University Nursing & Rehab Center
180 Epps Bridge Road, Athens, GA 30606 · For profit - Corporation · 122 certified beds · (706) 549-5382 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (74%) 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) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 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 held steady at 1 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 | 16.1% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 4.0% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.6% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 11.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.9% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.3% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.9% | 20.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 93.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.8% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 24.7% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.6% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.4% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 53.4% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 36.6% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 15.5% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.40 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.38 | 1.90 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
53.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.4% 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 47 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 0.22 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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 | 53.3%CMS range 41.4–65.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 7.3–13.4 | 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 | 40.4% | 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 | 53.2% | 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 | 29.8% | 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 | 93.8% | 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 | 97.7% | 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 | 69.6% | 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 | 2.1% | 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 | 3.1% | 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 | 7.9%CMS range 4.8–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 122 beds and averages 93.8 residents a day — about 77% occupied, or roughly 28 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 2.97 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.14 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 2.67 hrs/resident/day on weekends vs 3.09 on weekdays — 14% thinner on weekends. RN hours go from 0.13 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 74% 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 more than at the previous inspection — worsening. 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2026-05-14 · 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 interview, and review of the facility's policy titled DATING AND LABELING POLICY, the facility failed to ensure that food items were properly labeled, dated, and discarded in accordance with facility policy to prevent potential foodborne illness. This deficient practice had the potenitial to affect all 98 residents receiving an oral diet.Findings include:During tour of the kitchen on 05/11/2026 from 9:40 AM to 10:00 AM, and interview with the Dietary Manager (DM) revealed the following concerns:Observation of the walk-in freezer revealed a bag with french toast with use by date of 05/7/2026, a bag with hash brown patties, dated 04/19 with no use-by date indicated, a plastic-wrapped hash brown patties labeled with an open date of 04/19 with no use-by date indicated, and a bag uncooked french fries, dated 05/2/2026 and use by date 05/6/2026.Review of the facility's policy titled, DATING AND LABELING POLICY, revised date 01/1/2026, revealed under Policy: Kitchen will assure food safety by maintaining proper dates and labels to all ready to eat food…
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 · D2026-05-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Self-Administration of Medications, the facility failed to offer and assess a resident for administering her own calcium and medicated mouthwash for one of 49 sampled residents (R) (R48). This deficient practice had the potential to cause the resident to leave medication at her bedside until she was ready to take it and could endanger other residents who wander and are confused. Findings include: Review of the facility's policy titled Self-Administration of Medications, revised 01/2026, section 1, revealed that if the resident expressed his/her desire to self-administer medications, as part of their overall evaluation, the staff and or practitioner shall assess the resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.Review of the electronic medical record (EMR) revealed resident R48 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 · D2026-05-14 · 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 observations, staff and resident interviews, record review, and review of the facility's poliies titled Care Plans-Baseline, the facility failed to provide an updated baseline care plan for one of 49 residents sampled (R) (R8). This deficient practice had the potential to cause a lapse in care for Foley catheter care, JP (Jackson Pratt) drain, and surgical incision care. Findings include:Review of the facility's policy titled Care Plan-Baseline, revised 09/20/2023, section 1 revealed that to ensure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission. Section 2a and b state that the baseline care plan will include initial goals based on admission orders and Physician orders.Review of the electronic medical record (EMR) revealed R8 was admitted to the facility originally in 2023, but was hospitalized for a hernia repair surgery and was admitted on [DATE], with pertinent diagnoses, including but not limited 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 before2026-05-14 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure a physician's order was obtained for oxygen therapy administration for one resident of 13 residents (R) (R19) reviewed who were receiving oxygen therapy. This deficient practice had the potential to affect resident safety by administering oxygen without a current physician order.Findings include:Review of the electronic medical record (EMR) for R19 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD).Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition.Review of the care plan initiated 07/17/2025 revealed a focus stating, Staff explained to me that I need to keep O2 cannula on with humidifier bottle in place to prevent another nosebleed. Interventions included, Encourage me to wear O2 nasal cannula.Further 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.
- Potential for harm · D2026-05-14 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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, resident representative interview, staff interviews, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure one of five residents (R) (R10) reviewed for immunizations were provided education regarding influenza and pneumococcal immunizations and failed to ensure documentation related to vaccine administration, refusal, contraindication, consent, and/or declination for sampled residents reviewed for influenza and pneumococcal immunizations. The deficient practice had the potential to place the 98 residents at increased risk of vaccine-preventable illnesses, including influenza and pneumococcal disease.Findings included:Review of the facility policy titled Infection Prevention and Control Program, revised 09/2023, revealed, in part, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The policy further revealed, Policies and procedures are utilized as the standards 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 · D2026-05-14 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
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, record review, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure residents were timely offered the COVID-19 vaccine, educated regarding the risks and benefits of the COVID-19 vaccine, and failed to ensure documentation related to COVID-19 vaccine administration, refusal, contraindication, and/or consent for one of five sampled residents (R) (R9) reviewed for COVID-19 immunizations. This deficient practice had the potential to place R9 at increased risk of medical complications related to COVID-19. Findings include:Review of the facility policy titled Infection Prevention and Control Program, revised 09/2023, revealed, in part, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The policy further revealed, Policies and procedures are utilized as the standards of the infection prevention and control program. The policy additionally revealed infection…
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 before2025-04-03 · 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, interviews, and cleaning schedule review, the facility failed to maintain the cleanliness of the kitchen creating the potential for contaminated food to be served to 97 of 102 residents that received an oral diet. Findings include: 1. During the initial tour of the kitchen and interview on 3/31/2025 from 8:30 am to 9:15 am, the following was observed: a. The floor in the dish room was missing a section of tiles which measured approximately 11 inches by six inches making it an uncleanable surface. Several more tiles were missing underneath the counter in the dish room. The wall underneath the counter had a dark black substance on the entire wall. The Dietary Manager (DM) stated, We try to clean the wall with a power washer each week. It [wall] needs to be replaced. b. A plastic cover over the cart with the large baking pans had a buildup of grime and was sticky to touch. The cover was over the clean baking pans. c. The air conditioning unit, next to the cart with clean baking pans, was observed with a heavy buildup of dust, dirt, and an unidentifiable sticky…
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 · E2025-04-03 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 and interviews, the facility failed to provide necessary maintenance to five of 49 rooms creating an unsafe, uncomfortable, and unhomelike environment for eight of eight residents (Resident (R) 11, R48, R71, R43, R49, R64, R19, and R25) reviewed for the environment of 29 sample residents. This failure had the potential to affect the residents' homelike environment. Findings include: During observations and interviews on 3/31/2025 from 10:11 am to 11:30 am; at 4:58 pm; and on 4/1/2025 at 10:27 am, the following was observed: a. The end of the handrail was missing outside room [ROOM NUMBER] which exposed a sharp end creating the potential for injuries when residents utilized the rail. b. The call light bulb outside room [ROOM NUMBER] was burnt out. Staff would not know if R11, R48, or R71 turned on their call light for assistance if they were not at the nurses' station, at the opposite end of the hall, to hear the light ringing on the call board. c. There was no call light available for R43.…
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 · D2025-04-03 · 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, interviews, and review of the facility policy titled, Nail Care, the facility failed to ensure nail care was provided for two of three residents (Residents (R) 85 and R8) reviewed for activities of daily living (ADL). This failure had the potential to cause R85 and R8 to have unmet care needs. Findings include: Review of the facility's policy titled, Nail Care, revised 02/18, documented The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and prevent infections . General guidelines, nail care includes daily cleaning and regular trimming . Proper nail care can aid in the prevention of skin problems around the nail bed .Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments . 1. Review of R85's Face Sheet located under the Profile tab of the electronic medical record (EMR), revealed R85 was admitted to the facility on [DATE] with diagnoses which included hypertension, acute kidney failure,…
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 · F2023-12-09 · 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 observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to maintain proper infection control and prevention in 11 of 46 resident rooms (17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) related to storage of resident personal care items. In addition, the facility failed to adhere to and to serve food to residents in isolation using transmission-based precautions (TBP). The deficient practice had the potential to affect all facility residents by exposing them to infection. The facility census was 90. Findings include: Review of the facility policy titled, Infection Prevention and Control Program revised September 2023 revealed: 6. Prevention of Infection a. Important facets of infection prevention include: 3) educating residents, visitors, and staff and ensuring that they adhere to proper techniques and infection control practices…
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 13 citations
- Potential for harm · F2023-12-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff and resident interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship, the facility failed to establish an infection prevention and control program that included an Antibiotic Stewardship Program with included antibiotic use protocols and a system to monitor antibiotic use for four of 27 sampled residents (R) (R77, R38, R58, and R83). This deficient practice had the potential to affect all residents that receive antibiotics. The facility census was 90. Findings include: Review of the facility policy titled, Infection Prevention and Control Program with a revision date of September 2023 revealed: 3. Surveillance a. Standard criteria are used to distinguish between community-acquired from facility -acquired infections .4. Antibiotic Stewardship a. An antibiotic stewardship program shall be implemented as part of the overall infection prevention and control program. b. Culture reports, sensitivity data,…
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 · E2023-12-09 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 interviews, record review, and review of policy and procedures titled Transfer or Discharge, preparing a Resident for, and Bed-Holds and Returns, the facility failed to provide one resident (R) (R290) a discharge summary, three residents (R38, R4, and R291) and/or their representative a notice of transfer or discharge and the reason for the move in writing. Additionally, the facility failed to send a copy of the notice to the representative of the office of the State Long Term Care Ombudsman for four of 52 residents sampled (R290, R38, R4, and R291). Findings include: A review of the undated policy Transfer or Discharge, Preparing a Resident for revealed the policy statement was that residents will be prepared in advance for discharge. The Policy and Interpretation and Implementation section revealed lines numbered 2. A post discharge plan is developed for each resident prior to his or her transfer or discharge. 3. Nursing services are responsible for: (a) obtaining orders for discharge 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 · E2023-12-09 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record reviews, review of the manufacturer's package insert, and review of the facility policy titled, Administering Medications, the facility failed to ensure that one of three residents (R) (R61) received the correct dosage of medication as prescribed by the physician. The deficient practice had the potential to result in medication not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions. Findings include: Review of the undated facility policy titled, Administering Medications revealed the policy line numbered: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medications must check the label three times to verify the right resident, right medication, right dosage, right time, and right route of administration before giving the medication. 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.
- Potential for harm · D2023-12-09 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 and resident interviews, record review, and review of the facility policy titled, Resident Rights and Protected Health Information (PHI), Management and Protection of the facility failed to ensure privacy of clinical information for one resident (R) (R9), specifically by posting signage containing clinical information in R9 room and failed to ensure confidentiality of electronic medical records was maintained for seven residents, specifically by allowing the electronic medical record screen to be visible in a hallway. The sample size was 51 residents. Findings include: Review of the undated facility policy titled Resident Rights indicated the following: 1. Federal and State laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: (t) privacy and confidentiality. 8. The unauthorized release, access, or disclosure of resident information is prohibited. Review of the undated facility policy titled Protected Health Information…
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 · D2023-12-09 · tag F0624 — isolatedPrepare residents for a safe transfer or discharge from the nursing home.
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 interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to document preparation and orientation to ensure a safe and orderly discharge from the facility for one of 52 Residents (R) (R290) reviewed for discharges. Findings include: Review of the facility's policy titled Transfer or Discharge, Preparing a Resident for undated, Policy Statement revealed Residents will be prepared in advance for discharge. Review of the Electronic Medical Record (EMR) revealed R290 was re-admitted to the facility on [DATE] with diagnoses listed but not limited to infection and inflammatory reaction due to peritoneal dialysis catheter and cutaneous abscess of abdominal wall. She was discharged on 6/1/2023. Review of R290's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R290 was cognitively intact. Review of R290's Discharge MDS assessment dated [DATE]…
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 · D2023-12-09 · 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 staff interviews, record reviews, and review of the facility's policy titled, Bed-Holds and Returns, the facility failed to notify residents of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for two residents (R) out of 52 Residents (R4 and R38) reviewed for discharges. Findings include: Review of the facility's policy titled Bed-Holds undated, under the Policy Statement revealed Prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Under the Policy Interpretation and Implementation .revealed 3. Prior to transfer, written information will be given to the resident and the resident's representative that explains in detail: a. The rights and limitations of bed-holds; b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed…
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 · D2023-12-09 · 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
Based on observation, interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement the comprehensive-person centered care-plan for one of 52 Residents (R) (R59), related to dental services. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revision date September of 2023 under the Policy Statement revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Under the section titled, Policy Interpretation and Implementation revealed 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan will be consistent with the residents' rights to participate in the development and implementation of his or her plan of care, including the right to: (g) receive 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 · D2023-12-09 · 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 staff interviews, record reviews, and review of the facility's policy titled, Transfer or Discharge, Preparing a Resident for, the facility failed to complete a discharge summary that includes a recapitulation of the residents stay, reconciliation of medications, and a post discharge plan of care developed for one out of 52 Residents (R) (R87) reviewed for discharges. Findings include: Review of the policy titled Transfer or Discharge, Preparing a Resident for undated, revealed under section titled Policy Interpretation and Implementation 2. A post-discharge plan is developed for each resident prior to transfer or discharge. This plan will be reviewed with the resident, and/or his or her family at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Review of the Electronic Medical Record (EMR) revealed R87 was admitted to the facility on [DATE] with diagnoses listed but not limited to traumatic subarachnoid hemorrhage without loss of consciousness. She was…
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 · D2023-12-09 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing 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, staff interviews, record reviews, and review of the facility's policy titled, Referrals, Social Services, the facility failed to ensure one out of 52 Residents (R) (R24) received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, the facility failed to arrange appointments for vision or hearing services to meet the residents' needs. Findings include: Review of the facility's policy titled, Referrals, Social Services undated Policy Statement revealed, Social services shall coordinate most resident referrals with outside agencies. Under the section titled Policy Interpretation and Implementation revealed 1. Social services shall coordinate most resident referrals. Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. 2. Referrals for medical services must be based on physician evaluation to resident need and related physician order. 3. Social services will collaborate with nursing…
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 before2023-12-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and review of facility's policy titled, Oxygen Administration, the facility failed to ensure that two of 11 Residents (R) (R17 and R70) were administered oxygen therapy in accordance with the physician orders. In addition, the facility failed to ensure that all necessary administration equipment and supplies were in use for one of 11 residents (R70) reviewed with oxygen orders. Findings include: Review of the facility's policy titled, Oxygen Administration, undated, under subtitle Purpose revealed, The purpose of the policy is to provide guidelines for safe oxygen administration. Under subtitle Preparation revealed, Verify that there is a physician's order for this procedure. Review the physician orders or facility protocol for oxygen administration. Under subtitle, Steps in the Procedure revealed, Place an Oxygen in Use sign on the outside of the room entrance. Close the door. 3. Check the tubing connected to the oxygen cylinder to assure that it is free…
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 · D2023-12-09 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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, record review, and review of the facility's policy titled, Referrals, Social Services, the facility failed to provide timely assistance for one of 52 Residents (R) R59 sampled for dental appointments. Findings include: A review of the policy titled undated Referrals, Social Services revealed the policy statement as social services personnel shall coordinate most resident referrals with outside agencies. The section titled Policy Interpretation and Implementation revealed that social services shall coordinate most resident referrals, collaborate with nursing staff or other pertinent disciplines to arrange for services, document the referral in the resident's medical record, with administration maintain a listing of referral agencies, and assist with transportation arrangement to outside agencies, clinic appointments as appropriate. An observation and interview with R59 on 12/5/2023 at 1:56 pm revealed residents' teeth were in poor condition. The teeth did not appear clean.…
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 · D2023-12-09 · 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
Based on observation, staff interviews, record reviews, and reviews of the facility policy titled, Administering Medications, the facility failed to ensure the medication error rate was less than five percent. Four medication errors of 26 opportunities for three residents (R) (R28, R31 and R61) were observed during a medication pass. The medication error rate was 15.38 %. The deficient practice had the potential to result in medication not being given in accordance with the physician's orders and had the potential to affect the residents' clinical conditions. Findings include: Review of the undated facility policy titled Administering Medications revealed under Policy Interpretation and implementation: 2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. 3. Medications must be administered in accordance with the orders, including any required time frame. Medication Administration observation on 12/6/2023 at 8:05 am, revealed Certified Medication Assistant (CMA) BB was observed giving R28 their…
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 · D2023-12-09 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each 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 resident interview, staff interviews, record review, and review of the policy titled Referrals, Social Services, the facility failed to ensure one of 52 residents(R) (R59) was referred to an oral surgeon as recommended by physician in a timely manner. The deficient practice had the potential for R59 to have a delay in needed oral surgery as recommended by the facility contracted dentist. Findings include: A review of the undated facility policy titled, Referrals, Social Services, revealed under policy statement: social service personnel coordinate most resident referrals with outside agencies. Under Policy Interpretation and Implementation: Social services shall coordinate most resident referrals and will document the referral in the resident's medical record. Interview on 12/5/2023 at 1:56 pm with R59 revealed that he did see a dentist, but he thinks he needs to be seen by an oral surgeon but does not remember exactly what the dentist told him. He stated no one at the facility had spoken to him…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to CYPRESS SKILLED NURSING — 5 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 | 1 of 5 | 2.0 | -1.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 1 of 5 | 1.4 | -0.4 vs chain |
| Quality measures | 2 of 5 | 2.2 | -0.2 vs chain |
The other 4 homes this chain runs (chain average 2.0★, per CMS)
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 |
|---|---|---|---|
| OVITS, ISAAC | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2014 |
| PATTERSON, DIANNE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/07/2018 |
| CYPRESS SKILLED NURSING LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2014 |
| BENDER, SARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/02/2025 |
| MACATULA, MARIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/31/2017 |
| NORDHOLM, KATHERINE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/24/2014 |
| POPE, DOROTHY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/01/2003 |
| PUGHSLEY, SONIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 11/05/2024 |
| REDDICK, JOANE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/11/2025 |
| SIMS, DEMARIOUS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/18/2025 |
| UDO, EMEM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2023 |
| VAUGHAN, ALYSSA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/10/2025 |
CMS files one row per role, so the 26 rows in the source record cover these 12 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.
1 organizational owner 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.
About 76% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $477K 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 2023. 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, FY2023). 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 115467. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, 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.