A Columbus nursing home received a red warning symbol next to its listing on Medicare's website after being cited for mishandling its response to abuse allegations.
Magnolia Manor of Columbus Nursing Center-West has a health inspection rating of one out of five stars on Medicare's care-compare website, indicating its performance is "much below average." Its overall rating is two stars, meaning the nursing home performs "below average."
Investigations, reports and comments from patients or families show the nursing home has faced allegations of sexual abuse, failing to report significant medical incidents such as falls, and more in recent years.
Calls for change at the nursing home have been ongoing since August 2023, when Columbus resident Lisa Sparks started a Facebook group named Magnolia Manor Georgia Victims Fighting for Change. The group grew to more than 1,500 members during the last year and a half.
"People just started coming out of the woodwork," Sparks told the Ledger-Enquirer.
Asked a series of questions about the allegations, Magnolia Manor senior vice president for communications Ty Kinslow didn't directly answer the questions. Instead, he told the Ledger-Enquirer in an email that privacy laws prevent Magnolia Manor from commenting on any current or former resident. The nursing home remains committed to the well-being of its residents, he said.
"Magnolia Manor has been continuously licensed to care for its residents for almost two decades and remains in substantial compliance with federal and state regulations," he said. "Magnolia Manor engages residents, care providers, and family members on a daily basis and interacts with applicable agencies to address residents or family concerns and to enhance resident care."
Three patients were involved in two alleged sexual abuse incidents at Magnolia Manor, according to a September inspection report published by Medicare.
Identifying information about staff and patients was removed from the report to protect privacy, with the residents being referred to as R61, R24 and R97.
The first incident detailed in the report involved R61, who was diagnosed with type 2 diabetes, depression and anxiety. An assessment indicated R61 had short- and long-term memory deficits. She had refused care and sometimes had delusions or hallucinations.
Last August, R61 reported to a Magnolia Manor employee that female staff inappropriately touched her genitals.
A nurse told the employee that R61 also recently had been impacted with hard stool in her colon.
The employee informed a registered nurse who reported the incident to a Magnolia Manor administrator. The RN and the administrator spoke to R61, who said she didn't want certified nurse assistants to change her anymore.
An administrator at the facility informed inspectors that he did not interpret the allegation as potential abuse because the patient often refused care and the potential bowel obstruction had required staff to remove stool digitally from the resident.
The RN and the facility's social services director told inspectors that no measures were put in place after R61's report to ensure she was protected from further potential abuse. A complaint form was sent to the director of nursing, who told the inspectors that she was not involved in any follow-up related to the allegation.
R61 never was physically assessed concerning the potential abuse allegation, the director of nursing told the inspector, nor was she sent to the emergency department for evaluation.
"The administrator stated his expectation was that any resident who reported potential abuse should be protected from further potential abuse while an investigation in the alleged abuse was conducted," says the inspection report.
This wasn't done in R61's case, the administrator admitted to the inspector.
Inspectors found that proper reporting and evaluations were not done in another potential sexual abuse incident involving patients R24 and R97.
Two certified nursing assistants entered R24's room while doing rounds and found her lying in bed on a towel with her pants halfway down while R97 was coming out of her bathroom with his shirt up and pants halfway down.
Both patients had been diagnosed with Alzheimer's disease.
The CNAs reported the incident to a licensed practical nurse, and the administrator was made aware.
"He felt the incident did not need to be investigated or reported to the state because staff did not witness R24 or R97 doing anything," the inspection report says.
Sexual violence in older adults is under-researched, according to a study in the National Library of Medicine, but research suggests it rarely occurs.
However, the study found people who are victims of elder sexual abuse are less likely to be believed, especially if there are no signs of trauma to the body.
Studies conducted by the National Institute of Justice found that elderly sexual abuse victims who reside in nursing facilities are the least able to get a conviction out of acts perpetrated against them.
Part of the problem is that victims often cannot communicate well enough to identify what happened or who the perpetrator was, a report by the Nursing Home Abuse Center says.
The nursing home received four health deficiencies in its most recent inspection in September. Nursing homes are inspected about once a year, according to Medicare. If they receive complaints or perform poorly, they may receive more frequent inspections.
Three deficiencies were in the "Freedom from Abuse, Neglect and Exploitation" category. The last one was for an administration deficiency.
In Georgia, the average number of deficiencies in nursing homes is 6.1, which is lower than the national average of 9.6, according to Medicare. Although Magnolia Manor West had fewer deficiencies than the average, the level of harm of those four deficiencies led to the nursing home's low rating, according to how Medicare calculates its scores.
Medicare considered all the problems cited in the report to be an "immediate jeopardy to resident health or safety."
The deficiencies Magnolia Manor received were primarily because it failed to report potential abuse to the Georgia Department of Community Health and other required agencies, according to the health inspection report.
According to Magnolia Manor's Abuse Prohibition, Reporting and Investigation Policy, when a complaint or situation is identified, the administrator is supposed to notify the state agency and a resident representative. The ombudsman, an independent advocate who investigates complaints, also should be notified, pending an investigation. The administrator also should direct the investigation or notify the local police department.
Immediate jeopardy to residents because of this failure began in January 2024 and lasted until September 2024, the inspection report says.
Inspectors found Magnolia Manor failed to ensure residents are free from potential abuse, failed to report alleged violations of abuse or neglect and failed to investigate alleged abuse or neglect.
The failure to report created the potential for residents to again be sexually abused by staff or other residents, the inspection report says, which could lead to serious physical or psychological harm for each resident.
Sparks' mother, Linda Sestito, was admitted into Magnolia Manor around the start of the COVID-19 pandemic in 2020 after her hip was broken as she waited to have surgery. Her mother was bedridden while a resident in Magnolia Manor.
During that time, Sestito fell multiple times, Sparks said. These typically occurred because Sestito would try to do things for herself.
The final time Sestito fell in May 2021, a Magnolia Manor nurse called Sparks to inform her. The nurse told her that Sestito was fine, Sparks said, so she didn't worry because this had happened before.
When Sparks spoke with Sestito on the phone four days later, her mother was crying and complaining that she couldn't see. Sestito's symptoms worsened, and she was admitted to the emergency room that evening.
Staff at Magnolia Manor didn't inform emergency medical services that Sestito recently had fallen, Sparks said.
Documents from a Columbus Police Department investigation into Sparks' complaint found that, although Magnolia Manor nurses noted the fall in their records, the patient care report from EMS notes that "staff denies falls."
EMS reported Sestito was unable to form words, leaned to the right and her leg was twitching.
Doctors said that her mother had a brain bleed, Sparks said, and over a week into the hospital stay, a puzzled-looking neurologist approached Sparks.
"Are you sure she didn't fall?" he asked her.
Sparks was shocked to discover the hospital hadn't known her mother recently had fallen before this point.
Sestito died from a subdural hematoma after spending two weeks in the hospital.
After this incident, Sparks shared her story on Facebook and was shocked by the response.
"It was like every day I would log onto Facebook and have another five messages, 10 messages, 20 messages," she said. "I started writing them down."
Others began sharing on Facebook their stories and complaints about the nursing home.
Although Sparks feels Magnolia Manor was neglectful in the care of her mother and others, she said, much of the group members' allegations are difficult to prove.
CPD's investigation of the events leading up to Sestito's death was closed because of a lack of probable cause to establish criminal negligence, according to a CPD report.
Magnolia Manor staff wasn't interviewed by investigators because the U.S. Constitution protects individuals' rights regarding testimony or statements, according to a CPD report.
Although Magnolia Manor Nursing Center-West is the only Columbus area nursing home or assisted living facility out of 11 with a warning for abuse, it doesn't have the lowest rating from Medicare in Columbus.
Magnolia Manor Nursing Center-East, 2010 Warm Springs Road, has a lower overall rating of one star, with two stars for health inspections, three stars for staffing and one star for quality measures as of Feb. 2025. The east campus received two federal fines in the last three years totaling over $11,000 in 2022. Magnolia Manor East received deficiencies for quality of life, infection prevention and resident assessment and care planning.
Canterbury Health Care Facility in Phenix City also has a one-star overall rating, receiving one star for health inspections, two stars for staffing and three stars for quality measures as of Feb. 2025. The facility has not been fined in the last three years.
River Towne Center at 5131 Warm Springs Rd. also has an overall one-star rating. It received one star for health inspections and staffing and three stars for quality measures as of Feb. 2025. This facility has received 16 federal fines in the last three years, totaling over $110,000. Most of River Towne Center's deficiencies are related to quality of life and care.
Sparks is committed to motivating Magnolia Manor and the industry to improve their prevention of abuse or neglect, she said. And she believes her Facebook group provides a space for people to talk about these issues.
"I'm glad people have a place to come and talk," Sparks said. "But, ultimately, groups like mine shouldn't have to exist."