Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Muscogee Manor & Rehabilitation Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and diagnoses including bipolar disorder and dementia was observed with a blue pill floating in water on the bedside table after an LPN had administered divalproex sodium. The resident had no documented self-administration assessment or care plan, and the Unit Manager stated staff are expected to remain in the room to ensure residents swallow medications before leaving.
Private resident information was left visible in resident rooms and on a medication cart. Signs with clinical instructions were posted in the rooms of three residents, including one with severe cognitive impairment and renal disease, one with severe cognitive impairment and a colostomy, and one with a feeding tube and malnutrition; the records did not show that the residents or representatives requested the signage. In addition, an RNS left a laptop screen open on a med cart, allowing resident information to remain visible until staff returned.
Incomplete Care Planning for Hypertension and Oxygen Therapy: The facility failed to develop and/or implement comprehensive care plans for two residents. One resident with HTN had no care plan for BP management or metoprolol parameters despite low HR readings and a medication order for metoprolol. Another resident receiving oxygen for emphysema and asthma was observed at the wrong flow rate and without the ordered humidifier bottle, even though the care plan addressed oxygen therapy and staff confirmed the physician orders.
Insulin protocol and administration errors were identified for two residents with DM and severe cognitive impairment. For one resident, the MAR showed FSBS results below 50 mg/dl, but the MD was not notified as ordered and the recheck results were not documented. For another resident, an LPN did not hold the insulin pen in place long enough after injection, which could prevent the full dose from being delivered.
Oxygen Therapy Not Provided as Ordered: A resident with emphysema, asthma, and acute respiratory distress was ordered oxygen at 4 LPM via NC with tubing and humidifier changes every Monday. Staff observed the resident receiving oxygen at 3.5 LPM instead of 4 LPM, and later at 4 LPM but without the ordered humidifier bottle attached and in use. An LPN confirmed the missing humidifier, and the DON and Administrator confirmed staff were expected to follow the physician orders.
Failure to Check Vital Signs Before Metoprolol Administration: An LPN administered metoprolol to a resident with HTN without checking pulse or BP first. The resident had moderate cognitive impairment, and record review showed several prior HR readings below 60 bpm. The ADON, DON, and pharmacist stated that metoprolol should be monitored for HR and BP effects, and staff noted that parameters should be obtained from the MD for certain meds such as metoprolol.
Glucose test strips in two medication carts were found without open dates. An LPN confirmed the missing dates during observation, and the facility’s blood sugar checklist stated strips expire 3 months after first use. The ADON and DON both stated open dates should be placed on glucometer strip bottles when opened, and the DON noted that missing dates could result in inaccurate blood sugar readings.
The facility failed to properly label, store, and dispose of food items, potentially affecting 85 residents. Observations revealed unlabeled and expired food in the cooler, freezer, and pantry, with improper sealing and storage practices. Interviews with staff, including the FNM and LPN, indicated a lack of oversight and responsibility for managing food labeling and disposal, contributing to the deficiency.
A facility failed to provide a resident or their representative with written information about their rights to accept or refuse treatment and advance directives. The resident, with conditions like anoxic brain damage and protein calorie malnutrition, was on hospice care with a DNR order. Interviews revealed that the process for providing this information was not followed, as the advance directive form was not completed or signed.
A facility failed to submit a PASRR Level II for a resident with mental health diagnoses, including dementia and psychosis. The resident's diagnoses required a Level II screening to ensure appropriate care, but the facility lacked a PASRR policy, leading to a delay. Interviews revealed confusion among staff about the PASRR process and responsibilities, contributing to the oversight.
The facility failed to implement care plans for two residents regarding meal intake monitoring and did not develop a care plan for oxygen use for another resident. One resident with severe cognitive impairment had missing meal intake documentation, while another with little cognitive impairment also lacked consistent meal intake records. Additionally, a resident with COPD had no care plan for oxygen use, and their oxygen was set higher than ordered. Staff interviews confirmed the responsibilities for documentation and adherence to physician orders were not met.
A resident with severe cognitive impairment and a history of wandering eloped from a COVID unit due to an inoperable door alarm. The resident was moved from a locked dementia unit, and despite the facility's policy on accident prevention, the alarm system failed, allowing the resident to exit. The resident was found outside and returned by police, highlighting a lapse in supervision and safety measures.
A resident with chronic respiratory and heart conditions was observed receiving oxygen at 2.5 LPM instead of the physician-ordered 2 LPM. Staff interviews revealed that the respiratory therapist adjusted the oxygen level without obtaining a new physician order, contrary to facility policy. The MDS Coordinator had not completed a detailed care plan for the resident's oxygen therapy, and the DON expected staff to adhere strictly to physician orders.
The facility failed to prepare pureed food according to established procedures, affecting residents on a pureed diet. A staff member prepared pureed spaghetti without using a formal recipe, relying on experience and imprecise measurements. The Food and Nutrition Manager and Administrator were aware of the issue, which had the potential to affect 13 residents.
Medication Left Unswallowed at Bedside
Penalty
Summary
The facility failed to ensure that one resident, R57, swallowed a medication before the nurse left the room. R57 had been admitted in 2016 and had diagnoses including unspecified bipolar disorder with psychotic features, vascular dementia, bipolar disorder, tremor, and dementia in other diseases classified elsewhere. The quarterly MDS dated 02/03/2026 showed a BIMS score of 03, indicating severe cognitive impairment. The current comprehensive care plan revised 02/19/2026 did not include a plan for self-administration of medication, and the electronic medical record showed no evidence of an assessment for self-administration. During observation on 02/20/2026, R57 was sitting up in bed with a clear small cup of water and a blue pill floating in it on the bedside table. When asked about the cup contents, R57 stated it was a pill and continued looking at it. The cup with the pill remained on the bedside table during a later observation. The LPN stated she had given the blue pill, identified as divalproex sodium, to R57 that morning and was not sure why the resident did not swallow it. The Unit Manager stated staff are expected to stay in the resident's room to ensure residents swallow medication before leaving, and confirmed that R57 was not assessed for self-administration of medications.
Private resident information left visible in rooms and on a medication cart
Penalty
Summary
The facility failed to keep resident medical information private and confidential when clinical signage was posted in the rooms of three residents and when a medication cart laptop screen was left open and visible. The report states that the facility’s policies required resident health information to remain private, that MARs and electronic health record information must not be visible when not in direct use, and that only authorized staff should access the EMR system. Surveyors observed that private information was visible to unauthorized individuals in resident rooms and at the medication cart. For one resident with severe cognitive impairment, end-stage renal disease, type 2 diabetes, and a mechanically altered diet, signs were posted above the bed stating no milk products or pudding and listing aspiration precautions. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. For another resident with severe cognitive impairment, ostomy status, colostomy care orders, and diagnoses including cognitive communication deficit and intellectual disabilities, signs were posted next to the bed stating the resident had a colostomy bag and needed it changed when full, along with a turning schedule. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. For a third resident with a feeding tube and mild protein-calorie malnutrition, a sign was posted behind the head of the bed stating the resident was a tube feeder and that the head of the bed should be elevated at all times. The record did not show that the resident or representative requested the signage, and the resident was unable to answer questions about it. In addition, an RNS left a laptop screen open on a medication cart and walked away, leaving resident information visible while staff passed by. The RNS confirmed the screen was not locked and stated that anyone could see the resident information, and the DON and ADON stated that laptop screens were expected to be locked when not in use.
Incomplete Care Planning for Hypertension and Oxygen Therapy
Penalty
Summary
The facility failed to develop and/or implement a comprehensive care plan related to oxygen therapy and medication parameters for two residents. The facility policy titled Care Plan Policy stated the Care Plan Coordinator was responsible for timely review of a resident’s status and any change in needs following a hospital stay or other unexpected event, and for ensuring concerns or changes were updated in the care plan. Survey findings identified that the deficient practice involved R62 and R70 and was noted to have the potential to increase the risk of clinical complications for both residents. R62 was re-admitted to the facility with hypertension and had a Quarterly MDS documenting hypertension as an active diagnosis. The comprehensive care plan revised 01/16/2026 contained no documented evidence of a care plan for hypertension. Physician orders dated 12/23/2025 included metoprolol tartrate 50 mg twice daily for hypertension. During medication administration observation on 02/21/2026, an LPN administered metoprolol to R62 and there was no parameter for the medication. The LPN stated metoprolol was not to be administered if the resident’s heart rate was less than 60 and confirmed the resident had heart rate readings below 60 on a few occasions. The record review showed the last set of vital signs was on 02/19/2026. The NM, MDS Coordinator, and DON each confirmed there was no hypertension care plan for R62. R70 had diagnoses including emphysema, asthma, and acute respiratory distress, and the Annual MDS documented that the resident was receiving oxygen. Physician orders dated 02/03/2025 directed oxygen at 4 LPM via nasal cannula day and night for emphysema and asthma, and tubing and humidifier changes every Monday day shift. The care plan revised 02/05/2025 included oxygen therapy with an intervention to administer oxygen and monitor O2 saturation as ordered. However, observations on 02/20/2026 showed R70 receiving oxygen at 3.5 LPM instead of the ordered 4 LPM, and no humidifier bottle attached to the concentrator. On 02/21/2026, R70 was observed receiving oxygen at 4 LPM, but again without a humidifier bottle attached and in use. An LPN confirmed the oxygen was at the correct rate during the later observation but also confirmed the humidifier bottle was not attached per physician orders. The DON, Administrator, and MDS Nurse confirmed staff were expected to ensure the resident received oxygen at the correct flow rate and with a humidifier bottle according to the physician orders.
Insulin Protocol and Administration Errors
Penalty
Summary
The facility failed to follow the physician-ordered insulin protocol for two residents receiving insulin. For one resident with diabetes mellitus and severe cognitive impairment, the record showed physician orders to call the MD for finger stick blood sugar results below 50 mg/dl, but the MAR documented blood sugar results of 46 and 43 with no evidence that the physician was notified. The ADON stated the nurses gave juice and rechecked the blood sugar, but the recheck results were not documented, and the physician was not called as ordered. The facility also failed to accurately administer insulin from a pen device for another resident with diabetes mellitus and severe cognitive impairment. During observation of medication administration, an LPN did not keep the insulin pen in place for at least 10 seconds after pressing the button and removed it too quickly. The LPN acknowledged that removing the pen too soon could allow insulin to spill out and prevent the resident from receiving the correct dose. The ADON confirmed the insulin pen should be held in place for at least 10 seconds so the full dose is delivered.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that R70 received oxygen therapy in accordance with physician orders. R70 had diagnoses including emphysema, asthma, and acute respiratory distress, and the EHR showed that R70 was receiving oxygen. The MDS indicated that R70 was receiving oxygen and had a BIMS score of 07, showing little to no cognitive impairment. The physician order dated 02/03/2025 directed oxygen at 4 LPM via nasal cannula every day and night shift for emphysema and asthma, and another order directed tubing and humidifier changes every day shift every Monday. The care plan also identified oxygen therapy as a focus area and directed staff to administer oxygen and monitor O2 saturation as ordered. Observations showed that R70 was receiving oxygen from a concentrator by nasal cannula at 3.5 LPM on 02/20/2026, instead of the ordered 4 LPM, and there was no humidifier bottle attached to the concentrator. On 02/21/2026, R70 was observed receiving oxygen at 4 LPM, but again without a humidifier bottle attached and in use. An LPN confirmed that the oxygen was at the correct rate during the later observation but acknowledged that the humidifier bottle was not attached and in use as ordered. The DON and Administrator confirmed that staff were expected to ensure the resident received oxygen at the correct flow rate and with a humidifier bottle according to physician orders.
Failure to Check Vital Signs Before Metoprolol Administration
Penalty
Summary
The facility failed to follow acceptable standards of practice when administering metoprolol to one resident with hypertension and moderate cognitive impairment. The resident was readmitted with a diagnosis that included hypertension, and the physician’s order was for metoprolol tartrate 50 mg by mouth twice daily. The comprehensive care plan revised 09/23/2025 did not include a written care plan addressing hypertension and/or associated medications. During medication administration observation on 02/21/2026 at 8:50 AM, an LPN administered metoprolol 50 mg to the resident without checking a pulse or blood pressure beforehand. The LPN stated there were no ordered parameters and that metoprolol should not be given if the resident’s heart rate was less than 60 bpm. Record review showed the resident had multiple heart rate readings below 60 bpm on several dates in February and January 2026. The ADON and DON stated nurses should call the doctor for parameters on medications such as metoprolol, and the pharmacist stated the resident should be monitored for drops in blood pressure and heart rate when receiving metoprolol.
Glucose Test Strips Found Without Open Dates
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles when two bottles of glucose test strips in two medication carts were found without open dates. During observation and interview on 02/21/2026, one bottle of blood sugar test strips in medication cart 1 on the [NAME] Wing had no open date, and an LPN present during the review confirmed it. A second observation the same day in medication cart 2 on the [NAME] Wing found another bottle of blood sugar test strips with no open date, and the LPN present also confirmed it. Record review showed the facility’s Checklist for Blood Sugar documented that blood glucose monitoring solution/strips are dated and expire 3 months after first use. The facility requested a policy for blood sugar strips, but no policy was provided. During interview, the ADON stated the opening date should be placed on glucometer strip bottles when first opened because nurses would not know when the days are up. The DON stated it was her expectation that open dates be placed on glucometer strip bottles upon opening and that, without an open date, the strips may not be effective within the required time period and residents may have inaccurate blood sugar readings.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items, as well as the timely disposal of expired food, which could potentially affect 85 residents who receive food orally. Observations revealed multiple instances of food items in the walk-in cooler, freezer, and pantry that were not labeled with expiration dates, including cheddar and Swiss cheese slices, turkey burgers, milkshakes, and various opened bags of food such as beef patties and French fries. Additionally, several food items were found to be improperly sealed or stored, such as an opened jug of barbeque sauce that was not refrigerated and expired items like prune juice and graham crackers in the resident pantry. Interviews with facility staff, including the Food and Nutrition Manager (FNM), Licensed Practical Nurse (LPN), and the Administrator, highlighted a lack of oversight and responsibility for checking and discarding expired food items. The FNM expressed an expectation for kitchen staff to work as a team to manage food labeling and disposal, but admitted to not being responsible for checking resident pantries. The LPN on the [NAME] Wing acknowledged not checking for expired items beyond juices, and the Administrator stated that all food should be labeled and checked daily, with unit managers overseeing the resident pantries. However, the absence of a unit secretary responsible for pantry checks contributed to the oversight.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide a resident or their representative with written information regarding their rights to accept or refuse medical or surgical treatment, as well as information about advance directives. This deficiency was identified for one of the seven sampled residents, who had medical diagnoses including anoxic brain damage, tachycardia, and protein calorie malnutrition. The resident was on hospice care with a Do Not Resuscitate (DNR) order, and the care plan indicated a need to complete or update the advance directives document. Interviews with facility staff, including the Administrator in training and the Social Service Director, revealed that the process for providing advance directive information involved giving the document to residents or their families during the admission conference. However, in the case of the resident in question, there was no indication that the advance directive form was completed or signed by the resident or their representative. The facility's policy and admission agreement form included sections for acknowledging the execution of an advance directive, but these were not marked for the resident, indicating a lapse in ensuring the resident's or representative's informed decision-making capacity.
Failure to Submit PASRR Level II for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a mental health diagnosis, which was necessary for ensuring the resident received appropriate services and care. The resident, identified as R82, had a primary diagnosis of secondary malignant neoplasm of bone, along with vascular dementia, anxiety disorder, and psychosis not due to a substance or known physiological condition. Despite these diagnoses, the facility did not have a policy on PASRR, and the necessary Level II screening was not submitted in a timely manner. Interviews with facility staff, including the Social Service Director (SSD) and the Medical Records Coordinator, revealed a lack of clarity and communication regarding the PASRR process. The SSD indicated that clinical information was typically entered into the Georgia Medicaid Management Information System (GAMMIS) by the hospital, but if not, the facility would enter it. The SSD was in the process of submitting a Level II for R82 on the day of the interview, indicating a delay in the process. The Medical Records Coordinator noted that for new admissions, a DMA-6 form was completed, and if a resident was to stay longer than 30 days, the hospital would enter the necessary information into the Georgia portal. However, there was confusion about who was responsible for submitting the Level II, especially for residents with mental health diagnoses.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plans for three residents, leading to deficiencies in monitoring and recording meal intake and oxygen use. For one resident with severe cognitive impairment and a risk for weight loss, the care plan required recording meal intake percentages and offering food replacements for less than 25% consumption. However, documentation was missing for numerous days over a three-month period, indicating a failure to implement the care plan effectively. Another resident, who had little to no cognitive impairment and was at risk for nutritional deficits, also had a care plan that required recording meal intake percentages. Despite consuming between 51-100% of meals, there were several days without documentation of intake percentages. Interviews with staff confirmed that CNAs were responsible for documenting meal consumption in the electronic medical records system daily, but this was not consistently done. A third resident with moderate cognitive impairment and a diagnosis of COPD was using oxygen, but there was no care plan developed for oxygen use. Observations revealed the resident's oxygen was set at a higher level than ordered by the physician. The MDS Coordinator admitted to not creating a detailed care plan for oxygen use, and the DON expected staff to follow physician orders precisely. This lack of a specific care plan for oxygen use contributed to the deficiency.
Failure to Maintain Working Door Alarm Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure a working door alarm to prevent the elopement of a resident housed on a COVID unit. The resident, who had severe cognitive impairment and a history of wandering, was moved from a locked dementia unit to a COVID unit. Despite the facility's policy on accident and hazard prevention, the door alarm on the COVID unit was inoperable, allowing the resident to bypass two doors and exit the facility. The resident was later found outside by neighbors and returned by the police. Interviews with facility staff, including the Director of Nursing, Assistant Director of Nursing, Maintenance Director, and Administrator, revealed that the resident was not on one-on-one monitoring, and the alarm system failure was acknowledged. The resident was last seen in her room before being found outside, indicating a lapse in supervision and safety measures. The facility's attempt to manage the situation during the COVID outbreak led to the resident being moved, but the necessary safety precautions were not adequately maintained, resulting in the resident's elopement.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for a resident receiving oxygen therapy. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, chronic bronchitis, and atherosclerotic heart disease, was observed with oxygen set at 2.5 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted during multiple observations over two days. The facility's policy required that any changes in oxygen flow made by the respiratory therapist or nursing staff be communicated to the physician within 24 hours to obtain a new order, which was not adhered to in this case. Interviews with staff revealed a lack of adherence to the physician's orders and the facility's policy. An LPN confirmed the oxygen setting and indicated that the respiratory therapist determined the level unless changed by the physician. The MDS Coordinator admitted to not having completed a detailed care plan for the resident's oxygen therapy. The DON expressed that staff were expected to follow physician orders precisely and that care plans should be implemented according to diagnoses, which was not done in this instance.
Failure to Follow Pureed Food Preparation Procedures
Penalty
Summary
The facility failed to prepare pureed food according to established procedures, which compromised the nutritive value, flavor, and appearance of the food. Specifically, the facility did not use a recipe when preparing pureed food for residents on a pureed diet. Observations revealed that a staff member, [NAME] BB, was preparing pureed spaghetti without referring to a formal recipe. Instead, she relied on her experience and used a ladle to measure thickened powder, rather than following precise measurements. This practice was intended to serve 10 residents, with the desired consistency being nectar thick. Interviews with the Food and Nutrition Manager (FNM) and the Administrator highlighted a lack of adherence to the facility's policy. The FNM was aware that the cook was not following the recipe but mentioned that recipes could be printed for reference. The Administrator expected dietary staff to be trained and to follow recipes for pureed diets. The deficiency had the potential to affect 13 residents who were ordered a pureed diet, as the preparation did not adhere to the facility's policy to ensure the best possible product without compromising flavor and texture.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Towne Center | 3.7 mi | ★★★★★ | 8 | 0 |
| Magnolia Manor Of Columbus Nursing Center - East | 5.6 mi | ★★★★★ | 12 | 0 |
| Magnolia Manor Of Columbus Nursing Center - West | 5.7 mi | ★★★★★ | 3 | 0 |
| Ridgecrest Rehab & Skilled Nursing Center | 7.3 mi | ★★★★★ | 1 | 0 |
| Orchard View Rehabilitation & Skilled Nursing Ctr | 8 mi | ★★★★★ | 14 | 0 |
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