Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Manor Of Midway during CMS and state inspections, most recent first.
A resident with a documented allergy to sulfamethoxazole was given Bactrim DS after staff bypassed a safety alert and failed to verify the allergy with the provider. The pharmacy did not flag the order due to incomplete allergy records, and the resident experienced an allergic reaction after receiving multiple doses. Communication and documentation failures among nursing staff and the pharmacy contributed to the incident.
A resident with a seizure disorder was re-admitted from the hospital with new orders for an anticonvulsant and an antibiotic, but these medications were not entered into the EMR or administered. The omission was not identified by nursing or pharmacy staff, and the resident was later rehospitalized for seizure activity due to not receiving the required anticonvulsant.
The facility failed to maintain proper food safety and hygiene standards, as observed during a kitchen tour. The ice machine was dirty, and several food items in the walk-in cooler and freezer were either expired or not properly labeled and dated. Additionally, two dietary cooks were not wearing beard guards in the food preparation area. These deficiencies could potentially affect the 72 residents receiving an oral diet.
The facility failed to ensure privacy during ADL care for a resident with severe cognitive impairment, as privacy curtains were not fully drawn and window blinds were open. Additionally, a resident with a suprapubic catheter did not have a dignity bag covering the drainage bag, as observed on multiple occasions. Staff interviews confirmed these oversights, acknowledging the need for privacy and dignity in resident care.
A facility failed to provide a resident with a suitable chair, leading to improper body alignment, and did not assess two residents for appropriate placement on the Secured Unit. One resident was placed in an incorrect chair, causing discomfort, while two others were inappropriately housed in a unit meant for those with elopement risks, despite lacking such tendencies. Staff interviews revealed a lack of awareness regarding the residents' needs and placement criteria.
The facility failed to maintain a clean environment, with strong urine odors and missing floor tiles in a bathroom on Hall 3, and rust on raised toilet seats in two bathrooms on Hall 2. The Maintenance Director and DON confirmed these issues during a tour, and the Maintenance Director was unaware of the problems due to a lack of work orders. The Housekeeping Supervisor was also unaware of the odor issue, despite having a log for addressing such problems.
The facility failed to develop care plans for two residents, one lacking a plan to prevent future abuse after an altercation, and another without a plan for Restorative Nursing Services despite needing assistance with daily activities. Staff interviews confirmed these omissions.
The facility failed to provide appropriate care for three residents, leading to deficiencies in maintaining or improving their functional abilities. A resident with severe cognitive impairment was placed in an improperly fitted Geri-chair, another resident with intellectual disabilities was left without a footrest in a wheelchair, and a third resident with hemiplegia did not receive necessary restorative care services due to a misunderstanding about hospice care.
The facility failed to safely store personal care items in a shared bathroom, specifically a can of shaving cream, which was accessible to residents. The shaving cream posed a hazard due to its ingredients, with risks of explosion, respiratory issues, and ingestion. The ADON and an LPN confirmed the presence of the shaving cream and acknowledged the high risk of accidental ingestion by residents with low cognition and safety awareness.
A facility failed to ensure staff used PPE for a resident under Enhanced Barrier Precautions. Despite policy requirements, a CNA did not wear PPE during incontinent care, and PPE was not readily available in the resident's room. Staff interviews revealed a lack of focus on PPE use, with the ADON prioritizing privacy issues and the Administrator unaware of the non-compliance. The IPC acknowledged the need for clearer PPE instructions, and the CNA admitted to forgetting PPE use.
Failure to Prevent Administration of Allergen-Containing Medication
Penalty
Summary
A deficiency occurred when a resident with multiple documented allergies, including to sulfamethoxazole, was administered Bactrim DS, an antibiotic containing this allergen. The resident was admitted with a history of spinal stenosis, diabetes mellitus, hypertension, peripheral vascular disease, and other conditions. Upon admission, the resident's allergies were recorded in the facility's records, but a breakdown in communication and documentation led to the allergy not being properly updated in the pharmacy system. As a result, the pharmacy did not flag the order for Bactrim DS as contraindicated. The process failure began when an LPN received a telephone order for Bactrim DS after the resident exhibited symptoms of a urinary tract infection. The LPN bypassed a safety alert in the electronic medical record, incorrectly assuming that the provider was aware of the resident's allergy. The order was not properly verified with the provider, and the allergy was not communicated during the order entry process. The medication was administered from the emergency kit, and subsequent doses were given without further alerts, as the system did not continue to flag the allergy after the initial override. The resident experienced an allergic reaction, including flushing, redness, and rash, after receiving multiple doses of Bactrim DS. Staff interviews revealed confusion about the process for handling allergy alerts, the responsibilities for verifying allergies, and the communication between nursing staff, providers, and the pharmacy. The pharmacy's records were incomplete due to the allergy not being updated, and the facility's policies for medication orders and allergy documentation were not consistently followed, directly leading to the resident's exposure to a known allergen and resulting harm.
Failure to Administer Ordered Anticonvulsant Results in Resident Harm
Penalty
Summary
A deficiency occurred when a resident with a history of seizures and other complex medical conditions was re-admitted to the facility from an acute care hospital. Upon re-admission, the hospital's medication reconciliation report included new orders for Keppra, an anticonvulsant, and cephalexin, an antibiotic. However, these new medication orders were not entered into the facility's electronic medical record (EMR) and were not included in the resident's Medication Administration Report (MAR) from the time of re-admission through the date the resident was sent back to the hospital. Documentation by the receiving LPN did not indicate that new orders were verified with the physician, and the facility's process for double-checking and entering new orders was not followed as described in interviews with the ADON and DON. As a result of not receiving the prescribed anticonvulsant medication, the resident experienced seizure activity and required rehospitalization. The facility's policies required that new and readmission medication orders be clearly documented, verified, and entered into the EMR, but these steps were not completed for this resident. Interviews with staff revealed assumptions and gaps in communication regarding the entry and verification of new orders, contributing to the medication omission and subsequent harm to the resident.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards, as observed during a kitchen tour. The ice machine, located next to the handwashing station, was found to have dust and dirt around its interior, indicating inadequate cleaning. In the walk-in cooler, several food items, including romaine salad mix, slaw mix, cheese, and liquid eggs, were either expired or not properly labeled and dated after being removed from their original packaging. Similarly, in the walk-in freezer, waffles and pancakes were found unlabeled and undated after being removed from their original packaging. Additionally, during the kitchen tour, it was observed that two dietary cooks were not wearing beard guards while in the food preparation area, which is against the facility's hygiene protocols. Interviews with the acting Dietary Manager and the Administrator confirmed that the ice machine should be cleaned weekly, food items should be labeled and dated when opened, expired foods should be discarded, and staff with facial hair should wear beard guards. These deficiencies had the potential to adversely affect the 72 residents receiving an oral diet.
Privacy and Dignity Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure privacy during Activities of Daily Living (ADL) care for a resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation and rheumatoid arthritis. During an observation, it was noted that the privacy curtains were not fully drawn, and the window blinds were open, allowing visibility of the resident to anyone entering the room or from outside. This lack of privacy was confirmed by the Assistant Director of Nursing and a Certified Nursing Assistant (CNA) during the observation. The CNA later acknowledged the failure to provide full visual privacy during the provision of peri care. Additionally, the facility did not provide a dignity bag for a resident with a suprapubic catheter, as observed on multiple occasions. The catheter drainage bag was left uncovered and visible, contrary to the facility's policy. Interviews with a CNA, an LPN, and the Unit Manager confirmed that the drainage bag should have been covered with a dignity bag to maintain the resident's dignity. The staff acknowledged the oversight and confirmed the expectation that the dignity bag should always be in place.
Failure to Accommodate Resident Needs and Assess Placement
Penalty
Summary
The facility failed to provide a resident, identified as R18, with a chair that accommodated his height and ensured proper body alignment. R18, who had severe cognitive impairment and was non-ambulatory, was observed sitting in a Geri-chair that did not fit his height, causing him to slump and slide downward. The chair was not his assigned one, which was provided by Hospice and was left in the bathroom after being cleaned. Staff interviews confirmed that R18 was placed in the incorrect chair by the night shift and remained there throughout the day without attempts to correct the situation. Additionally, the facility did not assess two residents, R16 and R51, for appropriate placement on the Secured Unit. R16, with diagnoses including schizoaffective disorder and vascular dementia, was non-ambulatory and dependent on staff for care, with no documented behaviors or wandering tendencies. Despite this, R16 remained on the Secured Unit without reassessment. Similarly, R51, who had Alzheimer's Disease and was receiving hospice care, was non-ambulatory and dependent on staff, yet was placed in the Secured Unit without exhibiting wandering behaviors. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed a lack of awareness regarding the residents' conditions and the criteria for placement in the Secured Unit. The DON confirmed that the unit was intended for residents with elopement risks, yet both R16 and R51 did not meet these criteria. The failure to assess and accommodate the individual needs of these residents resulted in inappropriate care and placement, highlighting deficiencies in the facility's processes for ensuring resident rights and safety.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed in two of three halls. In bathroom 306 on Hall 3, a strong urine odor and missing floor tiles were noted during multiple observations. Additionally, in bathrooms 219 and 223 on Hall 2, raised toilet seats were found with dark brown substances, later identified as rust, coating their frames. During a tour with the Maintenance Director and the DON, both confirmed the presence of the urine odor, missing floor tiles, and rust on the toilet chairs. The Maintenance Director was unaware of these issues, stating that staff are required to submit a work order for repairs. The Housekeeping Supervisor also reported being unaware of the strong urine odor in room 306, despite staff having a log to address such issues.
Deficiencies in Care Planning for Abuse Prevention and Restorative Services
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific needs. For one resident, who had a history of cerebral infarction, vascular dementia, epilepsy, intermittent explosive disorder, and schizoaffective bipolar disorder, the facility did not create a care plan to monitor and prevent future occurrences of abuse. This resident was involved in a resident-to-resident altercation, resulting in an injury, but no care plan was developed to address or prevent such incidents. Interviews with the Unit Manager and MDS Coordinator confirmed the absence of an abuse care plan, and the Director of Nursing acknowledged that such a plan should have been completed. Another resident, admitted with hemiplegia/hemiparesis following cerebral infarction and moderate cognitive impairment, required total assistance with daily activities and had precautions for contractures noted. However, the facility did not document a plan of care for Restorative Nursing Services. The Restorative Care/RN admitted to not completing an assessment for this resident to receive the necessary restorative services for mobility, indicating a lapse in care planning for the resident's specific needs.
Deficiencies in Resident Care and Equipment Provision
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the functional abilities of three residents, leading to deficiencies in their care. Resident 18, who has severe cognitive impairment and multiple health conditions, was observed sitting in a Geri-chair that was not properly fitted, causing poor body alignment. The Director of Nursing confirmed that the resident was not in the assigned chair, which was left in the bathroom after being cleaned, and no attempt was made to place the resident in the correct chair. Resident 26, diagnosed with intellectual disabilities and severe cognitive impairment, was observed sitting in a wheelchair without a footrest, causing his feet to dangle. This oversight was confirmed by the Unit Nurse Supervisor, who acknowledged the risk of edema and foot drop due to the lack of a footrest. The Occupational Therapist noted that the wheelchair could be adjusted to prevent the resident's feet from dangling, but this was not done. Resident 40, with a history of hemiplegia and moderate cognitive impairment, was not receiving restorative care services for mobility or range of motion, despite precautions for contractures noted in the medical record. The Director of Nursing and the Restorative Care Nurse revealed that an assessment for restorative services was not completed due to a misunderstanding that hospice patients do not receive such services, which was later found to be incorrect.
Unsafe Storage of Personal Care Items in Shared Bathroom
Penalty
Summary
The facility failed to ensure that personal care items were safely stored in one of the shared bathrooms on the 300 Hall, specifically in room [ROOM NUMBER]. A can of personal shaving cream was observed on the bathroom sink, accessible to residents. The shaving cream's pamphlet listed warnings about its hazardous ingredients, including risks of explosion if heated, respiratory issues if inhaled, and nausea or vomiting if ingested. The Assistant Director of Nursing confirmed the presence of the shaving cream and acknowledged its potential hazard if ingested. An LPN also confirmed the shaving cream's presence and reported a high risk of accidental ingestion due to the low cognition and lack of safety awareness among wandering residents on the unit.
Failure to Use PPE During High-Contact Care
Penalty
Summary
The facility failed to ensure that staff used appropriate Personal Protective Equipment (PPE) for a resident under Enhanced Barrier Precautions (EBP). The facility's policy, dated June 2021, outlined the need for targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms. However, during an observation, it was noted that a Certified Nursing Assistant (CNA) did not wear PPE while providing incontinent care to a resident with a wound, despite the presence of EBP signage on the resident's door. Additionally, there was no PPE readily available in the hallway or inside the resident's room, and the signage lacked specific instructions on donning and doffing PPE. Interviews with facility staff revealed a lack of awareness and focus on PPE use during high-contact care. The Assistant Director of Nursing (ADON) was more focused on privacy issues rather than PPE compliance, and the Administrator was unaware of the PPE non-compliance issue. The Infection Control Preventionist (IPC) confirmed that PPE was not kept at the resident rooms but at the front desk, and acknowledged the need for more specific instructions on PPE use. The CNA involved admitted to forgetting to wear PPE, prioritizing resident care over PPE compliance.
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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 Midway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bryan County Hlth & Rehab Ctr | 10 mi | — | 11 | 0 |
| Abercorn Rehabilitation Center | 17.9 mi | — | 11 | 0 |
| Pruitthealth - Savannah | 18.2 mi | — | 1 | 0 |
| Coastal Manor | 21.1 mi | — | 0 | 0 |
| Oaks Health Ctr At The Marshes Of Skidaway Island | 21.5 mi | — | 7 | 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 August 2026) and official state health department websites.