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Harborview Health Center Of Augusta

3618 J Dewey Gray Circle, Augusta, GA 30909 · For profit - Limited Liability company · 120 certified beds · (706) 860-7572 Medicare & Medicaid certified

Call the home — (706) 860-7572 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
1 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (24) — 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 (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (64%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3647 J Dewey Gray Cir · (706) 863-9595 · Call to confirm hours
Pharmacy
3664 Wheeler Rd · (762) 222-3649 · Call to confirm hours
Grocery
630 Crane Creek Dr · (706) 993-9150 · Call to confirm hours
Park
3824 Maddox Rd · (706) 854-0149 · Typically dawn to dusk
Place of worship
844 Scott Nixon Memorial Dr · (706) 869-8187

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 1 of 5
Long-stay residentspeople who live here 2 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.8%15.3%15.4%better
Long-stay residents who lose too much weight8.4%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.1%0.9%0.9%better
Long-stay residents with a urinary tract infection3.2%2.5%2.0%worse
Long-stay residents with depressive symptoms58.9%11.3%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.1%3.2%3.3%typical
Long-stay residents whose ability to walk worsened12.5%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication17.5%20.5%18.9%typical
Long-stay residents given the seasonal flu vaccine75.5%95.0%95.3%worse
Long-stay residents with pressure ulcers6.5%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control13.7%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.6%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.6%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine63.2%78.4%79.4%worse
Short-stay residents rehospitalized after admission31.0%25.0%22.6%worse
Short-stay residents with an outpatient ER visit18.0%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.722.151.67typical
Long-stay outpatient ER visits per 1,000 resident days1.601.901.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. 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.

36.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 113 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

36.6%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
34.9%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 34.9% 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 66 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 27% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF36.6%CMS range 27.5–46.451.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.0–14.910.7%Oct 2022–Sep 2024no 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 discharge34.9%56.6%Oct 2024–Sep 2025CMS 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 discharge31.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge27.3%50.0%Oct 2024–Sep 2025CMS 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 identified89.8%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge96.4%98.7%Oct 2024–Sep 2025CMS 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization9.0%CMS range 5.4–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.071.02Oct 2022–Sep 2024CMS 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

0.81
RN hours/ resident / day
0.78
LPN hours/ resident / day
1.94
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
1.05
RN hoursweekends
63.8%
Total nursing turnover
69.6%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.1 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.94 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 3.50 hrs/resident/day on weekends vs 3.53 on weekdays — 1% thinner on weekends. RN hours go from 0.71 to 1.05 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% 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

6
deficiencies at the latest standard inspection (2026-06-04)
10
at the previous standard inspection (2025-06-05)

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.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 11 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2025-06-05 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure one of one Resident (R)107 reviewed for pain in the sample of 30 residents had his pain managed by ensuring the fentanyl transdermal patches had been available, his pain had been assessed in a consistent manner, and his physician had been notified of the missed pain management medication. This failure resulted in R107 experiencing pain when repositioned. Findings include: Review of the facility's policy titled, Pain Management dated 3/1/2024 revealed The facility must ensure that pain management is provided to residents who require such services .Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Facility staff will observe for nonverbal indicators, which may indicate the presence of pain. Those indicators include but are not limited to: .facial expressions (e.g. grimacing, frowning, fright, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-06-04 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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, staff interviews, and review of facility policies titled, Infection Prevention and Control Program, and Laundry, the facility failed to use proper infection control practices in the laundry area, when storing wash basins on two of five halls and during the provision of tracheostomy care for one of three residents (R) (R5) reviewed with tracheostomies. The deficient practice increased the risk of cross contamination, spread of infection, and increased risk of adverse clinical outcomes. Findings include: Review of the facility policy titled, Infection Prevention and Control Program, reviewed dated 02/01/2025, revealed in section 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. In section 13. Residents/Family/Visitor Education and Screening. c. Isolation signs are used to alert staff,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 facility policy titled, Preventative maintenance program, the facility failed to ensure residents were provided with a safe, clean, and comfortable environment, as evidenced by unclean Packaged Terminal Air Conditioner (PTAC) unit filters in three of nine rooms on 300 Hall (rooms [ROOM NUMBER]), two of 16 rooms on 400 Hall ( rooms [ROOM NUMBERS] ), and one of 16 rooms on the 500 hall (room [ROOM NUMBER]). This deficient practice had the potential to expose residents to poor air quality and contaminants throughout the environment. Findings Include: Review of facility policy titled, Preventive Maintenance Program. revealed 1. The maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the building's grounds and equipment are maintained in a safe and operable manner. 2. The maintenance director shall assess all aspects of the physical plant to determine if preventative maintenance is required. Required…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0554 — isolated
    Allow 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, resident and staff interviews, record review, and review of the facility policy titled, Self-Administration of medication, the facility failed to ensure that one of 60 sampled residents (R) (R7) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include:A review of the facility policy titled Self-Administration of Medications, revised December 2016, revealed the Policy Statement is that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident; . 5. The staff and practitioner will…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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's policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to assess and apply for PASARR II (Preadmission Screening and Resident Review) services for one of 60 sampled residents (R) (R1). This deficient practice had the potential for R1's mental health needs to go unmet.Findings include: Review of the electronic medical record (EMR) revealed R1 was admitted with pertinent diagnoses, including but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the left side, chronic obstructive pulmonary disease, major depressive disorder, general anxiety disorder, unspecified psychosis, and suicidal ideations.Review of R1 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 9, which indicated R1 had moderate cognitive impairment. Section GG, functional status, revealed R1 required extensive assistance for activities 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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, staff and resident interviews, and review of the facility policy titled, Activities of Daily Living, the facility failed to ensure that Activities of Daily Living care was provided for one dependent resident (R) (R28) related to bed baths and nail care. The deficient practice had the potential for to place R28 at risk of a diminished quality of life. Findings include:Review of the facility's policy titled, Activities of Daily Living, review date 03/01/2025, revealed in section, Policy Explanation and Compliance Guidelines, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the annual Minimum Data Set (MDS) dated [DATE] for R28 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact.Review of the care plan dated 05/31/2025 indicated R28's Focus: needs assist with grooming, bathing, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to discard expired medications on two of four medication carts reviewed. This deficient practice created the potential for expired, improperly stored medications to be used in resident care, placing residents at risk for compromised safety and potential adverse consequences.Findings include:Review of the facility's policy titled, Medication Administration, revealed under Policy Explanation and Compliance Guidelines: .13. Identify the expiration date. If expired notify the manager.Observation on 06/02/2026 at 7:56 AM of the medication cart for the 200 Hall revealed two pill bottles containing Novolog insulin vials that had been opened with expiration dates of 04/22/2026 and 05/09/2026; confirmation was done with Licensed Practical Nurse (LPN) CC.Observation of the 400 Hall medication revealed one insulin vial dated 05/27/2026 and confirmed by Certified Medication Aide (CMA) GG were observed on 400 hall medication cart and confirmed by Unit…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-06-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 observation and interview, the facility failed to ensure all items in the refrigerator, and freezer were sealed, labeled, and dated. These failures had the potential to affect 110 of 112 residents who received their meals from the kitchen at risk of foodborne illnesses. Findings include: During an observation on 6/2/2025 at 8:40 am with the kitchen cook (Cook 1) revealed the following observations: Located in the kitchen were four large plastic containers with lids that each contained breadcrumbs, thickener, flour, and sugar. The containers were not labeled and dated. The Walk-In Refrigerator contained metal containers of watermelon, ketchup, and cucumbers. These items were outdated and dated 5/27/2025. There was no labeling or dating on a bowl of icing, two sandwiches, one bag of sliced cheese, one bag of ham, poured glasses of iced tea and a cooked pan of broccoli. The pan of broccoli was not sealed to prevent air from touching the broccoli. The Walk-In Freezer contained one box of biscuits that were not sealed exposing the biscuits to air. Interview on 6/5/2025 at 5:32…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-05 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's policy titled, Medication Administration and review of the facility provided document titled Primary Pharmaceutical Provider Contract, the facility did not ensure medications were available for two of two Residents (R) (R107 and R220). This failure placed residents at risk for complications from missing medications. Findings include: Review of the facility's policy titled, Medication Administration dated 6/1/2024 revealed there was not a procedure for when a medication was not available. Review of the Primary Pharmaceutical Provider Contract dated 5/1/2025 revealed the pharmacy would Provide drugs and supplies as required for patients/residents and Nursing Facility in accordance with facility policy and procedures .Provide a regular delivery on Monday thru Saturday and after-hours deliveries 24 hours per day 7 days per week for new emergency or 'stat' orders not available in emergency kits or thru back-up pharmacy. 1. Review of R107'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-05 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the manufacturer's recommendations, the facility failed to ensure insulin pens or vials had pharmacy labels, were dated when opened, and were not used after the expiration date for two of two medication carts (100 hall and 200 hall). This deficient practice increased the risk of insulin used after the expiration date to be less effective which had the potential to cause high blood sugar levels. Findings include: Review of the manufacturer's recommendations for insulin glargine, Humalog, and Lispro from [Name] and Company revealed when the insulin vial and/or insulin pen was removed from refrigeration it was only effective for 28 days. Review of the manufacturer's recommendations for insulin Novolog and Aspart from Novo Nordisk revealed when the insulin vial and/or insulin pen was removed from refrigeration it was only effective for 28 days. Review of the manufacturer's recommendations for Toujeo Solostar from Sanofi revealed when the insulin vial and/or insulin pen…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 staff interview, record review, and review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, the facility failed to provide the resident and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for one of six Residents (R) (R59) reviewed for Advanced Directives. This failure created the potential the resident wishes would not be followed if the resident was unable to speak for themselves. Findings include: Review of the facility's policy, titled, Residents' Rights Regarding Treatment and Advance Directives dated 3/1/2025 revealed, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed on advance directive, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2025-06-05 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to update one of two Residents (R) R80 care plan interventions to include measures to prevent pressure ulcers. Specifically, R80 had acquired three pressure ulcers after readmission from the hospital and his care plan had not been revised with interventions to prevent the development of pressure ulcers. Findings include: Review of R80's Clinical Census in the Electronic Medical Record (EMR) under the Clinical Census tab revealed admission date of 1/2/2025, hospitalization on 2/13/2025 and readmission on [DATE]. Review of R80's Medical Diagnosis in the EMR under the Medical Diagnosis tab revealed diagnoses multiple fractures of ribs on the right side, lumbar vertebra fracture, prostate cancer, and diabetes mellitus type 2. Diagnoses added 2/13/2025 to 2/17/2025 hospitalization included deep vein thrombosis (DVT) of the right lower leg, and pneumonia. Review of R80's Care Plan in the EMR found under the Care Plan tab dated 1/14/2025 indicated…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure one of five Residents (R) (R80) who was at risk for acquiring a pressure ulcer had preventative measures in place to avoid the development of pressure ulcers. Specifically, R80 acquired three pressure ulcers after his readmission to the facility. Findings include: Review of R80 ' s Clinical Census in the Electronic Medical Record (EMR) under the Clinical Census tab revealed admission date of 1/2/2025, hospitalization on 2/13/2025 and readmission on [DATE]. Review of R80 ' s Medical Diagnosis in the EMR under the Medical Diagnosis tab revealed diagnoses multiple fractures of ribs on the right side, lumbar vertebra fracture, prostate cancer, and diabetes mellitus type 2. Diagnoses added 2/13/2025 to 2/17/2025 hospitalization included deep vein thrombosis (DVT) of the right lower leg, and pneumonia. Review of R80 ' s Care Plan in the EMR found under the Care Plan tab dated 1/14/2025 indicated at risk for altered skin integrity related…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interviews, the facility failed to arrange podiatry services for two (residents (R) 15 and 33) of two residents reviewed in the sample of 30 residents. The facility failed to ensure at risk residents receive appropriate foot care services. Findings include: Review of R33's Face Sheet found in his electronic medical record (EMR) under the Face Sheet tab revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and difficulty walking. Review of R33's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/10/25 in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R33's cognition was moderately impaired. During a review of R33's EMR, a document located under the Documents tab revealed a podiatry visit on 08/30/22. The document indicated that the facility requested podiatry services for R33 in relation to his toenails. The document also…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 observation, interview, record review, and facility policy review, the facility failed to ensure residents respiratory equipment was maintained and stored appropriately for one of two resident (Resident (R) 83) reviewed for respiratory care out of 30 sampled residents. These failures placed the resident, who has a tracheostomy, at risk for environmental contamination which could lead to respiratory infections. Findings include: Review of the facility's policy titled, Oxygen Administration dated 03/01/23 revealed .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Keep delivery devices covered in plastic bag when not in use . Review of R83's admission Record located in the resident's electronic medical record (EMR) under the Profile tab, revealed R83 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, chronic respiratory failure, gastrostomy, and tracheostomy. Review of R83's Physician Order dated 06/02/25 and located in…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's policies titled, Personal Protective Equipment and Handwashing/Hand Hygiene, the facility failed to ensure two of two staff (Certified Nursing Assistants (CNA) (CNA1 and CNA2) wore a gown and performed hand hygiene before, in-between, and after glove changes when they provided personal care to one Residents (R) (R107) who was on Enhanced Barrier Precautions (EBP); one of one Wound Care/Registered Nurse (WC/RN) failed to perform hand hygiene before, in-between, and after glove changes during wound care for R97; and two of two Certified Medication Aides (CMA) (CMA1 and CMA2) failed to sanitize the wrist blood pressure (B/P) cuffs between residents' use for R72 and R82. Findings include: Review of the facility's policy titled, Personal Protective Equipment (PPE) dated October 2018 revealed personnel who perform tasks that may involve exposure to blood/body fluids are provided proper PPE .PPE required for transmission-based precautions is maintained outside and inside the resident's room as needed. Review of the facility'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and review of the facility's policies titled, Resident Rights and Confidentiality of Personal and Medical Records, the facility failed to ensure personal information was kept confidential for two residents (R) (R19 and R20) of 20 sampled residents. Specifically, the residents' medication cards containing resident information were left unattended on top of the 400-unit Medication Cart. Findings include: Review of the facility's policy titled, Resident Rights, dated February 2021, documented .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA [Health Insurance Portability and Accountability Act] compliance officer. Review of the facility's policy titled, Confidentiality of Personal and Medical Records, revision date of 3/1/2023, documented This facility honors the resident'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0585 — failed to handle grievances — isolated
    Honor 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 interviews, record review, and review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure their grievance procedures were followed for one of one resident (R) (R 3) reviewed for grievances of 20 sampled residents. Findings include: Review of the facility's policy titled, Resident and Family Grievances, dated 1/30/2023, indicated .It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal .The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form .Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow-up .All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgement of complaint/grievance .In accordance with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 Pressure Injury/Wound Treatment Management, the facility failed to ensure that one of two Resident (R) (R 16) observed for pressure ulcer treatment, had a dressing maintained for a stage IV sacral ulcer. Specifically, there was no dressing covering R16's sacral pressure ulcer leaving it exposed to urine and feces. Findings include: Review of the facility's policy titled, Pressure Injury/Wound Treatment Management dated 3/1/2022, documented To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing, b. The dressing has dislodged, c. the dressing is soiled otherwise, or is wet. Review of R16's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated R16 was admitted to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and review of a policy provided by the facility titled Maintenance of Clinical Records, the facility failed to ensure that clinical records were complete and contained accurate documentation for three Residents (R) (R 3, R1, and R4) out of 20 sampled residents. Findings include: Review of a policy provided by the facility titled, Maintenance of Clinical Records, dated 3/1/2023, indicated .This facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided .In accordance with accepted professional standards of practices, the facility must maintain medical records on each resident that are .Complete .Accurately documented . 1. Review of R3's electronic medical records (EMR) titled admission Record located under the Profile tab, indicated the resident was admitted with diagnoses that included chronic pain, left hand contracture, and gastrostomy status. 1. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-10 · tag F0554 — isolated
    Allow 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, interviews, record reviews, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to assess one of 20 Residents (R) (R11) receiving topical medications for wound care, for the ability to self-administer a topical medication. This failure had the potential for medication error and to alter the effectiveness of the medication. Findings include; Review of the facility's policy titled, Resident Self-Administration of Medication dated 3/1/2023 under subtitle Policy Explanation and Compliance Guidelines revealed, 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record .4. The results of the Interdisciplinary Team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record 7. Bedside…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-10 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 interviews and record review, the facility failed to honor reasonable accommodations for preferences related to bathing for one of 36 sampled Residents (R) (R64). Findings included: Review of the clinical record revealed that R64 presented with diagnosis that included but not limited to hemiplegia, unspecified affecting left nondominant side; venous insufficiency (chronic) (peripheral); chronic venous hypertension (idiopathic) with ulcer of right lower extremity; contracture, left elbow; contracture, left hand; cerebral infarction; ataxia; and muscle wasting and atrophy. Review of R64's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed for Section C: Cognitive Patterns- a Brief Interview of Mental Status (BIMS) of 13; Section E: Behaviors- indicated no behaviors were noted; Section G: Functional Status-indicated limitations on one side with range of motion (ROM); required substantial to maximal assistance with staff doing more than half the effort with bathing/showers. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-10 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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, staff interviews, record review, and review of the policy, Comprehensive Care Plans, the facility failed to ensure one of 36 Residents (R) (R86) reviewed for care plans were followed. Specifically, the facility failed to verify placement for R86's percutaneous endoscopic gastrostomy (PEG) tube used to receive medications, fluids, and nutrition as specified in the care plan. Findings include: Review of the facility policy titled Comprehensive Care Plans, last reviewed 1/1/2023, revealed the person-centered care plan would include measurable objectives and timeframes to meet a resident's medical and nursing needs. The plan revealed qualified staff would carry out the interventions specified in the care plan. Review of R86's care plan dated 5/5/2023 revealed that nursing staff would verify tube placement before tube flushes or medication administration. During a medication administration observation for R86 on 12/9/2023 at 8:55 am, the Licensed Practical Nurse (LPN AA) did not verify PEG tube placement before administering medications or flushes. During an…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-10 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure 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

    Based on observation, staff interview, record review, and review of the facility's policy titled Medication Administration via Enteral Tube, the facility failed to properly utilize the percutaneous endoscopic gastrostomy (PEG) tube for one of seven Residents (R) (R86) that received medications, fluids, and nutrition via (by way of) a PEG tube. Findings include: Review of the facility's policy titled Medication Administration via Enteral Tube, dated, 3/1/2023, revealed staff must verify tube placement before administering fluid or medications. Review of the Competency Assessment Administering Medications through an Enteral Tube, form H5MAPR0004, revealed nursing staff would verify the PEG tube placement before medication administration. Medications should be poured into the barrel of the syringe while holding the tubing slightly above the level of insertion. The medications would drain from the tubing before a flush between medications. Review of R86's care plan dated 5/5/2023 revealed that nursing staff would verify PEG tube placement before tube flushes or medication…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to HARBORVIEW HEALTH SYSTEMS — 22 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 →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 2 of 52.1-0.1 vs chain
Staffing 2 of 52.4-0.4 vs chain
Quality measures 1 of 52.3-1.3 vs chain
The other 21 homes this chain runs (chain average 1.9★, 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 / managerTypeRoleShareSince
GA NC 14, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 04/27/2022
BRODERICK, ASHLYNIndividualW-2 MANAGING EMPLOYEEsince 04/27/2022
ENGLANDER, DAVIDIndividualCORPORATE OFFICERsince 04/27/2022
LEIBOWITZ, CHAIMIndividualCORPORATE OFFICERsince 04/27/2022

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.

$12.0M
Net patient revenuemost recent cost report
+5.7%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 63%Medicare 12%Other / private 25%

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

$293per resident / day
operating cost
$8,903per month
≈ monthly operating cost
$311per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Georgia
$8,821/mo
Nursing home (semi-private)
$9,429/mo
Nursing home (private)
$5,300/mo
Assisted living

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 115291. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-04, 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.

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