Presbyterian Village - Athens
1400 Live Oak Ln Bldg 100, Athens, GA 30606 · Non profit - Corporation · 40 certified beds · (706) 739-7690 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0606), cited Jul 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $18,545 in federal fines (most recent 2024-07-22)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (76%) runs well above the national median (45%)
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 | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 improved from 1 to 3 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 | 11.1% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.6% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.6% | 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 | 3.1% | 3.2% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.5% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.8% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 28.5% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 74.6% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 19.1% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 5.1% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.48 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 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.
57.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 165 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 41.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 65 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.79 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 57.2%CMS range 51.5–63.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.7%CMS range 8.6–15.7 | 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 | 41.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.4%CMS range 4.8–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 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 40 beds and averages 34.1 residents a day — about 85% occupied, or roughly 6 beds typically open. It runs fairly full. 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 4.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 4.06 hrs/resident/day on weekends vs 5.02 on weekdays — 19% thinner on weekends. RN hours go from 0.60 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 76% is well above 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 fewer than at the previous inspection — improving. 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.
29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · G2024-09-17 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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, interviews, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan, for one resident (R) (R4) reviewed for pain management. Actual Harm was identified on 9/16/2024 when Podiatrist GG failed to stop and assess R4 yelling out in pain while receiving Podiatry care and treatment. The sample size was 9. Findings included: Review of the electronic medical record (EMR) revealed that R4 was admitted to the facility with diagnoses that include but not limited to non-displaced fracture of sacrum, hypertension, mild dementia, anxiety, and depression. Review of the admission Minimum Data Set (MDS) dated [DATE], documented R4 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderate impaired cognition. Observation on 9/16/2024 at 10:18 am, while touring the facility, yelling was noted to be coming from…
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 · G2024-07-22 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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, staff interviews, review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, and review of job descriptions, the facility failed to provide pharmaceutical services that dispensed the correct dosage of physician ordered medication for one of twenty sampled residents (R) (R77). R77 was administered an incorrect dosage of lamotrigine (medication for seizures) for 13 days before a medication error was recognized. Harm was identified to have occurred on 7/15/2024 when R77 experienced a grand mal seizure due to receiving a subtherapeutic dose of lamotrigine. Findings include: Review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, with a review date of 10/5/2021, revealed the Purpose, Objective, and Goals. Purpose: Number 1. To strive to protect the safety and welfare of patients receiving medications while residing in a nursing center. These guidelines are consistent with all State and Federal laws and generally accepted principles of pharmacy 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.
- Actual harm · G2024-07-22 · 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 record review, staff interviews, review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers, and review of employee job descriptions, the facility failed to ensure one of 20 sampled residents (R) (R77) was free from a significant medication error related to not administering medications according to the physician orders. Specifically, R77 was ordered lamotrigine (a medication used to treat seizures) 250 milligrams (mg) extended release (ER) daily, but was only administered 25 mg per day, due to a pharmacy dispensing error. Actual harm was identified to have occurred on [DATE] when R77 suffered a grand mal seizure, as a result of a subtherapeutic dose of lamotrigine for 13 days. Findings include: Review of the policy titled Pharmacy Policy & Procedure Guide for Care Centers with a review date of [DATE] documented Purpose, Objective, and Goals. Purpose: Number 1. To strive to protect the safety and welfare of patients receiving medications while residing in a nursing center. 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 · Ecited before2024-09-17 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 record review, review of the Plan of Correction (POC), staff interviews, and review of the policy titled Care Plans - Comprehensive, the facility failed to follow the plan of care for three of three sampled residents (R) (R1, R2, and R22) related to monitoring and recording meal intake. Findings include: Review of the undated policy titled Care Plans-Comprehensive revealed the policy is to establish guidelines for providing individualized patient care that is multidisciplinary, consistent, coordinated, high quality, and cost effective; to provide guidelines for initiating, customizing, and following a goal-directed plan of care based on best practice. Policy: Number 1. An individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. Number 2. The facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family or representative, develops 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 · D2024-09-17 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 review of the policy titled Skilled Nursing Facility Resident Rights and Podiatry Policy, the facility failed to ensure the Podiatrist provided care in a dignified manner for one resident (R) (R4), while providing foot care, including cutting toenails and evacuation of left great toe subungual hematoma (collection of blood and clot between the nail bed and the nail plate in the fingers or toes), in a common day area with other residents in the common area. The sample size was 9. Findings include: Review of the undated policy titled Skilled Nursing Facility Resident Rights revealed the policy outlines the rights and protections afforded to residents of the skilled nursing facility in accordance with the federal and state laws. It aims to promote a safe, respectful, and supportive environment for all residents. Respect and Dignity: Residents have the right to be treated with dignity and respect. Conclusion: This policy is designed to protect the rights and well…
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 · D2024-09-17 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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, interviews, and review of the facility's policy titled Reporting Resident Abuse, Neglect, and Exploitation, the facility failed to provide a complete and thorough investigation of an allegation of abuse for one resident (R) (R13) reviewed for abuse. The sample size was nine. Findings include: Review of the policy titled Reporting Resident Abuse, Neglect and Exploitation, dated June 2021 Procedure 31-8-83 Investigations: a. The department shall immediately initiate an investigation after the receipt of any report. The department shall direct and conduct all investigations. b. The investigation shall determine the nature, cause, and extent of the reported abuse or exploitation, an assessment of the current condition of the resident, and an assessment of needed action and services. Review of the Electronic Medical Record (EMR) revealed that R13 was admitted to the facility on [DATE] with diagnoses including intestinal obstruction, compression fracture lumbar vertebra, kidney failure, 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 · Dcited before2024-09-17 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, review of the Plan of Correction (POC), interviews, and review of the document titled Bed Hold Letter, the facility failed to provide evidence that notice of the bed-hold policy and return was provided to the resident or residents' representative, upon transfer to the hospital for one of three sampled residents (R) (R6). This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents discharged emergently to the hospital. Findings include: Review of an undated document provided by the facility titled Bed Hold Letter, revealed that Medicare and private insurance companies will not pay to hold the bed at the nursing facility while the resident is hospitalized . The family may hold the bed by paying the private room rate. If you decide not to hold the bed, the facility will assign the bed to a new resident. Upon discharge from the hospital, the resident can be readmitted if a bed is available. Review of the electronic medical record…
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 before2024-09-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 and staff interviews, the facility failed to follow the Physician Orders to offer snacks between meals, for one of three sampled residents (R) (R1). Findings include: Review of the electronic medical record (EMR) revealed that R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, major depressive disorder, gastroesophageal reflux disease (GERD), and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 99, which indicated resident was not able to complete the assessment. Review of September 2024 Order Summary Report revealed an active order dated 8/29/2024 to offer snacks between meals. Review of the Nutrition/Dietary Note dated 8/6/2024 revealed that R1 requires setup and assistance with eating, intake remains poor, 25-50% of meals. Numerous supplements are offered daily to compensate for intake; however, overall consumption is not adequate to stabilize weight.…
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 · D2024-09-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
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, record review, staff interviews, and review of the policy titled Medication Management, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications are given as ordered by the physician. A total of 25 medication opportunities were observed, with two errors, for two of six residents (R) R5 and R16, for a medication error rate of 8%. Findings include: Review of the policy titled Medication Management dated June 2021 revealed the policy is to establish protocol for medication management. Medications are administered by licensed staff including Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Medication Assistants (CMA). Procedure Number 10: Orders required for all medications: facility staff will not allow its staff to assist with, provide supervision of self-administered medications, or administer any medications, including over the counter medications, unless there is a physician's order specifying…
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 before2024-09-17 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of the policy titled Infection Prevention and Control Program, the facility failed to ensure staff one of two nurses observed practiced acceptable infection control practices to prevent possible cross-contamination as evidenced by not performing hand hygiene during medication administration for three of six residents (R) (R5, R3 and R16). The deficient practice had the potential to increase the possibility of cross contamination. Findings include: Review of the undated policy titled, Infection Prevention and Control Program, revealed the Infection Prevention and Control Program includes a system for prevention, identification, investigation, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals. Hand Hygiene: cleanse hands to prevent the spread of potentially deadly infections. Hand Hygiene is the single most important prevention measure healthcare workers can do to prevent infections.…
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 · F2024-07-22 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, review of the Certifying Board of Dietary Managers and interviews, the facility failed to ensure that the dietary department had a designated staff as director of food and nutrition services, was a certified dietary or food service manager, or had a similar food service management or degree to provide the daily functions/duties of a Dietary Manager. This deficient practice had the potential to affect 25 of 25 residents who received meals in the facility. Findings include: Review of the document titled Certifying Board of Dietary Managers dated 4/2023 revealed States Recognizing the CDM, CFPP Credential reads all 50 states must follow the CMS federal guidelines as outlined in rule $483.60 Food and Nutrition Services and have adopted state-level regulations that meet or exceed the federal standards. Review of the employee file for the Dietary Manager (DM) revealed a hire date of 1/29/2021. The DM employee file revealed no certification or education degree in culinary art or any other food service management degree. Interview on 7/22/2024 at 10:27 am, during 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 · Ecited before2024-07-22 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 1. A review of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with diagnoses including neuropathic bladder, orthostatic hypotension, gastroesophageal reflux disease (GERD), muscle weakness, and depression. A review of the Annual Minmum Data Set (MDS) assessment dated [DATE] revealed that R5 presented with a Brief Interview for Mental Status (BIMS) of 14, indicating no cognitive impairment. A review of the Care Area Assessment (CAA) revealed R5 triggered for functional abilities (self-care and mobility), urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. A review of the July 2024 Order Summary Report revealed that R5 was ordered to receive escitalopram 10 mg tablet one time a day related to depression, with start date of 4/3/2024. A review of the care plan for R5 dated 4/8/2024 revealed no focus area for risk of pressure ulcer/injury, psychotropic drug use, functional abilities (self-care 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 · D2024-07-22 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and review of the facility policy titled Abuse/Neglect Prevention Program, the facility failed to ensure employee screening including a criminal background check was received prior to hiring one of 11 employees (Dietary Manager) reviewed for background screening requirements. Findings included: A review of the Abuse/Neglect Prevention Program dated 9/29/2023 revealed that an aggressive abuse prevention program will be implemented in order to identify potential persons capable of abusive behavior prior to hiring. Hiring Practices/Screening: A. This facility will conduct thorough investigation histories of individuals being considered for hire . We will check references and perform criminal background checks. Review of the employee file for the Dietary Manager indicated the date of hire was 1/28/2021. The Georgia Criminal History Check System (GCHEXS) background screening was received by the facility on 5/18/2021. During an interview on 7/21/2024 at 11:35 am, the Director of Human Resources (DHR) confirmed that there are some employees that have a…
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 16 citations
- Potential for harm · Dcited before2024-07-22 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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, interviews, and review of the facility's document titled Bed Hold Letter, the facility failed to ensure written notice of the bed-hold was provided to the resident or residents' representative upon transfer to the hospital for one of two residents (R) (R20) reviewed for hospitalization. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital. Findings include: Review of an undated document provided by the facility, titled Bed Hold Letter revealed that Medicare and private insurance companies will not pay to hold the bed at the nursing facility while the resident is hospitalized . The family may hold the bed by paying the private room rate. If you decide not to hold the bed, the facility will assign the bed to a new resident. Upon discharge from the hospital, the resident can be readmitted if a bed is available. Review of the medical record revealed R20 was admitted to the facility on…
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 · D2024-07-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
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, record review, and interviews, the facility failed to ensure that activities of daily living (ADL) care was provided for two of five dependent residents (R) (R5 and R15). Findings included: 1. A review of the electronic medical record (EMR) revealed that R5 was admitted to the facility on [DATE] with diagnoses including orthostatic hypotension, muscle weakness, and depression. A review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) date of 7/4/2024, revealed that R5 presented with a Brief Interview for Mental Status (BIMS) score of 14, indicating that she was cognitively intact. Review of the Care Area Assessment (CAA) revealed that R5 triggered for functional abilities (self-care and mobility). Observation on 7/20/2024 at 9:14 am, revealed that R5 was pleasant and alert, with ¼ inch length of chin hair. During an interview at this time, R5 stated that she would like to have the chin hair removed, but sometimes she does not notice it. She stated…
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 · F2023-04-16 · 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, staff interviews, and review of facility policies titled, Personnel, Foods Brought in by Family, and Food Production, the facility failed to ensure that food items were properly dated and labeled, and that staff wore proper hair restraints while in food service area. The deficient practice had the potential to affect the 26 residents on the skilled nursing unit that were receiving an oral diet. Findings include: Review of facility undated policy titled, Personnel dated 5/10/2013 revealed under procedure: 6. Employees preparing, handling, and serving food will use effective hair restraints to control loose hair. Review of the facility policy titled, Foods Brought in by Family dated 10/31/2018 revealed under Policy Interpretation and Implementation: All foods brought in must be properly labeled with the resident's name, current date and time, foods brought in will be discarded after 48 hours if not consumed by the resident. Observation on 4/14/2023 at 8:10 a.m. revealed dietary staff…
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 · Fcited before2023-04-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
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 the policy titled Infection Control/Returning to Work/Epidemic Surveillance Plan, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infections. The census was 26. Findings include: Review of the policy titled Infection Control/Returning to Work/Epidemic Surveillance Plan dated 6/2021, indicated the purpose of this policy is to establish the Infection Control Program for Presbyterian Village [NAME] (PVA). PROCEDURE: 1. PVA will provide at general orientation: a. Training provided to staff on effective measures for minimizing the spread of infections. b. Responding to disease outbreaks appropriately and participating in infection control investigations. c. Staff demonstrating their understanding and use of proper infection control practices in their delivery of care to the residents to…
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 · F2023-04-16 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and review of the policy titled Guidelines for Handling Multidrug-Resistant Organisms (MDRO) Management in LTCF, the facility failed to develop and implement an Antibiotic Stewardship Program (ASP) to include antibiotic use protocols and a system to monitor antibiotic usage for the past 12 months. The census was 26. Findings include: Review of the policy titled Guidelines for Handling Multidrug-Resistant Organisms (MDRO) Management in LTCF, dated 5/28/2021, revealed: PROCEDURE: 1. Administrative measures: Prevention and control is an organizational patient safety priority and requires administrative support and the assistance of a trained infection preventionist to assist with the coordination of a prevention and control measures. 9. Antibiotic Use and Stewardship: Monitor and control the use of antibiotics. The stewardship committee consists of the Medical Director, Nursing Staff, Director of Nursing (DON), Infection Preventionist, and the Administrator. DURING AN OUTBREAK: 6. Review antibiotic use to determine if it has a role in MDRO outbreak.…
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 · F2023-04-16 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review, staff interviews, and review of the policy titled Infection Prevention and Control Program, the facility failed to designate at least one qualified individual as the Infection Control Preventionist (ICP) who had completed specialized training in infection prevention and is responsible for the facility's infection prevention and control program (IPCP). This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility census is 26 residents. Findings include: Review of the undated policy titled Infection Prevention and Control Program revealed the policy of this facility's Infection Prevention and Control Program (IPCP), that based upon information from the Facility Assessment and national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. The facility was unable to provide documentation of an effective Infection Control program, as the primary responsibility of the ICP. Interview on 4/15/2023 at 11:00 a.m. with Administrator, stated 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 · E2023-04-16 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
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 and record review, the facility failed to ensure sufficient nurse staffing on a 24-hour bases to care for residents needs related to (1) ensuring that residents and their representatives were included and able to participate in the planning process for three of 14 sampled residents (R) (R#9, R#19, and R#16); (2) the facility did not have a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week; (3) facility failed to follow physician orders related to a treatment for a skin tear for one of 14 sampled residents (R) (R#27). Findings include: 1. A review of the clinical record revealed that R#9 was admitted to the facility on [DATE]. Her son is her POA. The family attended the care plan meeting on 2/23/22 and 5/27/22. There was no additional documentation in the clinical record to indicate that there were any additional care plan meetings after 5/27/22. A review of the Minimum Data Set (MDS) assessments (admission assessment dated [DATE], Quarterly assessment…
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 · E2023-04-16 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility did not have a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week. Findings include: A review of the Payroll Based journal (PBJ) staffing data revealed the following: No RN hours for at least 8 consecutive hours a day on 10/16/22, 11/6/22, 11/7/22, 11/8/22, and 11/20/22. On 4/15/23 at 1:17 p.m. Human Resources Staff II confirmed that she reports the PBJ data. She was asked for the information from October 2022 and November 2022. She stated that she has been employed at the facility since 2020. On 4/16/23 at 10:03 a.m. during an interview with Human Resources Staff II, she recanted her earlier statement and stated that she does not do the reporting to PBJ. She stated that the administrator and corporate staff reports the PBJ data. On 4/16/23 at 11:27 a.m. in an interview with the Administrator, he stated that the three units (Skilled Nursing, Assisted Living, and Memory Care) are all in the same building and share staff. He brought in documentation that there was RN coverage in the building on other units…
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 · E2023-04-16 · 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, interviews, and review of the policy titled Influenza Vaccine Program, the facility failed to offer and/or administer the pneumonia and influenza vaccine to four residents (R) (R#9, R#13, R#16, and R#19) of five residents reviewed for the vaccines. Findings include: Review of policy titled Influenza Vaccine Program dated May 18, 2021, revealed it is the policy of this facility that annually residents are offered immunization against influenza. Residents are offered an influenza vaccine October 1 through March 31 annually unless the immunization is medically contraindicated, already immunized, or the resident/representative chooses to refuse. PROCEDURE: 3. All new admissions will be screened and given the influenza vaccine unless specifically ordered otherwise by the Primary Physician on admission orders. 4. Every admission is screened using the criteria contained within the standing protocol and given the vaccine, if indicated, after receiving education regarding the vaccine. 5. Licensed…
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 · D2023-04-16 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 and interviews, the facility failed to ensure that residents and their representatives were included and able to participate in the planning process for three of 14 sampled residents (R) (R#9, R#19, and R#16). Findings included: 1. A review of the clinical record revealed that R#9 was admitted to the facility on [DATE]. Her son is her Power of Attorney (POA). The family attended the care plan meeting on 2/23/22 and 5/27/22. There was no additional documentation in the clinical record to indicate that there were any additional care plan meetings after 5/27/22. A review of the Minimum Data Set (MDS) assessments (admission assessment dated [DATE], Quarterly assessment dated [DATE], Quarterly assessment dated [DATE], Quarterly assessment dated [DATE], and Annual assessment dated [DATE]) revealed that R#9 was assessed to present with a Brief Interview Mental Status (BIMS) of 10, indicating moderate cognitive impairment. 2. A review of the clinical record revealed that R#19 was admitted to 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 · D2023-04-16 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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, interviews, and review of the policy titled Baseline Care Plan Policy, the facility failed to develop a baseline care plan for one of 14 sampled residents (R) (R#28), that included goals and interventions to meet the immediate care needs present upon admission. Findings include: Review of the undated policy titled Baseline Care Plan Policy, revealed the objective of the baseline care plan is intended to promote continuity of care and communication among nursing home staff, increase safety, and safeguard against adverse events, and inform the resident and/or representative of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. PROCEDURE: 2. Information for the baseline care plan will be based upon admission orders, information from the transferring provider and discussion with the resident and representative. 3. The care plan will include at minimum the following: a. Initial goals based on admission orders b. Physician orders c.…
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 · D2023-04-16 · 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 record review, staff interview, and review of facility policies titled, Written Care Plan and Care Planning Procedures, facility failed to ensure the care plan for one resident (R) (R#4) was revised after a fall. Findings include: Review of facility policy Written Care Plan dated 6/2021 revealed: 'Policy Statement- To develop a plan of care for staff to use as a guide for the delivery of care and services to the residents. Review of facility undated policy Care Planning Procedures, revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition changes. The Care Planning/Interdisciplinary Team is responsible for reviewing and updating of care plans: when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay; and at least quarterly. Resident #4 was admitted to the facility 2/3/2023 with diagnoses of but not…
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 · D2023-04-16 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 and interviews, the facility failed to ensure a discharge plan was developed and documented by the interdisciplinary team based on residents needs for one of 14 sampled residents (R) (R#28). Findings include: A review of the undated policy titled, Transfer and Discharge, provided no information regarding the facility policy and procedure for discharge planning for residents admitted for short term stay. Review of the clinical record revealed R#28 was admitted to the facility on [DATE] with diagnoses including but not limited to orthopedic aftercare for Lumbar Spine Decompression L3-L5. He was discharged to the community on 1/15/2023. The resident's Discharge Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. Section A revealed the resident had a planned discharge to the community. Review of the Care Plan, dated 1/8/2023, revealed no evidence of documentation related to discharge planning. Continued review 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 · D2023-04-16 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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, staff interviews, and review of policy titled Transfer and Discharge Policy, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a post discharge plan of care, or a final summary of the resident's status for one resident (R) (R#28). The sample size was 14 residents. Findings include: Review of the undated policy titled Transfer and Discharge Policy, revealed Presbyterian Home will provide sufficient preparation and orientation to residents to ensure safe and orderly discharge. Review of the clinical record for R#28 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to orthopedic aftercare for Lumbar Spine Decompression L3-L5, spinal stenosis, polyarthritis, and depression. The resident's Discharge Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. Section A revealed the resident had a planned discharge to 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 before2023-04-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 and record review, the facility failed to follow physician orders related to a treatment for a skin tear for one of 14 sampled residents (R) (R#27). Findings include: A review of the clinical record revealed that R#27 is a [AGE] year-old male admitted to the facility on [DATE]. Interdisciplinary note dated 3/21/23 revealed, wound to left forearm area, cleansed with wound cleaner, area pat dry and soft OptiForm dressing applied for protection. Original Treatment Order dated 3/21/23 noted Generic dressing change daily; cleanse skin tear to left lower anterior forearm area with wound cleanser, pat dry and apply soft optifoam dressing daily until health. Updated order on 4/16/23 to reflect cleanse skin tear to right lower anterior forearm area with wound cleanser, pat dry and apply soft optifoam dressing daily until health. On 4/16/23 at 12:20 p.m. R#27 was observed in bed. He was pleasant but confused. His upper right arm was observed with a large, discolored area and a scabbed over…
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 · D2023-04-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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, record reviews, interviews, and review of the facility policy titled Fall Prevention Assessment and Management Guidelines , the facility failed to assure the safety of one resident (R#4) with a history of falls, by not applying a bed alarm while resident was asleep in bed and a chair alarm while she was up in the wheelchair and complete documentation of neuro-checks post fall. The sample size is 14. Findings include: Review of the policy undated titled Fall Assessment and Management Guidelines , indicates residents who have sustained at least one fall are at risk of future falls. After a fall: Follow-up with an assessment log/intervention care plan with Interdisciplinary Team (IDT). Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to, repeated falls, unspecified trochanteric fracture of right femur, restless leg syndrome, other abnormalities of gait and mobility, unspecified dementia mild with other behavioral…
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
$18,545 in federal fines across 3 penalties. 1 Medicare payment denial on record.
- $5,263 — penalty dated 2024-07-22
- $5,264 — penalty dated 2024-07-22
- $8,018 — penalty dated 2024-07-22
- Medicare payment denial — starting 2024-08-30 for 63 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| HAIRE, DEANNA | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 01/01/2025 |
| MEYER, TAMMY | Individual | CORPORATE OFFICER | since 05/22/2020 |
| PATTERSON, STEPHEN | Individual | CORPORATE OFFICER | since 02/01/2020 |
| PEARCE, CHAD | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 01/01/2025 |
| BUENO, YOLIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2021 |
| HONEYCUTT, MATTHEW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2025 |
| ALSTON, LATIVIA | Individual | TRUSTEE OF THE SNF | since 01/01/2021 |
| FUNDERBURK, KEITH | Individual | TRUSTEE OF THE SNF | since 01/01/2024 |
| GLOVER, MARION | Individual | TRUSTEE OF THE SNF | since 01/01/2019 |
| HAUPTFUHRER, GEORGE | Individual | TRUSTEE OF THE SNF | since 01/01/2024 |
| JONES, THOMAS | Individual | TRUSTEE OF THE SNF | since 01/01/2021 |
| MARKLE, DAVID | Individual | TRUSTEE OF THE SNF | since 01/01/2024 |
| MCAFEE, LAURENE | Individual | TRUSTEE OF THE SNF | since 01/01/2025 |
| MORGAN, JAMES | Individual | TRUSTEE OF THE SNF | since 01/01/2023 |
| ROOKER, APRIL | Individual | TRUSTEE OF THE SNF | since 01/01/2024 |
| SNEED, DAVID | Individual | TRUSTEE OF THE SNF | since 01/01/2025 |
| SPARKS, ROBERT | Individual | TRUSTEE OF THE SNF | since 01/01/2025 |
| STEWART, DAVIS | Individual | TRUSTEE OF THE SNF | since 01/01/2022 |
CMS files one row per role, so the 22 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $279K 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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Georgia Medicaid page for homes that do.
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 115775. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-18, 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.