Magnolia Manor Of Midway
652 North Coastal Highway 17, Midway, GA 31320 · Non profit - Corporation · 169 certified beds · (912) 884-3361 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.8% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.5% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 0.8% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.5% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 18.3% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.4% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 4.9% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.5% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 75.0% | 78.4% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.56 | 2.15 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.29 | 1.90 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 6.3–16.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 169 beds and averages 81.5 residents a day — about 48% occupied, or roughly 88 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.55 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.89 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.14 hrs/resident/day on weekends vs 3.72 on weekdays — 16% thinner on weekends. RN hours go from 0.72 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Actual harm · G2025-10-09 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and a review of the facility policies titled Admissions and Medication Orders, the facility failed to protect one of 33 sampled residents (R) (R4) with allergies. Harm was identified to have occurred on 9/24/2025 when R4 was administered Bactrim DS (an antibiotic medication) that was listed as a known allergy for the resident, resulting in an allergic reaction to the medication (flushing (feeling hot), redness, and rash).Findings included:A review of the facility's policy titled Admissions, reviewed and updated in October 2016, revealed that it is the intent of the facility for the charge nurse to record information, including but not limited to the following, in the designated place (nurses' notes, admission nurse assessment, etc) . any known allergies.A review of the facility's policy titled Medication Orders, reviewed and updated in October 2017, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-10-09 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy titled Medication Orders and Admissions revealed the facility failed to order an anticonvulsant for one of 17 sampled residents (R) (R1) who received an anticonvulsant for seizures and an antibiotic. Harm was identified to have occurred on 2/15/2025, when R1 was rehospitalized for seizure activities due to not receiving the required anticonvulsant medication.Findings included:A review of the facility policies titled Admissions, reviewed and updated in October 2016, revealed that it is the intent of the facility to gather necessary information upon a resident's admission to the facility. The procedural guidelines reflect that residents' readmission and new admission data must be recorded. A review of the policy titled Medication Orders, reviewed and updated in October 2017, revealed that medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-05 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure three of five residents (R) (R2, R6, and R69) reviewed for pneumococcal/flu vaccines was offered a pneumococcal and flu vaccine and were provided the risks and benefits for pneumococcal and flu vaccines. The facility failed to ensure that two of five residents (R3 and R75) were provided with the risks and benefits prior to receiving the pneumococcal vaccine. This had the potential for the residents to have an increased risk of contracting pneumonia and flu, and for those who received the pneumococcal and flu vaccines without consent, and providing the risks and benefits did not provide the residents and or representatives the right to make an informed decision before being given the pneumococcal vaccine. Findings included:1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-05 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure one of five residents (R) (R2) responsible party had received the risks and benefits explained before they declined for the resident to receive the COVID-19 vaccine/ booster. The facility failed to ensure that two of five residents (R6 and R75) responsible parties, received the risks and benefits before receiving the COVID-19 vaccine/booster. Additionally, the facility failed to ensure two of five residents (R69 and R3) responsible party were given the opportunity to make a decision if they wanted their residents to receive a COVID-19 vaccine/ booster. This had the potential for an increase in contracting COVID-19 and for the responsible parties not being provided with the risks and benefits in order to make an informed decision. Findings included:1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Resident tab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to prevent abuse for three of 26 sampled residents (R) (R1, R23, and R8).Findings included:1.Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder.Review of R1's Care Plan located under the RAI [Resident Assessment Instrument] tab of the EMR, dated 02/28/23, contained the following Problem area, [R1] has been making false accusations to any and all staff that are caring for him. The care plan's goal specified, [R1] will not make accusations against staff by next review. The care plan's approach for staff included, Family informed of behaviors.Behavioral health group to follow [R1] for his psychological care. Staff educated to only give care in pairs to be witness to his accusations. Staff to investigate his accusations when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime and reporting of all alleged abuse violations to the State Agency (SA) for three of 26 sampled residents (R) (R1, R23, and R8). Findings included:1. Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, Major depressive disorder, dementia, and anxiety disorder.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/25, located in the RAI tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severe cognitive impairment. 2. Review of R23's Face Sheet located under the Resident tab of the EMR, revealed R23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to develop a comprehensive care plan following victimization of abuse for two of 26 sampled residents (R) (R1 and R23).Findings included:1. Review of R1's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R1 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, major depressive disorder, dementia, and anxiety disorder.Review of R1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/22/25, located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15 which indicated severe cognitive impairment.Review of the facility provided undated investigative documentation, revealed a staff member witnessed R8 threatened to slap R1 and kill him and his family on 10/18/25 at 3:21 PM.Review of R1's Care plan located under the RAI tab of the EMR, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review, the facility failed to revise a comprehensive care plan following aggressions of abuse for one of 26 sampled residents (R) (R8). Findings included:Review of R8's Face Sheet located under the Resident tab of the electronic medical record (EMR), revealed R8 was admitted to the facility on [DATE] with diagnoses which included parkinsonism, schizoaffective disorder, bipolar disorder, anxiety disorder, history of traumatic brain injury, altered mental status, and schizophreniform disorder. R8 was discharged from the facility on 11/26/25.Review of R8's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/25, located in the RAI [Resident Assessment Instrument] tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.Review of R8's Care plan located under the RAI tab of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and facility policy review, the facility failed to ensure assistive devices and treatment were attempted for one of seven residents (R) (R69) reviewed for positioning/mobility. This had the potential for the residents to experience a further decline in range of motion (ROM). Findings included:Review of R69's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] with diagnosis of hemiplegia and hemiparesis (paralysis/loss of strength) following a cerebral infarction (stroke) affecting his right dominant side. Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/25 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) was unable to be completed. The resident was noted to be severely impaired for daily decision making. The MDS further revealed the resident had impaired ROM of the upper extremity…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-05 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of policies and procedures, the facility failed to assess the entrapment risk of bedrails used for mobility assistance and obtain consent for one of three residents (R) (R47) reviewed for accident hazards.Findings included:Review of R47's Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R47 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and depression. Review of R47's quarterly Minimum Data Set (MDS) located under the RAI [Resident Assessment Instrument] tab of the EMR with an Assessment Reference Date (ARD) of 10/01/25, revealed R47 had Alzheimer's disease, no upper and lower extremity impairments, and was dependent on staff to help with rolling from side to side. It was recorded that R47 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact. Review of R47's Care plan located under the RAI tab of the EMR,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-06-14 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to properly label opened food items in the walk-in refrigerator and walk-in freezer, discard expired foods in the walk-in refrigerator, clean the ice machine, and ensure that kitchen staff wore beard guards while in the food preparation area. These deficient practices had the potential to adversely affect the 72 residents receiving an oral diet. Findings include: During a tour of the kitchen on 6/11/2024 from 11:00 am to 12:00 pm, observation of the ice machine, located next to the handwashing station, revealed dust and dirt around the inside of the ice machine in the top corners and the bottom interior of the lid. Observation of the walk-in cooler on 6/11/2024 at 11:09 am revealed two bags of romaine salad mix and one bag of [NAME] slaw mix with a use-by date of 6/2/2024. Continued observation of the walk-in cooler revealed three half-stacks of cheese not in the original packaging and undated and unlabeled, and one undated and unlabeled open box of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-14 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and a review of the facility policy titled Treatment of Residents, the facility failed to ensure privacy was provide during Activity of Daily Living (ADL) care for one of nine residents (R) (R23), the facility also failed to ensure a privacy bag was provided for one of three residents R7 that utilized a urinary catheter. Findings include: Review of the undated facility policy titled, Treatment of Residents under Intent: It is the intent of facility that all residents should be treated fairly and with kindness, respect, and dignity. Under Procedural Guidelines number (3). Residents should be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by. (4). Privacy of a resident body should be maintained during toileting, bathing and other activities of personal hygiene. 1.Record review for R23 revealed the following diagnoses but not limited to atrial fibrillation, malignant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 5 citations
- Potential for harm · D2024-06-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of facility documents, and review of the facility policy titled, Residents' Rights Protection, the facility failed to ensure one of nine residents (R) R18 was provided with a chair that accommodated his height and ensured body alignment. The facility also failed to ensure two of 28 residents, R16 and R51 were assessed for placement on the Secured Unit (Unit 3). The deficient practice had the potential to prevent R16, R18, and R51 from receiving care that accommodated their individual care needs. Findings include: Review of the undated facility policy titled, Residents' Rights Protection under Specific Rights: 1. Rights to Self-Determination the resident has the right: 1C.) to reside and receive services with reasonable accommodation by the facility of individual needs and preferences. A.Record review for R18 revealed diagnoses included but not limited to, dementia, benign prostatic hyperplasia, personal history of transient ischemic attack (TIA), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility failed to maintain a clean sanitary environment free of odor, replacing missing floor tiles, and ensure resident's equipment was free from rust on two of three halls. Finding include: A policy for this specific issue was requested but not provided. 1. Observations on 6/11/2024 at 11:50 am, 6/12/2024 at 2:00 pm., and 6/13/2024 at 12:49 pm, in bathroom [ROOM NUMBER]-306 on Hall 3, a strong urine odor and missing floor tiles were noted. 2. Observation on 6/11/2024 at 12:02 pm and 6/13/2024 at 12:52 pm, in bathroom [ROOM NUMBER]-219 on Hall 2 revealed a raised toilet seat was positioned over the toilet. A closer observation revealed dark brown substances coating the frame of the raised toilet seat. 3. Observation on 6/11/2024 at 12:03 pm and 6/13/2024 at 12:23 pm, in bathroom [ROOM NUMBER]-223 on Hall 2 revealed a raised toilet seat positioned over the toilet. A closer observation revealed dark brown substances coating the frame of the raised toilet seat.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview ,record review, and review of the facility policy titled, Care Planning Policy, the facility failed to develop a plan of care for two of 14 residents (R) (R16 and R40). Specifically, the facility failed to create a plan of care to monitor and prevent future occurrences of abuse for R16 and failed to develope a care plan for restorative services for R40. Findings include: Review of the facility policy titled, Care Planning Policy dated October 2016 under Procedural Guidelines number 1. A comprehensive person-centered care plan shall be developed and implemented for each resident that includes measurable objectives and time frames that meet a resident 's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessments. Record review of R16's medical record revealed the following diagnoses but not limited to cerebral infarction, vascular dementia moderate behavior disturbances, epilepsy, intermittent explosive disorder, and schizoaffective bipolar…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Restorative Nursing, the facility failed to ensure three of 18 residents (R), (R18, R26, and R40) received services required to maintain or improve their functional abilities. Specifically, the facility failed to ensure R18 was provided with a Geri-chair that was properly fitted to ensure adequate body alignment, failed to provide equipment (footrest) for R26 to prevent potential for foot drop, and failed to provide Range of Motion (ROM) for left hand contracture for R40. Findings include: Review of the undated facility policy titled, Restorative Nursing revealed It is the Intent of the facility to provide nursing interventions that promote the resident's ability to attain or maintain the highest level of functioning as possible. Procedural guidelines: number 2. The facility's rehabilitative/restorative nursing care program is designed to assist each resident to maintain their highest level of functioning. Number 3.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-14 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility policy titled Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) for one of five residents (R) (R23) reviewed for Enhanced Barrier Precautions. This deficient practice had the potential to place R23 and other residents at risk for avoidable infections. Findings include: A review of the facility policy titled, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, under Executive Summary number 2. Enhanced Barrier Precautions (EBP) is an approach of target gown and glove use during high-contact resident care activities, designed to reduce transmission of S. aureus and MDRO (multidrug -resistant organism). 3. EBP may be applied when contact precautions do not otherwise apply to residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO. 4.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MAGNOLIA MANOR SENIOR LIVING — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.6 | -0.6 vs chain |
| Staffing | 4 of 5 | 3.2 | +0.8 vs chain |
| Quality measures | 2 of 5 | 3.6 | -1.6 vs chain |
The other 4 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MAGNOLIA MANOR INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/10/2019 |
| ADKINS, SCOTT | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 09/10/2019 |
| TODD, MARK | Individual | CORPORATE OFFICER | — | since 07/01/1995 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $712K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115553. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.