PruittHealth - Augusta
2541 Milledgeville Road, Augusta, GA 30904 · For profit - Corporation · 100 certified beds · (706) 738-2581 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has a citation for mishandling residents’ money or property (F0567)
- it has 2 actual-harm citations
- a high number of inspection citations overall (33) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $180,483 in federal fines (most recent 2025-06-26)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 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 | 5.0% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.7% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.8% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 11.9% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 90.4% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.0% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 11.0% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.2% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.8% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 82.0% | 78.4% | 79.4% | typical |
| Long-stay hospitalizations per 1,000 resident days | 0.63 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.56 | 1.90 | 1.80 | better |
§ 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.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 45% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 100 beds and averages 84.6 residents a day — about 85% occupied, or roughly 15 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 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 2.56 hrs/resident/day on weekends vs 4.17 on weekdays — 39% thinner on weekends — a notable drop. RN hours go from 0.42 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
33 citations, most serious first. The 12 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2025-06-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 the facility's policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to protect the residents' right to be free from physical and sexual abuse by other residents for two of two residents (R) (R96 and R92) reviewed for abuse out of a total of 31 sampled residents. Actual harm occurred when R96 was physically abused by R64, resulting in R96 receiving a fractured clavicle and head laceration. Additionally, R92 was sexually abused by R93. Findings include: Review of the facility's policy titled, Freedom from Patient Abuse, Neglect Exploitation, Mistreatment and Misappropriation of Property Mission Statement, revised 11/15/2024, noted, It is the mission of [Corporation name] and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2025-06-26 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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, staff interviews, record review, and review of the facility's policy titled Pressure Injury Prevention Program, the facility failed to monitor for changes and intervene when a pressure ulcer worsened for one of six residents (R) (R9) reviewed for pressure ulcers out of a total sample of 33. R9 was first identified with a pressure ulcer on 3/21/2025. There was no documented monitoring of the pressure ulcer from 3/21/2025 until 3/31/2025, when the pressure ulcer was noted to have worsened from excoriation to an unstageable pressure ulcer requiring debridement. This caused R9 actual harm when she was subsequently found to have a wound infection and osteomyelitis (infection in the bone). Findings include: Review of the facility's policy titled, Pressure Injury Prevention Program, dated 3/18/2021, revealed, . pressure injury prevention includes assessing for the risk of development. A risk assessment should be performed on admission, at regular intervals, and when the resident experiences a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-06-26 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week. The failure created the potential for a negative impact on residents' quality of care and had the potential to affect 84 of 84 residents who resided at the facility. Findings include: Review of the Payroll Based Journal (PBJ) report, submitted by the facility, noted four days of non-coverage of Registered Nurses during the second quarter of 2025. The dates were identified as 2/8/2025 (Saturday), 2/9/2025 (Sunday), 3/15/2025 (Saturday), and 3/16/2025 (Sunday). Review of the staffing records, provided by the Staffing Coordinator (SC), revealed there was no RN coverage on the four identified dates as required. During an interview on 6/26/2025 at 9:31 am, both the SC and the Director of Nursing (DON) confirmed that there was no RN scheduled on the specified dates. The DON stated, I will come in when we don't have someone to be in the building. I'm sure I was here. The DON acknowledged, at the time 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 · F2025-06-26 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility's policy titled Infection Prevention and Control Plan, the facility failed to have an effective antibiotic stewardship program. This had the potential to result in residents receiving unnecessary antibiotics, increase the risk of multi-drug-resistant organisms (MDROs), and could adversely affect 84 of 84 residents who resided at the facility Findings include: Review of the facility's policy titled Infection Prevention and Control Plan, revised 6/21/2024, revealed the Facility Administrator and Director of Health Service are responsible for supporting the Infection Preventionist . The Infection Preventionist is responsible for directing all infection control activities and assessing, developing, implementing, monitoring, evaluating and managing the Infection Prevention and Control Program . The section for antibiotic stewardship included, . Monitor antibiotic susceptibility results to detect clinically significant antibiotic resistant bacteria . Monitor appropriate and inappropriate antibiotic utilization in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-26 · 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 staff interviews, the facility failed to ensure a safe, clean, homelike environment on two of three units (Unit 1 and Unit 2). Specifically, there was a strong urine smell on Unit 1 and 10 rooms on Unit 1 and Unit 2 (Rooms 1, 2, 4, 9, 13, 20, 21, 23, 25, and 26) with damaged drawer fronts. The deficient practice had the potential to place the residents residing in the rooms at risk of living in a non-homelike environment and had the potential to place the residents at risk of injury related to the damaged drawer fronts. Findings include: 1. During an observation of Unit 1 on 6/23/2025 at 11:45 am, a strong smell of urine was noted. This smell was in the entire hallway, and it was stronger by Rooms 2, 7, 9, and 10, with the strongest smell coming from room [ROOM NUMBER]. Observations on 6/23/2025, at 1:00 pm, 3:00 pm, and 4:45 pm of Unit 1 Hall, revealed that the strong smell of urine continued. There were no times when the smell had decreased in intensity. During an observation 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 · Ecited before2025-06-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
3. During an observation on 6/25/2025 at 8:30 am of R49's incontinent care, Certified Nurse Aide (CNA)1 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 10:40 am of R192's incontinent care, CNA7 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an observation on 6/25/2025 at 11:03 am of R54's incontinent care, CNA2 failed to wash her hands after she discarded the dirty brief and dirty gloves prior to donning clean gloves to apply the clean brief. During an interview on 6/25/2025 at 11:15 am, when asked when she would change gloves during the incontinent care process, CNA2 stated that she would change gloves and wash her hands if the resident had a bowel movement. CNA2 stated that she did not recall being trained to change gloves during the incontinent care process. During an interview on 6/26/2025 at 9:50 am, CNA7 stated that she realized that she should have changed…
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 · E2025-06-26 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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, facility document review, and review of the facility policy titled Pest Control: Dietary Services, the facility failed to have an effective pest control program for the facility's only kitchen. This deficient practice had the potential to place the 84 residents residing in the facility at risk for adverse health effects and a diminished quality of life. Findings include: Review of the facility's policy titled Pest Control: Dietary Services, revised 4/11/2016, revealed, . It is the policy of [facility name] that the Dietary Department is free of rodents and insects at all times to help ensure food is prepared and served in a sanitary environment . Review of the facility's pest control receipts, dated 1/06/2025 through 6/21/2025, provided by the facility revealed: On 1/6/2025: Target Pest: cockroaches, locations insecticide was applied included break room- interior, front door- introduction point, laundry/housekeeping- interior, rear door- introduction point, side door-…
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 · D2025-06-26 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 the facility's policy titled Patient Discharges and Transfers, the facility failed to provide written notification of a facility-initiated transfer to the resident/responsible party (RP) for one of two residents (R) (R72) reviewed for hospitalization out of a total sample of 31. The failure had the potential to affect the residents and/or their representative concerning the residents' appeal rights. Findings include: Review of the facility's policy titled, Patient Discharges and Transfers, dated 3/24/2015, revealed, . When infusion therapy services are discontinued or transferred, the patient will meet [facility name] Pharmacy Services criteria for discharge or transfer. The policy did not address providing written notice to a resident or their representative when transferred to the hospital. Review of R72's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 3/18/2025, and located in the Resident Assessment Instrument (RAI) tab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-26 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to review and revise the comprehensive care plans for four of four residents (Resident) 96, R27, R35, and R9) out of a total sample of 31. The failure placed the residents at risk for unmet care needs and their inability to meet their maximum practicable level of functioning. Findings include: Review of the facility's policy titled, Care Plans, revised [DATE], noted, . The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment . 1. Review of R96's Face Sheet, located in the electronic medical record (EMR) under the Profile tab, identified R96 was admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, unsteadiness 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 · Dcited before2025-06-26 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, the facility failed to investigate the underlying issue for significant weight loss and assess the resident for goals and interventions for weight loss for one of three residents (R) (R82) reviewed for nutritional status out of a total sample of 31. This deficient practice had the potential to place R82 at risk of unmet nutritional needs. Findings include: Review of R82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 5/12/2025, located in the Resident Assessment Instrument (RAI) tab of the Electronic Medical Record (EMR), revealed an admission date of 2/12/2025, had a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating her cognition was severely impaired, weighed 207 pounds, was prescribed a therapeutic diet, and had diagnoses of unspecified fracture of lower end of left tibia, sequela, schizophrenia, unspecified, and muscle weakness. Review of R82's Orders, dated 2/12/2025, and located in the EMR under the Order tab, revealed R82 was to receive a NAS [No Added…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, F-689 Accidents - Water Temperatures, the facility failed to ensure comfortable hot water temperatures were maintained below 110 degrees Fahrenheit (F) for 12 of 40 rooms and for one of two shower rooms. The facility census was 92. Findings include: Review of the facility's policy titled, F-689 Accidents - Water Temperatures dated 1/10/2023 revealed the policy of this facility is to maintain safe water temperatures in resident care areas. Task instructions Number 1 (one) stated: For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees F, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees F. Observations during the initial tour on 1/9/2023 beginning at 10:12 am through 2:16 pm revealed, unsafe water temperatures ranging from 113.0 degrees F 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 · E2024-01-11 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observations, staff interviews, record review, and review of facility's policies titled Medication Administration: General Guidelines and Medication Administration: Insulin Injections, the facility failed to ensure the medication error rate was less than five percent (5%). Specifically, two of four nurses observed during medication administration omitted an antihypertensive medication, administered insulin using the wrong technique and administered supplements without a physician's order resulting in an error rate of 11.54 percent . The facility census was 92. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines dated 4/10/2019, revealed medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's policy titled, Medication Administration: Insulin Injections dated 10/27/2020, under the Policy Statement revealed, It is the policy of this facility that the procedures outlined in this policy must be followed to aid…
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 21 citations
- Potential for harm · D2024-01-11 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Nursing: Patient/Resident Rights, Accommodation of Needs, the facility failed to provide a Geri wheelchair to one of 44 Residents (R) (R39). This failure has the potential for diminished quality of life, and to affect the resident's mental and psychosocial wellbeing. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs dated 12/1/2023 under section titled A. Call Light System revealed, (5). Respond to request. If an item is not available, or a request is questionable, get assistance from Charge Nurse. Return to patient/resident promptly. Review of R39's medical records revealed, she admitted to the facility with diagnoses that included muscle weakness (generalized), contracture of muscle, right lower leg, contracture of muscle, left lower leg, morbid (severe) obesity due to excess calories, and unsteadiness on feet. Review of R39's Quarterly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to provide a safe/clean/comfortable/homelike environment for two rooms on Station one, one room on Station two, and two rooms on Station three. These rooms contained missing hinges from closet doors, missing wood from a closet drawer, stained countertops, a baseboard in disrepair, a stained bathtub with a missing faucet and a dirty fan. The facility census was 92 residents. 1.Observation on 1/9/2024 at 11:27 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/10/2024 at 9:50 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/11/2024 at 10:05 am of room [ROOM NUMBER] revealed bed 39-A closet door hinge missing and bed 39-B closet's drawer door missing wood. Observation on 1/11/2024 at 10:25 am of room [ROOM NUMBER] revealed a stained countertop, baseboard in disrepair, and a stained…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, review of the facility's policy titled, MDS Assessment Accuracy and review of the Resident Assessment Instrument (RAI) Manual 3.0 User's Manual, the facility failed to document the discharge status for three of 42 Residents (R) (, R101, R104, and R106) who discharged from the facility. Findings include: Review of the facility's policy titled, MDS Assessment Accuracy, dated 12/6/2022, Policy Statement revealed the following: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. Review of the Resident Assessment Instrument (RAI) Manual 3.0 User's Manual, version 1.18.11, dated October 1, 2023, revealed the following in Section A2105 Discharge Status, Item Rationale: This item documents the location to which the resident is being discharged at the time of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning, Demographic and outcome…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-11 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities Program, the facility failed to ensure an ongoing program of activities based on activity preference assessments for one of 44 Residents (R) (R39). This failure has the potential to decrease the resident's quality of life and psychosocial wellbeing related to the ability not to participate in group activity and socialize with other residents within the facility. Findings include: Review of the facility's policy titled, Activities Program under Procedure revealed, 3. There shall be at least one different structured recreational activity provided daily each week that shall accommodate residents needs/interest/capabilities as indicated in the care plan. Review of Resident Face Sheet for R39 revealed, she admitted to the facility with diagnoses that included muscle weakness (generalized), contracture of muscle, right lower leg, contracture of muscle, left lower leg, morbid (severe) obesity due…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-11 · 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 and resident interviews, record review and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that one of 44 sampled Residents (R) (R73), received oxygen per physician's orders and to ensure safe administration of oxygen as evidenced by no oxygen in use signage. Findings include: Review of the facility's policy titled, Oxygen Administration dated 8/2/2023 revealed, under the Policy Statement: It is the policy of the facility to provide oxygen safely and accurately to appropriate patients/residents. Review of R73's Electronic Medical Record (EMR) revealed she was admitted with diagnoses including, but not limited to chronic systolic heart failure, pulmonary hypertension, atrial fibrillation, and ventilator associated pneumonia. Review of R73's admission [NAME] Data Set (MDS) dated [DATE], revealed Section C-Cognitive Patterns: Basic Interview Mental Status score of 13, which indicated she was cognitively intact; Section O- Special Treatments…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review and review of the facility's policy titled, Handwashing, the facility failed to reduce the spread of germs and decrease the spread of infection for one of 44 sampled Residents (R) (R25). Specifically, the facility failed to perform hand hygiene during treatment of a sacral wound. Findings include: Review of the facility's policy titled, Handwashing dated 9/19/2017, Policy Statement revealed, It is the policy of the facility that partners will clean their hands by either using soap and water or antiseptic hand sanitizer. Cleaning your hands reduces the spread of germs and decreases the spread of infections. Under the section titled, Procedure revealed When to perform hand hygiene: Before eating, Before and after any direct patient skin contact, After contact with blood, body fluids, excretions, mucus membranes, non-intact skin, or wound dressings, After any contact with objects/medical equipment on the vicinity of the patient, If your hands move from a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-08-12 · 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, interviews, and review of the policy titled COVID-19 Isolation and Cohorting Process and job descriptions titled LPN (Licensed Practical Nurse) Skin Integrity Coordinator, and Registered Nurse Skin Integrity Coordinator, the facility failed to ensure that infection control measures were followed for standard precautions during the provision of wound care for one resident (R) R#87; in addition, the facility failed to ensure staff followed appropriate protocol for personal protective equipment (PPE) use. The sample size was 39. Findings include: 1.Review of the policy titled COVID-19 Isolation and Cohorting Process revised 7/27/22, revealed [name] will provide designated Levels of units within the center for isolating and cohorting residents when making decisions to accept hospital and community admissions, transfers and with management of COVID-19 positive and presumptive in-house residents during the COVID-19 pandemic .When entering the Level I or II area/room, you must make sure you have…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-08-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 record review, observations, interview, and review of the policy titled, Oxygen Administration, the facility failed to maintain the cleanliness of the oxygen concentrator filter, change nasal canula tubing, and bag nasal canula tubing and Continuous Positive Airway Pressure (CPAP) mask when not in use, for four residents (R) (R#5, R#31, R#52, and R#55) of four residents reviewed who required respiratory care. Findings include: Review of the policy titled, Oxygen Administration, revised 11/01/19, revealed it is the policy of.to provide oxygen in safely and accurately to appropriate patients. Scope: This policy applies to Nurses .Procedure .Equipment: Oxygen Concentrator .Infection Control Policy of O2 Humidifier Bottles .7. The large external, black filter should be washed with soap and water once each week and as needed (PRN). Dry with towel and reinsert. Do not discard unless damaged . Regulate liter flow rate to ordered .flow rate.change oxygen tubing . 1. Review of R#5's undated Face Sheet in 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 · E2022-08-12 · tag F0712 — patternEnsure that the resident and his/her doctor meet face-to-face at all required visits.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility document review, the facility failed to ensure residents received physician monthly visits for the first 90 days of admission and/or every 60 days thereafter for six residents (R) (R#2, R#6, R#17, R#34, R#40, R#71) of seven residents reviewed for physician visits. Findings include: Review of the facility document that was provided with the orientation checklist titled, Time Frames for initial Assessments undated revealed, CMS requirements for physician visits states that the resident must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Must be seen means that the physician must make actual face to face contact with the Resident . 1. Review of R#2's Face Sheet in the electronic medical record (EMR) revealed R#2 was admitted to the facility on [DATE] with the diagnoses of mild protein calorie malnutrition, alcohol abuse with withdrawal, dementia with behavioral disturbance, muscle…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 record review, observations, interviews, and review of policy titled Patient/Resident Bills of Rights, the facility failed to ensure one resident (R) (R#23) of 39 sampled residents was provided dressing care/assistance with respect, consideration, or recognition of R#23's dignity. Specifically, facility staff failed to ensure R#23's shirt was put on properly which increased R#23's risk for alternation with his psychosocial well-being. Findings include: Review of policy titled Patient/Resident [NAME] of Rights, revised 2/27/18, revealed .You have the right to have one's property and person treated with respect, consideration, and recognition of patient/resident dignity and individuality. Review of facility-provided document titled Position Description .Certified Nursing assistant (CNA) . modified 6/16, revealed .Provides each of the assigned patients with routine daily nursing care and services .assists residents with dressing and undressing . Review of R#23's undated Face Sheet in the Electronic Medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
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 reviews, observations, interviews, and review of the policy titled, Position Description, the facility failed to ensure residents were provided menus in order for them to have food choices for three residents (R) (R#20, R#40, and R#81) and the facility failed to provide one resident (R) (R#87) of five reviewed a shower, whose preference was to receive a shower instead of a bed bath. Findings include: 1. Review of the Face Sheet in the electronic medical record (EMR), revealed R#20 admitted to the facility on [DATE]. Review of R#20's Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an assessment reference date (ARD) date of 6/6/22 showed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R#20 had moderately impaired cognition. During an interview on 8/8/22 at 12:45 p.m. with R#20, he said, when I was at the rehabilitation place they let you choose what you want, here no one gives you a menu to choose from. 2. Review of the Face Sheet in 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 · D2022-08-12 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 review of the policy titled, Disbursements-Cash/Checks from Resident Trust Accounts, the facility failed to ensure one resident (R)(R#55) of two residents sampled for residents' funds, representative had readily and reasonable access to those funds. Specifically, the facility failed to honor R#55's representative (family) request for disbursement of funds. Findings include: Review of policy dated 10/9 titled Disbursements-Cash/Checks from Resident Trust Accounts revealed .The Financial Counselor will disburse cash to family . Review of R#55's undated Face Sheet located in the Electronic Medical Record (EMR) revealed R#55 was admitted to the facility on [DATE] (current) with (latest return) of 8/3/22. Review of R#55's diagnoses located in the EMR, revealed R#55 had multiple diagnoses to include dementia. Review of R#55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/31/22, revealed R#55's Brief Interview Mental Status (BIMS) score was a three out of 15,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, the facility failed to timely report an injury of unknown origin for one resident (R) (R#55) of two reviewed for abuse. Specifically, R#55 was noted with knee swelling and the report was not submitted timely. Findings include: Review of the policy titled Freedom from Patient Abuse Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement reviewed 1/8/19 revealed .Our policies and procedures establish standards of practice for .investigation and responding/reporting of abuse, neglect, exploitation, mistreatment, and misappropriation of property. Review of R#55's Face Sheet in the electronic medical record (EMR) revealed R#55 was initially admitted to the facility on [DATE] with the latest return of 8/3/22. Review of diagnoses located in the EMR, revealed R#55 had multiple diagnoses to include fracture…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the policy titled Investigation of Patient Abuse, the facility failed to conduct a thorough investigation for one resident (R) (R#70) of two reviewed for alleged staff to resident abuse. Specifically, the facility did not conduct all aspects of R#70's allegation of abuse by failing to interview relevant witnesses and report the alleged incident to the local law enforcement. Finding include: Review of facility policy titled Investigation of Patient Abuse . with a revision date of 10/9/20 revealed policy .provider to investigate allegations and occurrences of patient abuse .The provider should assure that precautions are taken to protect the health and safety of the resident during the course of and following the investigation .Documentation of the investigation should include .Action taken by provider (e.g., safeguarding .police documentation .Interviews should be conducted of all individuals who have relevant information . Review the Face Sheet in the Electronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled, Occurrence Reduction Program, the facility failed to ensure staff provided quality of care for one resident (R) (R#55) of one resident reviewed in accordance with the resident's care plan. Specifically, the facility failed to ensure staff transferred R#55 correctly with a Hoyer lift from her bed to her wheelchair and back. Findings include: Review of policy titled Occurrence Reduction Program dated 11/21/17 revealed .healthcare center recognizes that due to the fragility of the patient/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident .In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk .These interventions will be included in the care plan . Review of R#55's undated Face Sheet in her Electronic Medical Record (EMR) revealed R#55 was most recently admitted to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-12 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled, Patient/Resident [NAME] of Rights, the facility failed to ensure two residents (R) (R#3 and R#16) of eight reviewed were invited to participate in care plan meetings. Findings include: Review of the policy titled Patient/Resident [NAME] of Rights, revised 2/27/18 stated .You have the right to participate in the development and periodic revision of the plan of care/service . Review of the policy titled Care Plans, revised 7/21/21 stated .Focus is on the patient/resident as the center of control. Supports each resident in making his or her own choices. Includes making an effort to understand what each patient/resident is communicating, verbally and nonverbally, to identify what is important to each patient/resident with regard to daily routines and preferred activities and having and understanding of the patient/resident's life before coming to reside in the health care center .The patient/resident and or the patient/resident's representative…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, and policy review titled, Restorative Nursing Program, the facility failed to provide restorative nursing services to four residents (R) (R#3, R#16, R#53, and R#87) of four residents sampled for restorative services. Findings include: Review of the policy titled, Restorative Nursing Program, revised on 11/4/21, indicated It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintain [sic] optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) or a License [sic] Practical Nurse (LPN) and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff .Restorative nursing care will be documented in the HER [health electronic record] or paper form . 1. Review of R#3's undated Face Sheet located in the Electronic Medical Record (EMR) revealed an admission date on 7/27/21 with a primary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observations, interviews, and review of the facility policy titled, Smoke Free Policy, the facility failed to ensure that one of 39 sampled residents (R) (R#291) was free of potential accidents while residing in the facility. Specifically, R#291 was found smoking outside of the facility without supervision, Additionally, the facility was a smoke free facility. This had the potential for a risk of injury to the resident or possible other residents. Findings include: Review of the facility's policy titled, Smoke Free Policy, revised on 2/14/22, revealed .smoking is not allowed on the healthcare center premises by visitors, partners or patient/residents .The admission Director or admitting Licensed Nurse will inform patient/residents and/or legal representative of the smoking policy upon admission .This policy applies to all partners, patients/residents and visitors in the healthcare center .An assessment, utilizing The Smoking Observation Form in the Electronic Health Record is completed at least quarterly thereafter only if the answer to either of the first…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-12 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and review of the policy titled, Documentation: Charting Activities of Daily Living, the facility failed to ensure one resident (R)(R#50) of one resident reviewed for bladder and bowel incontinence was provided incontinence care in a timely manner. Findings include: Review of the policy titled, Documentation: Charting Activities of Daily Living . dated 2/18/21, revealed .It is required for Activities of Daily Living (ADL) care given by Certified Nursing Assistants (CNAs) and Nurses to be documented . in patient's/resident's Electronic Healthcare Record (EHR) .Scope: This policy applies to Certified Nursing Assistants and Nursing Staff . Review of R#50's undated Face Sheet in the Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE]. Review of R#50's diagnoses located in the EMR revealed multiple diagnoses including pressure ulcer of right buttock Stage 4, muscle weakness, adult failure to thrive, and lack of coordination. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-12 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews, and review of the policy titled, Hydration: Dietary Services, the facility failed to ensure two residents (R) (R#70, and R#23) of two residents reviewed for hydration were provided pitchers containing ice/water. Findings include: Review of the policy titled Hydration: Dietary Services revealed .It is the policy of [name] that patients/residents will be adequately hydrated .This policy applies to all partners employed by [NAME] Health (sic) . dated reviewed 10/6/21 and .Each patient/resident will be provided a drinking glass and water pitcher in their room .Water pitchers are filled with ice/water at least but not limited to, twice per day Water pitchers will be cleaned and sanitized at least, but not limited to, two times per week . Review of facility document titled Position Description dated modified 9/16 revealed .Certified Nursing Assistant (CNA) .Provides each of the assigned patients with routine daily nursing care and services 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.
- Potential for harm · D2022-08-12 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that one of one resident (R) (R#293) reviewed for pain management received routine and as needed pain medication in a timely manner. Findings include: A request was made for a policy related to pain management and none was provided. Review of R#293's undated Face Sheet in the Electronic Medical Record (EMR) revealed an admission date of 8/8/22, with a primary diagnosis of spinal stenosis of the cervical region. Comorbidities included pressure ulcer of sacral region, cervicalgia, type 2 diabetes mellitus without complications, and hypertension. Review of a hospital document titled, Narcotic Prescriptions, dated 7/22/22, revealed R#293's physician orders (PO) for Ultram (50 mg [milligrams] tablet) dispense 10 (ten) tabs), 50 mg PO (by mouth) Q6H (every six hours) PRN (as needed) for a pain scale of four to six, No Refills, and Percocet 10/325 mg (1 each tablet) dispense 10 (ten) tabs, give one tab PO Q6H, PRN for a pain scaled of seven to 10. No…
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
$180,483 in federal fines across 6 penalties.
- $157,740 — penalty dated 2025-06-26
- $4,017 — penalty dated 2024-01-11
- $4,017 — penalty dated 2024-01-11
- $4,017 — penalty dated 2024-01-11
- $5,346 — penalty dated 2024-01-11
- $5,346 — penalty dated 2024-01-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 2.8 | -1.8 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ENGEL, CHRISTINA | Individual | W-2 MANAGING EMPLOYEE | since 06/02/2019 |
| PRUITTHEALTH INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2008 |
| PRUITT, NEIL | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 12/01/2018 |
The source lists no ownership percentage for any party here — 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.
This home reported $2.1M paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
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 115334. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, 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.