Magnolia Ridge: Staff Threw Ashtray at Resident - AL
The July 25, 2023 incident at Magnolia Ridge triggered an immediate jeopardy citation from federal inspectors who found the 132-bed facility failed to protect residents from mistreatment in multiple cases spanning more than a year.
The resident who was struck, identified in inspection records as RI #60, had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and major depressive disorder. The 83-year-old had a care plan specifically addressing verbal outbursts and cursing directed at staff and other residents.
According to progress notes from Licensed Practical Nurse #27, the incident began when RI #60 "had thrown (an) ash tray at a staff member and it hit (RI #287) on the right side of (his/her) head and ear." But investigators later discovered the initial report was backwards.
"CNA #41 was the one that threw the ashtray first," LPN #27 told inspectors during interviews in March 2025, nearly two years after the incident. The nurse explained that RI #60 was "talking to people not present and might have been talking to the voices in his/her head."
CNA #41 had worked with RI #60 before and "knew how to deal with RI #60's behaviors," LPN #27 said. "She was a seasoned CNA and knew how to deal with aggressive residents." But instead of following protocol to walk away from verbal aggression, "she triggered him/her."
The facility's own behavioral health policy required staff to "interact and communicate in a manner that promotes mental and psychosocial well being" and to "remove resident/patient from environment, if needed" while "speaking in a calm, reassuring voice."
CNA #40 told inspectors that someone confronted by a caregiver throwing an ashtray would experience "fear and most likely increase agitation." The protocol for RI #60's known behaviors was clear: "walk away, ignore the behavior, and report it to the nurse."
Nurse Educator RN #18 said the aide's response was completely inappropriate. "The staff should have walked away if they were getting upset and certainly should not have acted aggressive back toward the resident and thrown anything." The harm included "potential for physical injury to the resident or anyone around" while "aggravating the situation and made it worse by escalating the behavior."
Administrator interviews revealed the facility substantiated the incident as mistreatment. CNA #41 "intended to strike RI #60 by throwing an ashtray," the current administrator said. Staff witnessing such behavior "should act to protect the resident at all times and report the incident immediately."
The Former Administrator described how CNA #41 "became upset and reacted by throwing the ashtray" after RI #60 cursed at her. "Someone could get hurt when staff became upset and responded by throwing an ashtray at a resident," she said.
LPN #27 characterized CNA #41's action as "mental abuse" that "would have made RI #60 feel upset and angry."
But the ashtray incident was not isolated. Federal inspectors documented two other serious cases of resident-to-resident violence that the facility failed to prevent through proper behavioral interventions.
On May 24, 2023, RI #487 got into a verbal altercation with a dietary aide who told the resident "he would whip their ass." The resident, who had vascular dementia with behavioral disturbance and a history of verbal outbursts, cursed at the Dietary Manager Assistant when denied a grilled cheese sandwich.
Despite RI #487 exhibiting behaviors nine out of 31 days in May 2023, the facility never updated the resident's care plan after the kitchen incident.
Social Services Assistant #19 later told inspectors the May incident "should have been documented in RI #487's care plan and nurses' notes, but she did not see it documented." The lack of documentation meant staff couldn't learn "what may trigger him/her" or "how to handle resident's care."
"Had the incident on 05/24/2023 been documented appropriately it could have possibly prevented the incident on 07/01/2023," she said.
On July 1, 2023, RI #487 became angry when roommate RI #41 allegedly yelled at him for turning on a television. RI #487 "walked over to (RI #41's) side of the room, where (RI #41) was in the bed, and hit (him/her) on the fist with (his/her) fist and twisted (RI #41's) left hand."
Hospital records documented RI #41 was admitted for "ASSAULT" with an "acute fracture of the ring finger." The facility's investigation found RI #487 struck his roommate's hand and twisted it, requiring surgical repair.
Social Worker #17 said she was unaware of the May kitchen incident and "was only aware of the incident that occurred on 07/01/2023." She wasn't notified of prior altercations between the roommates, preventing intervention that might have included a room change.
A third violent incident occurred September 12, 2024, when RI #339 stabbed roommate RI #3 in the left hand with an ink pen, requiring three stitches. The attacker was a military veteran with post-traumatic stress disorder and depression who had been exhibiting escalating behaviors for months.
RI #339's progress notes documented throwing a phone at staff, giving managers "the middle finger," and refusing care. An August psychiatric evaluation noted the resident "threw a phone across (his/her) room" and experienced "night terrors" and "flashbacks" of "shooting people."
Despite these warning signs, RI #339's care plans addressed only verbal behaviors and included no guidance for physical aggression, night terrors, or the level of supervision needed to protect roommates.
On the night of the stabbing, RI #339 had "refused to go to bed after telling the CNA (he/she) was ready to go to bed. Cursed and yelled at the CNA and then went back outside." Less than two hours later, the pen attack occurred.
RI #3 told inspectors he "tried to defend himself/herself from the roommate" and "was scared" during the attack. RI #339's written statement described accusing his roommate of stealing items, then stabbing him when the victim "rolled (his/her) wheelchair towards me."
The facility took immediate corrective actions for all three incidents, including terminating staff involved in the ashtray throwing, providing one-on-one supervision for aggressive residents, and conducting facility-wide abuse prevention training. Multiple residents were transferred to psychiatric facilities for evaluation.
However, inspectors noted the pattern revealed systemic failures in behavioral health assessment and intervention. The facility's own policies required comprehensive behavioral care plans and staff training to prevent exactly these types of incidents.
Social Services Assistant #19 summarized the core problem: "Not communicating or documenting behaviors could lead to other behaviors and aggression that may impact residents." When new staff arrived, they needed awareness of resident behaviors "for protection of all."
RI #487 was ultimately discharged home in September 2023 with recommendations to continue psychiatric services. RI #339 never returned to the facility after the stabbing incident.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Ridge from 2025-03-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
MAGNOLIA RIDGE in GARDENDALE, AL was cited for violations during a health inspection on March 19, 2025.
The 83-year-old had a care plan specifically addressing verbal outbursts and cursing directed at staff and other residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at MAGNOLIA RIDGE?
- The 83-year-old had a care plan specifically addressing verbal outbursts and cursing directed at staff and other residents.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in GARDENDALE, AL, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from MAGNOLIA RIDGE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 015133.
- Has this facility had violations before?
- To check MAGNOLIA RIDGE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.