Pruitthealth - Athens Heritage
960 Hawthorne Avenue, Athens, GA 30606 · For profit - Individual · 104 certified beds · (706) 549-1613 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,801 in federal fines (most recent 2024-01-09)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 28% of its spending goes to commonly-owned related companies
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 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 — 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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 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 4 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 | 1.3% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.7% | 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 | 1.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.5% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.1% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.6% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 2.9% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.0% | 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 | 100.0% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.7% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.8% | 11.6% | 12.0% | 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.
65.4% 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 153 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.7% 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 27 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 24% 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 | 65.4%CMS range 57.4–74.3 | 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 | 13.3%CMS range 9.5–16.5 | 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 | 66.7% | 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 | 66.7% | 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 | 70.4% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 2.6% | 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 | 0.0% | 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 | 7.6%CMS range 4.7–13.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.91 | 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 104 beds and averages 87.7 residents a day — about 84% occupied, or roughly 16 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.74 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.79 hrs/resident/day on weekends vs 3.69 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.87 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2024-01-09 · 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 record review, interviews, and review of the policy titled Occurrence Reduction Program, the facility failed to provide adequate supervision to prevent accidents for one of three sampled residents (R) (R1). Actual harm occurred on 12/29/2022, when R1 fell out of bed and suffered a compression fracture of T2/T3 vertebrae, a laceration on her forehead which required sutures, skin tears and multiple bruises to bilateral upper extremities. Findings include: Review of the policy titled Occurrence Reduction Program reviewed 12/9/2021, revealed the policy documents in an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implement upon identification of risk and after a fall. These interventions will be included in the care plan. Review of the clinical record revealed R was admitted to the facility on [DATE] with diagnoses including morbid obesity, chronic obstructive pulmonary disease (COPD), chronic kidney disease, major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medications by Patients/Residents, the facility failed to ensure unauthorized and unsecured medications were not left at the bedside for two of 41 sampled residents (R) (R17 and R86). This deficient practice had the potential to place R17 and R86 at risk of medical complications related to unauthorized medication use. Findings include:Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, revised 1/28/2020, revealed the Procedure section included . 6. All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the Charge Nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary.1. Review of the electronic medical record (EMR) for R17 revealed diagnoses including, but not limited to, chronic systolic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility-provided document titled Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room, the facility failed to maintain a clean, homelike environment in two of 12 resident rooms (rooms [ROOM NUMBERS]) on the 300 Hall. This deficient practice had the potential to place the residents residing in the rooms at risk of living in an unsanitary living environment and a diminished quality of life.Findings include: Review of the undated facility-provided document titled Housekeeping: Discharge and Monthly Deep Cleaning of the Resident Room revealed the Purpose section stated To detail the proper steps for the discharge and monthly deep cleaning of resident rooms in order to create a sanitary and comfortable environment for the resident. The Procedure section included, 1. Before beginning the deep/discharge clean, confirm with Maintenance Director and Housekeeping Supervisor that all Maintenance and floor care needs ( .PTCA [Packaged Terminal Air…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-04 · 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
Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to ensure hazardous chemicals were not stored in one of 34 sampled residents' (R) (R9) rooms. This deficient practice had the potential to place R9 at risk of medical complications related to hazardous chemicals. Findings include: Review of the facility's policy titled Occurrences, revised 1/11/2024, revealed the Policy Statement section included, .To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Review of the electronic medical record (EMR) for R9 revealed diagnoses including, but not limited to, muscle weakness, end-stage renal disease, dependence on renal dialysis, unspecified symptoms and signs involving cognitive functions, dysphagia following cerebral infarction, and aphasia following cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment for R9, dated 6/17/2025, revealed Section…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-04 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered according to the physician's orders for two of 25 residents (R) (R5 and R34) receiving oxygen treatment. This deficient practice had the potential to place R5 and R34 at risk for respiratory complications. Findings include: Review of the facility's policy titled Oxygen Administration, revised 8/2/2023, revealed the Policy Statement section stated, It is the policy of [name of corporation] to provide oxygen safely and accurately to appropriate patients/residents. The Procedure section included, . 4. Regulate liter flow to ordered/desired flow rate. If using portable e-tank, check for full tank, and regulate flow. Turn main control valve on completely and then regulate liter flow meter to ordered/desired flow rate. 1. Review of the electronic medical record (EMR) for R34 revealed diagnoses, including but not limited to, unspecified systolic (congestive) heart failure, ischemic cardiomyopathy, old myocardial…
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 before2024-05-16 · 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
Based on observations, staff interviews, and review of the facility's policy titled, Labeling, Dating, and Storage, the facility failed to ensure food stored in the main kitchen and in the unit kitchenette's, were labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for all residents. The facility census was 83 residents. Findings include: Review of the facility's policy titled, Labeling, Dating, and Storage, revised 11/11/2022, indicated, Food and beverage items will have an identifying label as well as a received date and opened date . for items prepared onsite, a 'use by' date will be indicated. 1. Observation on 5/13/2024 at 9:20 am revealed the following items in the walk-in refrigerator during the initial kitchen tour: A bag of shredded cheese and a block of cheese with no use by date. Nineteen cartons of chocolate milk dated 5/11/2024. Four ½ (one-half) gallon of buttermilk, dated 5/9/24. A container labeled puree turkey, dated 5/9/2024-5/11/2024. A container of cubed potatoes dated…
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 · E2024-05-16 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Advance Beneficiary Notics (ABNs), the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or Notice of Medicare Non-Coverage (NOMNC) for two out of three Residents (R) (R23 and R76) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. The sample size was 29 residents. Findings include: Review of the facility's policy titled Advance Beneficiary Notics (ABNs) with a revised date of 7/19/2016 revealed, Policy Statement: The company recognizes the residents have the right to be informed in writing. in a timely fashion, about their liability for payment not of services prior to the provisions of those services if Medicare is expected to pay. The purpose of an Advance Beneficiary Notice (ABN) is to inform the resident that Medicare will probably not pay for a certain item or service in a specific situation, even if Medicare might pay for the item or…
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 · E2024-05-16 · 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, staff interviews, and review of the facility's policies titled, Pneumococcal Vaccinations and Influenza (Flu) Vaccinations for Health Care Center Residents, the facility failed to provide documentation the pneumococcal and influenza vaccines had been offered, given, or previously received outside of the facility for five of five Residents (R) (R286, R23, R12, R72, and R76) reviewed for immunizations. The sample size was 29 residents. Findings include: Review of a policy provided by the facility titled, Pneumococcal Vaccinations, dated 8/29/2023 revealed All residents who reside in this healthcare center are to receive the pneumococcal vaccine(s) within the current CDC guidelines unless contraindicated by their physician or refused by the resident or residents family. If the resident is cognitively impaired, the responsible party will be contacted, and their wishes will be followed in this matter. Review of a policy provided by the facility title, Influenza (Flu) Vaccinations for Health…
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 before2024-05-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to evaluate and determine if it was appropriate for a resident to self-administer medications for one of 29 sampled Residents (R) (R51). This failure placed the resident at risk for inappropriate and unsafe medication use. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, dated 1/28/2020 revealed, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center . Review of R51's undated Face Sheet, revealed R51 was readmitted with a diagnosis that included chronic obstructive pulmonary disease. Review of R51's quarterly Minimum Data Set (MDS), located in the EMR (electronic medical record) under the MDS 3.0 Assessment tab, with an 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 · D2024-05-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, the facility failed to ensure the call button to activate the emergency call light was accessible for one out of 29 sampled Residents (R) (R53) . This failure placed the resident at risk of accident, injury, and/or unmet needs related to an inability to call for staff assistance. Findings include: Review of R53's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted with diagnoses that included heart disease, stage 3 (three) chronic kidney disease, hemiplegia and hemiparesis, contracture of right knee, dysphagia, ataxia, aphasia, vascular dementia, mood disturbance and anxiety, depression disorder and post-traumatic stress disorder (PTSD). Review of R53's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/29/2024 and located in the MDS tab of the EMR, revealed she scored six out of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R53 required total assistance with toileting, dressing and maximal assistance with…
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 before2024-05-16 · 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
Based on observations, resident and staff interviews, and record review, the facility failed to perform nail care for one out of 29 sampled Residents (R) (R38) requiring substantial or maximal assistance from staff for personal hygiene needs. Findings include: Review of R38's undated Face Sheet, revealed R38 was readmitted with diagnoses that included diabetes, hypertension and frequent falls. Review of R38's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 3/5/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating R38 was moderately cognitively impaired. R38 was also coded as requiring substantial or maximal assistance from staff for personal hygiene. Review of R38's care plans revealed there was no documentation regarding nail care. Observations on 5/13/2024 at 3:47 pm and on 5/14/2024 at 9:28 am revealed R38's fingernails were long with brown debris visualized under them. During an interview on 5/15/2024 at 9:02 am, Licensed Practical Nurse (LPN)1 stated, Her…
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 19 citations
- Potential for harm · D2024-05-16 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, and record review, the facility failed to provide podiatry services to one out of 29 sampled Residents (R) (R38). This failure had the potential to affect one resident's bilateral foot health. Findings include: Review of R38's undated Face Sheet, provided by the facility, revealed R38 was readmitted with diagnoses that included but not limited to diabetes, hypertension, and frequent falls. Review of R38's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 3/5/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R38 had moderate cognitive impairment. Further review of the MDS revealed, R38 required substantial or maximal assistance from helper for personal hygiene. Observation conducted on 5/13/2024 at 3:47 pm revealed R38's toenails were long and unkept. Observation conducted on 5/14/2024 at 9:28 am revealed R38's toenails were long and unkept. During an interview on 5/15/2024 at 9:02 am, 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 · D2024-05-16 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff and resident interviews, the facility failed to accommodate a resident's allergies for one of 29 sampled Residents (R) (R286). Specifically, the facility served R286 foods that were documented as allergies. This deficient practice had the potential to result in harm with an allergic reaction and reduced consumption for R286. Findings include: Review of R286's Face Sheet tab of the Electronic Medical Record (EMR) revealed he was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), type II diabetes (DMII), depression, anxiety, Parkinson's disease, and renal dialysis. R286's allergies were listed as black pepper, cayenne pepper, onions and strawberries. Review of R286's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/4/2024 and located in the MDS tab of the EMR, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition. Review of R286's Care Plan dated 5/5/2024 and located in the Care Plan tab of the EMR, revealed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-09 · tag F0585 — failed to handle grievances — widespreadHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and review of the facility policy titled Grievances: Healthcare Centers, the facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding call light response time, and lack of staff's response to residents unmet needs. The census was 89. Findings Include: Review of the policy titled Grievances: Healthcare Centers, revised date11/21/2022 defined a grievance as complaints with respect to care and treatment furnished to a patient, as well as that which has not been furnished. The policy is for the facility to process grievances and complaints in a prompt, reasonable, and consistent manner. All partners shall take an active part in efforts to resolve grievances and complaints without discrimination or retaliation against a person filing a grievance or complaint. Grievances and complaints should be resolved within three business days and be presented to the monthly Quality Assurance and Performance Improvement Committee. The Administrator is responsible for overseeing the grievance process. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-09 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 Quality Assurance and Performance Improvement Policy (SNF), the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) Program that identified ongoing concerns related to resolving resident grievances and concerns related to dietary services and call light responses. The census was 89. Findings Include: Review of the Quality Assurance and Performance Improvement Policy (SNF) reviewed on 6/2/2022 revealed the purpose of the Quality Assurance and Performance Improvement (QAPI) Program is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission, and commitment to caring pledge. The process is that all partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the QAPI program. Each center must develop, implement, and maintain an effective,…
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 · D2024-01-09 · 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, staff and resident interviews, and review of the policies titled, admission Orders and Peripherally Inserted Central Catheters (PICC), the facility failed to review, verify, document, and transcribe physician orders for one of three sampled residents (R) (R24). Specifically, R24 was admitted to facility with a PICC line, but there were no physician orders for use or care of the device. Findings include: Review of the policy titled admission Orders dated September 2022, indicated the policy in order to assure quality patient/resident care and to comply with Federal law, it is necessary that completed and accurate physician orders for the patient/resident's immediate care be obtained. Number 1: The orders must be reviewed by the admitting nurse and should at least address the patient/resident's dietary needs, medications (if applicable), and routine care to maintain or improve the patient/resident functional abilities. Number 2. The admitting nurse will make every effort to obtain admission…
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 · F2022-10-02 · tag F0725 — failed to have enough nursing staff — widespreadProvide 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 observations, interviews, and record review, the facility failed to ensure there was sufficient staffing to provide the assistance residents needed with activities of daily living (ADLs). This deficient practice had the potential to affect all 81 residents in the facility. Findings include: Review of the 'Residents Census and Conditions of Residents' form revealed the facility had a census of 81 residents on 9/30/22. Of these 81 residents, 33 residents were dependent on staff for bathing, 30 were dependent on staff for dressing, 35 were dependent on staff for transferring, 35 were dependent on staff for toileting, and 12 were dependent on staff for eating. It also revealed 43 residents required the assistance of one or two staff for bathing, 46 residents required the assistance of one or two staff for dressing, 43 residents required the assistance of one or two staff for dressing, 41 residents required the assistance of one or two staff for toilet use, and 65 residents required the assistance of one or…
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 · F2022-10-02 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interview, the facility failed to ensure that the daily nurse staffing information was posted daily and readily accessible to residents and visitors on three of three survey dates, 9/30/22, 10/1/22 and 10/2/22. The facility census was 81. Findings include: Observation on 9/30/22 at 8:34 a.m. during initial tour of the facility, revealed that the required daily nurse staffing information could not be located. Observation on 9/30/22 at 4:11 p.m. revealed the daily nurse staffing information could not be located. Observation 10/1/22 at 10:18 a.m. and 10/1/22 at 3:25 p.m. revealed the required daily nurse staffing information could not be located. Observation on 10/2/22 at 7:57 a.m. and 10/2/22 at 2:23 p.m. revealed the required daily nurse staffing information could not be located. Interview on 10/2/22 at 2:25 p.m., Staffing Coordinator (SC) revealed she has never been told staffing schedule or the staffing hours are supposed to be posted in a high visible area for staff and visitors. Interview on 10/2/22 at 2:35 p.m., the Director of Health Services…
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 before2022-10-02 · 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 the policy titled Labeling, Dating, and Storage, the facility failed to label, and date opened food items. This deficient practice had the potential to effect 74 of 88 residents receiving an oral diet. Findings include: A review of the policy titled Labeling, Dating, and Storage, revised 1/8/21, revealed that the policy did not address the labeling of items with the date after opening. A further review revealed that foods would be stored in their original containers, wrapped tightly with film, foil, etc., and clearly labeled with the name of the item and the use by date. Observation on 9/30/22 at 7:50 a.m., of the dry goods in the kitchen revealed the following items were unlabeled and undated after opening: Sahara Burst Lemon Juice Reconstituted, 32 ounces, no expiration date. Imperial Instant Food Thickener, eight ounces, Best by Date 8/8/24. Sahara Teriyaki Sauce, one gallon, delivery date 9/5/22. Arrezzio Cooking Oil, one gallon, delivery date 7/11/22.…
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 · D2022-10-02 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 policy titled Advanced Directives: Georgia, the facility failed to ensure that the health records which included the physician orders, accurately reflected the code status wishes for two residents (R) (R#7 and R#17). The sample size was 33 residents. Findings include: A review of the policy titled Advanced Directives: Georgia last revised [DATE], revealed revocation of any advance directive for health care will become effective only upon communication to the attending physician by the patient/resident or by a person acting at the patient/resident's direction. The attending physician shall record in the patient/resident's medical record the time and date when the attending physician received notification of the written revocation. 1. Review of the electronic medical record (EMR) for R#7 revealed she was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, diabetes mellitus, congestive heart failure, dementia with…
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 · D2022-10-02 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility procedure titled Lippincott procedures-SBAR (situation, background, assessment, recommendation) Communication, the facility failed to notify the Physician and responsible party (RP) of a change in condition for one resident (R#86). The sample size was 33 residents. Findings include: Review of facility procedure titled Lippincott procedure-SBAR Communication dated [DATE] reads: SBAR, an acronym that stands for situation, background, assessment, and recommendation, is a communication tool that can be adapted for use in various situations. It's useful for framing a conversation in a neutral way, setting expectations for the content of the conversation, and ultimately improving communication among caregivers. SBAR facilitates effective, efficient, consistent, and focused communication. SBAR communication provides a systematic approach to communication during care transitions and in situations in which communication information about the patient's…
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 · D2022-10-02 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to report an injury of unknown origin for one resident (R) (R#77) of 33 sampled residents. Findings Include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 7/29/19, revealed any injury of unknown source should be immediately reported to the Administrator of the provider entity. Further review revealed the State should be notified within two hours after the unknown injury is reported or identified. The Administrator or designee would then direct an investigation into the incident. Additionally, the Ombudsman should also be notified as required by State law. Review of the electric medical record (EMR) revealed R#77 was admitted to the facility on [DATE], with a past medical history of dementia with behavioral disturbances,…
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 · D2022-10-02 · 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, staff interview, and review of the facility policy titled Bed Holds and Room Reserves, the facility failed to provide written bed hold information to the resident or the resident's representative when residents were transferred to the hospital for one resident ( R) (R#85) of 33 sampled residents reviewed for transfers. The findings include: The facility's policy entitled, Bed Holds and Room Reserves, dated 9/2009, read Any patient/resident who is transferred or discharged for the healthcare center to be readmitted , in accordance with applicable regulations, including determining that there are no medical care issues that the medical staff believes the healthcare center will be unable to treat. Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any…
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 · D2022-10-02 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 the Minimum Data Set (MDS) information was accurately documented for four of 33 sampled residents. Findings include: A request on 10/2/22 at 4:32 p.m. for a facility policy revealed the facility did not have policies and/or procedures related to MDS documentation or accuracy. 1. Review of the electric medical record (EMR) revealed R#77 was admitted to the facility on [DATE], with a past medical history of dementia with behavioral disturbances, anxiety, hypertension, congestive heart failure (CHF), cerebral infarct, acute embolism and thrombosis, osteoarthritis, enlarged prostate, gait abnormalities, and traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration. A review of the quarterly MDS assessment dated [DATE], Section G-Functional Status revealed the following: B. Transfer (1) Self-performance did not occur. Activity (or any part of the ADL) was not performed by resident or staff at all over the entire 7-day…
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 · D2022-10-02 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the policy titled, Care Plans, the facility failed to develop a person-centered care plan for one resident (R) (R#135) for incontinence; and failed to follow the care plan for two residents (R#20 and R#45) for activities of daily living (ADL) care. The sample size was 33 residents. Findings include: Review of the policy titled Care Plans, revised 7/21/21, revealed that the interdisciplinary team will develop a comprehensive person-centered care plan for each patient/resident within seven days after completing the comprehensive assessment. The patient/resident and/or the patient's representative would participate to the extent practicable in the care planning process. The person-centered care plan would be developed to include measurable goals and timeframes to meet a patient's/resident's medical, nursing, and psychosocial needs. The services would be to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs identified…
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 · D2022-10-02 · 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 staff interview, the facility failed to develop a discharge plan with an Interdisciplinary Team (IDT) meeting for one resident (R) (R#85) of 33 sampled residents. Findings include: Review of the electronic medical record (EMR) for R#85 revealed she was admitted to the facility on [DATE] with diagnoses that include diabetes mellitus, chronic obstructive pulmonary disease (COPD), hypertension (HTN), urinary tract infection and severe protein calorie malnutrition. Further review of the clinical records revealed the resident was discharged on 12/18/21. Review of the Social Services notes during the resident's stay revealed there was discussion between the IDT and the resident's guardian related to the resident's goal of returning to live in her previous home in an assisted living community. However, a further review of the records revealed no actual discharge plan documented for R#85. Review of a social services note dated 12/17/21 revealed that the Social Services Director (SSD) spoke 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 · Dcited before2022-10-02 · 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 record review, observations, and interviews, the facility failed to ensure that activities of daily living (ADL) were provided for two dependent residents (R) (R#20 and R#45) related to personal hygiene including dressing and facial hair care. The sample size was 33. Findings include: 1. Review of the electronic medical record revealed R#20 was admitted to the facility on [DATE] with diagnoses of but not limited to respiratory distress, cerebral vascular accident (CVA), dysphagia, gait abnormality, chronic obstructive pulmonary disease (COPD), diabetes, encephalopathy, and hyperlipidemia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was coded as five, which indicates severe cognitive impairment. Section G-Functional Status revealed activities of daily living (ADL) assistance was coded as activity did not occur (any part of the ADL) was not performed by resident or staff at all over the entire 7-day period, for dressing, and personal…
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 · D2022-10-02 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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, interviews, and review of the policy titled Medication Administration: Enteral Tubes, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident (R) (R#47), who was observed during the observation of medication administration, by failing to verify placement or check residual prior to administering medications. Findings include: Review of the policy titled Medication Administration: Enteral Tubes, revised 1/31/20, the healthcare center will provide safe and effective administration of medications via feeding tube only upon Physician Order. Procedure & Key Points: 5. Verify tube placement using the following procedure: aspirate stomach contents with syringe. Review of the electronic medical record (EMR) for R#47 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to multiple sclerosis, sepsis, quadriplegia, hypertension (HTN), diabetes, and gastrostomy tube. 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 · D2022-10-02 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services 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 observation, record review, interviews, and review of the Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement, the facility failed to provide evidence for ongoing communication between the facility and the dialysis center for one resident (R) (R#61) of two residents reviewed for dialysis. Findings include: Review of the Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement dated 1/12/21, under section B. Obligations of Operator's Long Term Care Facility 1. Information Sharing: For the purposes of care coordination, in advance of each Resident's dialysis treatment, Long Term Care Facility shall furnish all information and documentation necessary for Dialysis Facility to provide safe and appropriate care, including any and all information reasonably requested by Dialysis Facility. Review of the electronic medical record (EMR) for R#61 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to end-stage renal…
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 · D2022-10-02 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 policy review, the facility failed to ensure that psychotropic medications were not ordered as needed (PRN) beyond 14 days and failed to document the reason for the extension or the period during which the extended order should be in effect for two residents (R ) (R#243 and R#45), of five residents reviewed for unnecessary medications. Findings include: CMS 483.45(e)(4) regulations state that a PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident ' s medical record and indicate the duration for the PRN order. Psychotropic medication order should be limited to 14 days unless the attending physician or prescribing practitioner documents their clinical rationale in the medical record and indicates the duration for the PRN order. 1. Review…
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
$16,801 in federal fines across 3 penalties.
- $4,017 — penalty dated 2024-01-09
- $6,284 — penalty dated 2024-01-09
- $6,500 — penalty dated 2024-01-09
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.
Part of a chain
This home belongs to PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.9 | +1.1 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ATHENS HERITAGE PROPERTIES, INC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 01/24/2011 |
| UNITED HEALTH SERVICES OF GEORGIA, INC. | Organization | DIRECT OWNERSHIP INTEREST | since 11/27/2013 |
| PRUITT, NEIL | Individual | DIRECT OWNERSHIP INTEREST; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 02/02/2026 |
| LISA P HAMBY TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/12/2020 |
| NEIL L PRUITT JR TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 08/12/2020 |
| NWP 2020 CHILD TR FBO J PAIGE PRUITT | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/22/2021 |
| NWP 2020 CHILD TR FBO LISA P HAMBY | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/22/2021 |
| NWP 2020 CHILD TR FBO NEIL L PRUITT JR | Organization | INDIRECT OWNERSHIP INTEREST | since 06/22/2021 |
| PRUITT FAMILY TRUST | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 06/22/2021 |
| UHS-PRUITT HOLDINGS, INC. | Organization | INDIRECT OWNERSHIP INTEREST | since 09/19/2007 |
| UNITED HEALTH SERVICES INC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/27/2013 |
| BAILY, JANEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/03/2025 |
| SHAH, ARPIT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/21/2025 |
| PRUITT, NANCY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 06/16/2025 |
| SMALL, PHILIP | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 06/16/2025 |
| J PAIGE PRUITT TRUST | Organization | ADP OF THE SNF | since 06/22/2021 |
| PRUITTHEALTH CONSULTING SERVICES, INC. | Organization | ADP OF THE SNF | since 11/26/2013 |
CMS files one row per role, so the 26 rows in the source record cover these 17 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.
12 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115509. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-04, 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.