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 Creek Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A resident with diabetes, intact cognition, and partial to moderate ADL dependence had thick, overgrown toenails that had not been trimmed despite the resident repeatedly telling staff they needed cutting. Nursing notes over several months contained no indication that toenail care was needed or that a podiatry referral was made, and the facility lacked a nail care policy. The DON reported that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services enrolled residents for podiatry, but the podiatrist had not provided services in the facility for several months. The ADON stated staff tried to cut the resident’s toenails, yet no documentation of this attempt existed.
A facility failed to investigate an alleged resident-to-resident abuse incident where a resident with intact cognition and certain medical conditions reported feeling afraid after another resident entered their room, shook their bed, and made threatening gestures. Despite the incident being reported to the police and facility staff, no thorough investigation was conducted, and the facility's response was limited to staff education on preventing the second resident from wandering.
A facility failed to update a care plan for a resident with increased wandering and exit-seeking behaviors. Despite an elopement band and staff redirection, the care plan lacked documentation of these behaviors. Observations and reports confirmed the resident's continued wandering and intrusion into other residents' rooms, which was not reflected in the care plan. An LPN confirmed that such behaviors should be included in the care plan.
A facility failed to ensure a call light was within reach for a legally blind resident, who required moderate assistance with daily activities. The resident, a fall risk, expressed frustration at being unable to locate the call light while sitting in a recliner. A CMA confirmed the call light was out of reach, noting the resident sometimes yelled for help when needed.
A resident with legal blindness reported that their bed had not been made for several days, and there were pillows without pillowcases. An extra mattress was improperly stored in the room, which was confirmed by a CMA who noted the resident was a fall risk.
A resident with a surgical wound on the right hip did not receive wound care as per physician orders, which specified the use of a silver dressing. The facility staff used a different dressing, causing skin breakdown, due to a misunderstanding about the availability of the silver dressing. The resident reported that the staff cited cost as a reason for not using the prescribed dressing, despite it being provided by the hospital.
A resident was discharged with medications not prescribed to them, including those belonging to another resident. The facility lacked a policy for medication dispensing at discharge, leading to the error. The resident reported the issue, and the facility later retrieved the incorrect medications.
A resident with congestive heart failure and edema experienced a significant weight gain of 36 pounds over 15 days, but the facility failed to notify the physician as required by policy. Despite the resident's condition and documented edema, the physician was only informed after a nurse's progress note indicated severe edema. This represents a deficiency in the facility's communication and adherence to its policies.
Three residents with significant medical conditions, including dementia and Alzheimer's, were left without necessary care for extended periods, despite being dependent on staff for activities of daily living. Observations revealed that these residents were not checked on or provided with required care every two hours, as stipulated in their care plans. Staff interviews confirmed the lack of timely care, and the DON acknowledged the deficiency.
A resident with congestive heart failure experienced a significant weight gain of 36 pounds over 15 days, but the facility failed to notify the physician in a timely manner or conduct necessary assessments. Despite persistent edema and discomfort, the resident's condition was inadequately monitored, leading to a hospital admission for CHF exacerbation.
The facility failed to provide adequate staffing, resulting in delayed care for residents. Observations showed residents with dementia and incontinence were left without care for extended periods, and staff confirmed that insufficient aides made it impossible to meet care requirements. Residents and family members reported long wait times for assistance, and the DON admitted that the standard of quality care was not being met.
The facility failed to maintain infection control measures for several residents, including improper glove changes and lack of enhanced barrier precautions. An LPN did not sanitize hands between glove changes for a resident with pressure ulcers, and CNAs did not change gloves during peri care for another resident. Additionally, a resident with an indwelling catheter was not placed on enhanced barrier precautions upon returning from the hospital, and a CNA did not wear a gown during catheter care.
A resident with paraplegia and high blood pressure experienced a decline in their ability to perform ADLs, requiring more assistance over time. Despite this decline, the facility did not complete a significant change assessment, as confirmed by the ADON during a review.
The facility failed to allow a resident to return after hospitalization, lacking a written policy on post-hospitalization returns. The resident, with multiple diagnoses, was emergency discharged due to harmful behaviors. The facility did not provide a signed discharge notice or physician summary, and the hospital was unaware of the discharge status.
Failure to Provide and Document Necessary Toenail Care
Penalty
Summary
The facility failed to provide appropriate toenail care for one resident when surveyors observed the resident’s toenails to be thick, overgrown, and approximately half an inch long. The resident, who had intact cognition with a BIMS score of 13, had been admitted with diagnoses including diabetes mellitus and required partial to moderate assistance with most ADLs. A significant change assessment documented these needs, yet nurse’s notes from late August through January contained no indication that the resident’s toenails required cutting or that a podiatry referral was needed. The resident reported that their toenails had needed cutting since admission and that they had informed staff on multiple occasions. The facility had no policy related to nail care, and although the DON stated that LPNs were expected to assess toenails weekly as part of skin assessments and that nursing and social services were responsible for signing residents up for podiatry services, there was no documentation that this occurred for this resident. The podiatrist reported that services were last provided in the facility several months earlier, and the ADON stated staff had attempted to cut the resident’s toenails but this was not documented. These combined observations and record reviews showed that the facility did not ensure toenail care was provided or documented for this resident in accordance with their needs and stated practices.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an incident of alleged resident-to-resident abuse involving a resident with intact cognition and diagnoses including cerebral infarction, insomnia, and depressive disorder. The incident involved another resident entering the first resident's room, shaking their bed, and making threatening gestures, which caused the first resident to feel afraid. Despite the incident being reported to the police and the facility's Director of Nursing (DON) and administrator, the facility did not conduct a thorough investigation as required by their policy. The police advised keeping the residents separated, but the facility's response was limited to educating staff about preventing the second resident from wandering into the first resident's room. The facility's policy mandates a thorough investigation of any alleged abuse, including completing an incident report and obtaining information about the incident. However, the facility did not interview other residents or staff related to the incident, and the administrator and DON did not consider the incident as abuse. The lack of a comprehensive investigation and failure to follow the facility's policy on abuse allegations led to the deficiency identified in the report.
Failure to Update Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to update a resident's care plan to address wandering behavior, which was identified as a deficiency. Resident #2, who had diagnoses including depression, exhibited increased wandering and exit-seeking behaviors as noted in a behavior note dated 08/06/24. Despite the presence of an elopement band and staff redirection, the care plan dated 09/06/24 did not document any care areas related to wandering or elopement behaviors. A comprehensive assessment on 09/23/24 inaccurately documented the resident as having severely impaired cognition and no behaviors. Subsequent observations and reports on 11/04/24 and 11/05/24 confirmed the resident's continued wandering and intrusion into other residents' rooms, which was not reflected in the care plan. An LPN confirmed that wandering and elopement behaviors should be included in a resident's care plan.
Failure to Ensure Call Light Accessibility for Blind Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident with legal blindness, leading to a deficiency in accommodating the resident's needs and preferences. The resident, who had a diagnosis of severe vision impairment and required moderate assistance with activities of daily living, was observed sitting in a recliner with the call light placed by the side of their drawer, out of reach. The resident expressed frustration at being unable to locate the call light when they needed assistance. A Certified Medication Aide (CMA) confirmed that the resident, who is a fall risk, sometimes used the call light or yelled for help when assistance was needed. The CMA also observed that the call light was indeed out of the resident's reach.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a homelike environment for a resident diagnosed with legal blindness. On September 5th, the resident reported that their bed had not been made for several days, and there were two pillows without pillowcases along with two personal pillows. Additionally, an extra mattress was improperly stored in the resident's room by a wall table. A Certified Medication Aide (CMA) confirmed the resident's bed was unmade and expressed uncertainty about the presence of the extra mattress, noting that the resident was a fall risk.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to perform wound care according to physician orders for a resident with a right femur fracture, who was admitted with a surgical wound on the right hip. The physician had ordered the use of a silver dressing every five days or as needed until healed. However, the treatment administration record showed that the silver dressing was applied only once, and there was no documentation for its use on a subsequent date. The resident's medical record lacked any new wound care orders or reasons for not using the silver dressing as prescribed. During a physician visit, it was noted that the resident had a saturated gauze dressing instead of the ordered silver dressing, which was causing skin breakdown. The resident reported that the facility staff did not use the silver dressing due to its cost, despite having been provided with it by the hospital. An LPN confirmed that the facility typically used the silver dressing when ordered and that any deviation from the prescribed treatment should have been documented. The DON later reported that the nurse responsible for the resident's care was unaware of the availability of the silver dressings and used a different dressing until the resident's doctor's appointment.
Medication Dispensing Error at Discharge
Penalty
Summary
The facility failed to accurately dispense medication to a resident being discharged, leading to a significant medication error. The resident, who had undergone a right artificial hip replacement and had intact cognition, was discharged with medications that were not prescribed to them. The discharge summary indicated that the resident and their husband were given medications and educated on administration times. However, the medications sent home included several that were not ordered for the resident, such as Eliquis, Levothyroxine, Hydralazine, Loperamide, and Atarax. This error was discovered when the resident reported receiving another resident's medication along with their own. The facility lacked a policy related to medication dispensing at discharge, which contributed to the oversight. The Certified Medication Aide (CMA) involved admitted that the resident was discharged with medications left in stock, and another resident's medication was mistakenly included in the same bin. The CMA acknowledged that each package should have been checked against the resident's discharge orders. The Director of Nursing (DON) confirmed that the error was reported by the resident and that the medication was eventually picked up by the facility. The DON also noted that the discharge nurse should have reconciled the medications before the resident left the facility.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain in a resident diagnosed with congestive heart failure and edema. The resident experienced a severe weight gain of 36 pounds, or 17.24%, over a 15-day period. Despite the facility's policy requiring physician notification for significant weight changes, there was no documentation that the physician was informed of this weight gain. The resident's weight was recorded as 208.8 pounds on May 23 and increased to 244.8 pounds by June 7. A subsequent weight check on June 12 showed a slight decrease to 240.2 pounds, but the weight gain remained significant at 31.4 pounds, or 15.04%, since May 23. The Director of Nursing (DON) acknowledged that the physician had not been notified in a timely manner, despite the resident's condition of heart failure and documented edema. The DON stated that the physician was only asked to see the resident on June 13, following a nurse's progress note indicating 4+ pitting edema and edema to the forearm. The DON confirmed that the physician had not been notified earlier, even when the resident exhibited 3+ edema to the lower legs and arms. This lack of timely communication with the physician represents a deficiency in the facility's adherence to its own policies and procedures regarding significant changes in a resident's condition.
Failure to Provide Timely Care for Dependent Residents
Penalty
Summary
The facility failed to provide timely assistance with care for three residents who were dependent on staff for activities of daily living. Resident #12, diagnosed with dementia, anxiety, major depression, hypertension, and hyperlipidemia, was observed from 5:00 a.m. to 9:10 a.m. without receiving any care, despite being incontinent and requiring assistance for toileting and hygiene. The care plan indicated that incontinent care should be provided every two hours, but Resident #12 was left in a geri-chair for over four hours without care. Resident #18, with Alzheimer's, a history of falling, osteoarthritis, chronic atrial fibrillation, and dysphagia, was also observed from 5:00 a.m. to 9:27 a.m. without receiving care. The resident was dependent on staff for toileting and hygiene, requiring two staff members for assistance. Despite the care plan's requirement for care every two hours, Resident #18 was left in a geri-chair for over four hours without any staff intervention. Resident #36, diagnosed with anemia, congestive heart failure, depression, anxiety, and dementia, was observed from 5:00 a.m. to 10:10 a.m. without receiving care. The resident was dependent on staff for toileting and hygiene, requiring two staff members for assistance. Despite the care plan's requirement for care every two hours, Resident #36 was left in a geri-chair for over five hours, resulting in dried feces on their buttocks. Staff interviews confirmed that care was not provided as required, and the Director of Nursing acknowledged the deficiency.
Failure to Monitor and Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to adequately assess and monitor a resident who experienced a significant weight gain of 36 pounds, equating to a 17.24% increase over 15 days. The resident, who had a diagnosis of congestive heart failure and edema, was not re-weighed or had their physician notified in a timely manner as per the facility's policy. The resident's weight increased from 208.8 pounds to 244.8 pounds, and there was no documentation of the physician being informed of this severe weight gain. Despite the resident's condition, including persistent bilateral leg pain and significant peripheral edema, the facility did not conduct necessary assessments such as vital signs, lung sounds, or edema evaluations. The physician was eventually notified and ordered an increase in Lasix dosage, but the nursing staff failed to document assessments for worsening symptoms on several occasions. The resident continued to experience severe edema and discomfort, with no timely intervention or monitoring documented. The deficiency was further highlighted when the resident was eventually sent to the emergency room for evaluation and treatment after the physician was notified of the continued weight gain. The resident was admitted to the hospital for a congestive heart failure exacerbation. The facility's lack of timely notification to the physician and inadequate monitoring of the resident's condition contributed to the deficiency identified in the report.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, as evidenced by observations, record reviews, and interviews. The staffing sheets from June 7 to June 21, 2024, indicated that during the 6:00 p.m. to 6:00 a.m. shift, there was only one nurse and two aides available for the long-term care side on several dates. This staffing level was inadequate to provide the necessary care for the facility's census of 77 residents. Several residents were observed to have gone without care for extended periods. Resident #12, who had diagnoses including dementia and incontinence, was left without care for over four hours. Similarly, Resident #18, with Alzheimer's and a history of falls, was not attended to for over four hours. Resident #36, who required extensive assistance due to dementia and decreased mobility, was left without care for over five hours, resulting in dried feces on their buttocks. Staff interviews confirmed that the lack of sufficient aides made it impossible to provide care every two hours as required. Additional interviews with residents and family members highlighted the impact of inadequate staffing. Residents reported long wait times for call lights to be answered and delays in receiving assistance, such as repositioning or receiving water. A resident group meeting further confirmed that the majority of residents experienced delays in care, particularly during night shifts. The Director of Nursing acknowledged that the facility only followed state guidelines for staffing and admitted that the standard of quality care was not being met.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control measures during the provision of care for several residents. For Resident #4, who had severe cognitive impairment and was dependent on staff for activities of daily living, the facility did not adhere to enhanced barrier precautions during wound care. An LPN was observed not sanitizing their hands between glove changes and not changing gloves after providing incontinent care, despite the resident being incontinent of bowel during the procedure. Additionally, there were no gowns or gloves available behind the resident's door for enhanced barrier precautions. Resident #9, who had a recent urinary tract infection and an indwelling catheter, was not placed on enhanced barrier precautions upon returning from the hospital. The door to the resident's room was not marked to alert staff to use enhanced barrier precautions, and no gowns or gloves were supplied. The IP nurse acknowledged a breakdown in the process for enhanced barrier precautions, as the signs were not put back up after the resident's return from the hospital. For Resident #32, who was frequently incontinent of bowel and urine, CNAs were observed not changing gloves during the provision of peri care. One CNA used a wipe to clean their gloves after applying ointment, and another did not change gloves after cleaning the resident's buttocks. Additionally, Resident #42, who had an indwelling catheter, was not provided with proper PPE during catheter care. A CNA was observed emptying the resident's catheter without donning a gown, despite enhanced barrier precautions being in place.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced a decline in their ability to perform activities of daily living (ADLs). The resident, who had diagnoses including paraplegia and high blood pressure, was initially assessed as being independent with oral hygiene and requiring varying levels of assistance with other ADLs. However, a subsequent quarterly assessment showed a decline, with the resident needing more assistance in multiple areas, including substantial maximal assistance with lower body dressing. Despite this decline in two or more areas, the facility did not complete a significant change assessment, as confirmed by the Assistant Director of Nursing (ADON) during a review of the assessments.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, violating the requirement to permit residents to return post-hospitalization or therapeutic leave. The resident, admitted with diagnoses including peripheral vascular disease and depressive disorder, was cognitively intact and exhibited no behaviors until an incident on 12/26/23. On that date, the resident displayed harmful behaviors, including combative actions, lighting fires, and making false emergency calls, leading to an emergency discharge to the hospital by police. The facility did not have a written policy on permitting residents to return after hospitalization or therapeutic leave, and the discharge notice was not signed by the resident. Additionally, the facility did not provide a discharge summary signed by a physician in the resident's medical record. The facility's administrator confirmed the emergency discharge due to the resident being a danger to himself and others, and acknowledged the lack of a policy on involuntary discharges. The hospital case manager reported being unaware of the resident's discharge status and was informed by the facility that the resident could not return due to unmet needs. The case manager also noted the resident's desire to return to the facility and the difficulty in finding alternative placement. The Administrative Law Judge overruled the involuntary discharge, citing non-compliance with federal regulations regarding written notice.
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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 Altus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| English Village Skilled Nursing And Therapy | 1 mi | ★★★★★ | 0 | 0 |
| Mangum Skilled Nursing And Therapy | 18.4 mi | ★★★★★ | 0 | 0 |
| Ayers Nursing Home | 20.7 mi | ★★★★★ | 0 | 0 |
| Hobart Nursing & Rehabilitation | 28.5 mi | ★★★★★ | 4 | 0 |
| Colonial Manor Ii | 34.1 mi | ★★★★★ | 2 | 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.