continued to document the resident as Full Code, despite the physician's order and supporting documentation reflecting the DNR status. Record reviews and staff interviews confirmed that the care plan was not updated to reflect the change in advance directive status. The Director of Nursing acknowledged that the care plan should have been revised when the physician's order changed the resident's status, and that the MDS Nurse was responsible for updating the care plan upon notification of such changes. The deficiency was identified through review of documentation and staff interviews, which revealed a lack of timely revision to the care plan in accordance with the resident's current advance directive status.
Lack of Physician Order for Hospice Services
Penalty
Summary
The facility failed to ensure that a resident admitted with multiple diagnoses, including stroke with right-sided hemiplegia and hemiparesis, vascular dementia, and adult failure to thrive, had a physician's order for hospice services. Documentation showed that the resident was admitted to hospice and was receiving regular hospice care and services, as indicated by hospice nurse progress notes and a Minimum Data Set (MDS) assessment, which coded the resident for hospice services. However, a review of the resident's medical record revealed that there was no physician order for hospice services present. Interviews with facility staff, including a unit manager and the DON, confirmed that hospice orders should be placed in the electronic medical record by the ordering provider, and that sometimes written orders could be kept in a hospice binder at the nurses' station. Despite these procedures, both the hospice binder and the electronic medical record lacked the required physician order for hospice services for this resident. The administrator also confirmed that residents receiving hospice care should have an order in the electronic medical record.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedure effectively, resulting in a delay in reporting an allegation of sexual abuse. A resident reported to a Nursing Assistant (NA) that she was inappropriately touched by a male staff member. The NA informed a Staff Nurse, but the Staff Nurse did not take further action to investigate or report the allegation. The Director of Nursing (DON) was also unaware of the situation until several days later, indicating a breakdown in communication and reporting procedures. The Occupational Therapist (OT) was informed by the resident of the alleged abuse and took the resident to the Admission's Coordinator, who documented the allegation and informed the Administrator. However, the Administrator did not read the statement immediately and failed to report the incident within the required timeframe. This oversight led to a delay in notifying law enforcement, Adult Protective Services, and the State Agency, as well as a delay in initiating protective measures and an investigation. The alleged perpetrator, a male Nursing Assistant, was not suspended until several days after the initial report was made to the Administrator. The facility only took action after the police arrived to investigate the report of abuse. This series of inactions and delays highlights the facility's failure to adhere to its own policies and procedures for handling allegations of abuse, resulting in a significant delay in addressing the resident's allegations and ensuring her safety.
Failure to Transcribe Catheter Flush Order Correctly
Penalty
Summary
The facility failed to correctly transcribe a nephrology order for a resident with a suprapubic urinary catheter, leading to a deficiency in care. The resident, who was diagnosed with neurogenic bladder, had an order from a nephrology consultation to flush the catheter with 15 to 30 milliliters of sterile saline every 12 hours. However, the order was incorrectly entered into the system as a one-time order, resulting in only one flush being performed. This error affected the resident's care, as the catheter was not flushed as frequently as prescribed. Interviews with the resident, staff, and nurse practitioner revealed that the resident was aware of the order and had requested the flushes, but they were not performed. The Assistant Director of Nursing and the Corporate Nurse Consultant confirmed the error in the order entry, which led to the absence of a standing order for the catheter flushes in the Medication Administration Record. Despite the oversight, the resident did not exhibit signs or symptoms of a urinary tract infection during the period when the flushes were missed.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to maintain the dignity of residents by not answering call bells in a timely manner, which was evident for three residents. Resident #10, who has chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, diabetes mellitus, and osteoarthritis, reported waiting up to two hours for her call light to be answered, resulting in her sitting in urine and bowel movements. This issue was also noted in Resident Council minutes over several months, indicating a recurring problem with call light response times and ADL care by Nursing Assistants (NAs). The Assistant Director of Nursing (ADON) acknowledged pulling NA #1 for other duties, but the Director of Nursing (DON) was unaware of the wait times and emphasized that call lights should be answered promptly by all staff. Resident #3, who has Parkinson's Disease, diabetes mellitus, and dementia, also experienced delays in call light responses. During an observation, NA #2 was seen sitting at the nurses' station while call lights were activated. NA #2 admitted to assuming another NA would handle the call lights. Resident #3 reported waiting up to 30 minutes for assistance and expressed frustration and helplessness due to the delays. The DON reiterated that all staff are expected to respond to call lights in a timely manner. Resident #4, who has heart failure, COPD, difficulty walking, and a history of falls, similarly experienced delays in call light responses. During an observation, NA #2 was again noted sitting at the nurses' station while call lights were activated. Resident #4 reported waiting 30 minutes for assistance and expressed anger and upset over the delays. The recurring issues with call light response times were documented in Resident Council minutes, and the ADON confirmed pulling NA #1 for other duties, expecting other NAs to cover the section.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to communicate its efforts to address concerns raised during Resident Council meetings and to resolve repeat concerns over a period of eight consecutive months. The Resident Council minutes from September 2023 to April 2024 consistently documented residents' complaints about Nursing Assistants (NAs) not providing adequate activity of daily living (ADL) care, slow call light response times, and food being served cold. However, there was no evidence that the facility reviewed or discussed its responses to these concerns in subsequent meetings. Additionally, the facility's concern log did not document any concerns from the Resident Council during this period. Interviews with the Administrator and Resident Council leaders confirmed that the concerns were not addressed, and the previous Activities Director, who was responsible for communicating these concerns, could not be reached for comment. Residents expressed frustration over the lack of feedback and resolution regarding their complaints. The Resident Council President and Co-President specifically mentioned issues with NAs not adhering to the bath schedule, leaving residents soiled for extended periods, and congregating at the nurses' station instead of starting work on time. The Administrator was unaware that these concerns had not been addressed, indicating a breakdown in communication and follow-up within the facility's management. The previous Activities Director, who was supposed to relay these concerns to the appropriate department heads, was no longer employed at the facility, further complicating the issue.
Repeated Deficiencies in Resident Rights and Accommodation of Needs
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that were put into place following the recertification and complaint investigation surveys. This failure was evident in two areas: Resident Rights/Exercise of Rights and Reasonable Accommodation of Needs/Preferences. Specifically, the facility did not answer call bells for residents needing extensive assistance with activities of daily living (ADLs), affecting three residents. Additionally, the facility did not provide privacy cover over a urinary catheter drainage bag for one resident during a previous survey. These issues were cited during the recertification and complaint surveys and were repeated in subsequent surveys, indicating a pattern of non-compliance. The facility also failed to place call lights within reach for two residents, preventing them from requesting staff assistance. In another instance, the facility did not provide a dependent resident with a wheelchair to accommodate her size and inability to sit up, forcing staff to borrow a wheelchair from another resident. These deficiencies were observed during both the recertification and complaint surveys and were repeated in subsequent surveys. The Administrator acknowledged the repeated citations but believed that the current interventions were effective for the issues previously cited.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to place the call lights within reach for two residents, Resident #5 and Resident #7, which prevented them from requesting staff assistance. Resident #7, who has severe cognitive impairment and requires assistance with activities of daily living (ADLs), was observed with his call bell tied to the bottom of the grab rail, out of his reach. Despite staff indicating that they check call bell placement, it was confirmed that the call bell was not within reach during the observation. Resident #7 has a history of falls and requires prompt assistance, making the inaccessibility of the call bell a significant issue. Resident #5, who has chronic osteomyelitis and difficulty walking, was also found with her call bell out of reach, located on the floor behind a box at the head of her bed. Despite having intact cognition and requiring assistance with ADLs, Resident #5 was unable to locate her call bell and stated it had been out of reach for a while. Staff interviews confirmed that the call bell was not checked for proper placement, even though it is a part of the care plan to ensure it is within reach. Both residents' care plans emphasize the importance of having the call bell within reach to prevent falls and ensure timely assistance, which was not adhered to in these instances.
Failure to Investigate and Analyze Resident Fall
Penalty
Summary
The facility's administration failed to investigate and complete a root cause analysis for a fall involving a resident diagnosed with a disorder of the brain, repeated falls, and paranoid schizophrenia. The resident, who had severely impaired cognition and required assistance for mobility, experienced a fall while attempting to move backward in her wheelchair. Despite the incident being documented, there was no evidence of an at-risk meeting or a root cause analysis being conducted to address the fall and implement effective interventions to prevent recurrence. The Director of Nursing (DON) confirmed that falls are typically discussed in morning meetings and documented in nursing notes, but acknowledged that no at-risk meeting or root cause analysis was conducted for this particular fall. The lack of documentation and follow-up on the fall incident indicates a failure in the facility's process for addressing and mitigating fall risks, leaving the resident vulnerable to future accidents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 245 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Thomasville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Ridge Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Piedmont Crossing | 4.1 mi | ★★★★★ | 0 | 0 |
| Westchester Manor At Providence Place | 4.1 mi | ★★★★★ | 3 | 0 |
| Meridian Center | 5.8 mi | ★★★★★ | 9 | 2 |
| Westwood Health And Rehabilitation | 6.2 mi | ★★★★★ | 18 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Magnolia Gardens Center For Nursing And Rehabilita.
100% money-back within 48 hours.
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.