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Memorial Manor Nursing Home

1500 East Shotwell Street, Bainbridge, GA 39819 · Government - Hospital district · 107 certified beds · (229) 246-3500 Medicare & Medicaid certified

Call the home — (229) 246-3500 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent May 2025
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
Worth asking about
  • 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
  • a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
  • its facility-reported quality-measure rating is low (2/5)

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1504 E Evans St · (229) 246-6600 · Call to confirm hours
Pharmacy
Walgreens<0.1 mi
1410 E Shotwell St · (229) 246-1441 · Call to confirm hours
Grocery
1615 E Shotwell St · (229) 248-0832 · Call to confirm hours
Park
Bainbridge Georgia · Typically dawn to dusk
Place of worship
1693 Martin Luther King Jr Dr · (229) 421-1343

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 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 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.

Overall rating2★
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 increased27.5%15.3%15.4%worse
Long-stay residents who lose too much weight7.8%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder2.1%0.9%0.9%worse
Long-stay residents with a urinary tract infection3.9%2.5%2.0%worse
Long-stay residents with depressive symptoms0.5%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened30.8%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.9%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.5%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control13.2%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table25.0%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.6%1.4%better
Long-stay hospitalizations per 1,000 resident days1.262.151.67better
Long-stay outpatient ER visits per 1,000 resident days1.381.901.80better

§ 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.

10.1%U.S. median 10.7%
Went back to hospital

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 SNFnot 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 SNF10.1%CMS range 7.2–14.710.7%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 dischargenot 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 dischargenot 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 dischargenot 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 identifiednot 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 settingnot 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 dischargenot 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 staynot 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 worsenednot 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 hospitalizationnot 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 SNFs0.701.02Oct 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

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

7
deficiencies at the latest standard inspection (2025-05-01)
3
at the previous standard inspection (2023-02-09)

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.

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.

19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.

  • Potential for harm · E2025-05-01 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor 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 observation, staff and resident interviews, record review, and review of the facility's policy titled Dignity, the facility failed to ensure residents ate in a dignified manor in that the facility supplied plastic utensils during meal service affecting three of 34 sampled Residents (R) (R3, R21, and R35). The plastic utensils were difficult for some of the residents to grip and carry food to their mouth for residents with certain disease processes. Findings include: Review of the facility's undated policy titled Dignity revealed, All Residents are to be treated with dignity, respect, consideration, and in a manner that recognizes their individuality. 1. During an interview on 4/28/2025 at 12:57 pm, R21 stated that she ate all meals in her room. When asked why she had plastic utensils, R21 said that was what always came with the trays. Review of the admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed R21 was admitted on [DATE]. Review of the Quarterly Minimum…

    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 · D2025-05-01 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    Based on staff interviews, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to report an alleged staff to-resident verbal abuse to the State Agency (SA) within the required time frame for one of one resident reviewed for abuse. Specifically, an allegation of verbal abuse by Licensed Practical Nurse (LPN) 1 to a resident. The deficient practice had the potential for continued episodes of unreported abuse, which posed potential for intimidation or mental anguish for the victimized residents. Findings include: Review of the facility's policy titled, Abuse Prohibition Policies and Procedures, revised 4/1/2015, indicated The Director of Nursing and/or designee shall ensure that the Compliant Center is notified immediately, or as soon as practical, of all allegations which appear to a reasonable person to be related to patient abuse,. Review of the facility's staff abuse education packet titled, The Many Forms of Resident Abuse and Neglect, indicated There are multiple types of abuse, including: Physical Abuse, Mental…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to protect residents during an active investigation of alleged staff to resident verbal abuse by Licensed Practical Nurse (LPN) 1, who was permitted to work while the facility's Administrator conducted an active investigation for one of one abuse investigation reviewed. The deficient practice had the potential for continued episodes of staff-to-resident verbal abuse and the potential for victimized residents to suffer from intimidation or mental anguish. Findings include: Review of the facility's policy titled Abuse Prohibition Policies and Procedures dated 4/11/2025 indicated, Protection of resident(s) during investigation: The safety of the resident(s) will be immediately secured by the first facility employee aware of the alleged abuse. Review of the intake form received from the State Agency (SA) revealed an allegation dated 3/19/2025 in which Licensed Practical Nurse (LPN) 1 verbally abused a resident from an anonymous source.…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-01 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to assist one out of 34 sampled Residents (R) (R44) with turning and repositioning. The deficient practice has the potential to cause the resident skin breakdown. Findings Include: Review of R44's Electronic Medical Record (EMR) revealed R44 admitted to the facility with diagnoses that include but not limited to of venous insufficiency, diabetes, and peripheral vascular disease. Review of R44's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/5/2025 in the EMR under the MDS tab for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R44 was cognitively intact; Section GG (Functional Abilities and Goals) revealed, resident was dependent with rolling left to right, sit to lying, lying to sitting and sitting to standing position. Observation on 4/29/2025 at 10:21 am, R44 was in bed lying on her back with feet elevated in boots to off load heals. Observation on 4/29/2025 at 11:00 am, R44 remains lying on her back in bed.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-01 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide 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

    Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for two out of 34 Residents (R) (R44 and R45) reviewed for incontinent care. This failure placed the residents at risk for skin breakdown and/or risk for transmission of infection to the urinary tract. Findings include: Review of the facility's Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 11/7/2024 for CNA5, dated 11/11/2024 for CNA7, and dated 11/12/2024 for CNA 3 indicated, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. Review of the Nursing Procedure Guide for Long-Term Care on Perineal Care provided by the Clinical Care Coordinator (CCC), documented, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water,…

    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 · D2025-05-01 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to have a system in place to ensure ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments for one of one Resident (R) (R47) receiving dialysis treatments. The failure created the potential for the resident's quality of care to be compromised. Findings include: Review of the admission Record located under the Profile tab in the Electronic Medical Record (EMR) noted R47 was readmitted on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of Physician's Orders dated April 2025 located in the EMR under the Orders tab, revealed, R47 received dialysis on Monday, Wednesday, and Friday each week. Review of R47's Progress Notes located in the EMR under the Progress Notes tab revealed, there was no documented communication between the facility and dialysis center pre and post treatments to include an assessment of the residents' health status.…

    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 before2025-05-01 · 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 record review, the facility failed to adhere to infection control practices during peri care related to the staff failing to change gloves and perform hand hygiene for three out 34 sampled residents (R44, R45, R308). Findings include: Review of the facility's Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 11/7/2024 for CNA5, dated 11/11/2024 for CNA7, and dated 11/12/2024 for CNA 3 indicated, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. Review of the Nursing Procedure Guide for Long-Term Care on Perineal Care provided by the Clinical Care Coordinator (CCC), documented, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. 1. Observation…

    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 · Ecited before2024-10-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide 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

    Based on observations, staff interviews and review of the facility's policy titled, Care of the Resident with a urinary catheter, the facility failed to ensure that four of six residents (R) (R2, R3, R9, R10) with indwelling catheters were secured and stored properly. Specifically, the facility failed to ensure that R2, R3, and R10's catheter tubing was secured with catheter straps, and R9's catheter drainage bag was not stored on the floor. Findings included: Review of the facility's policy Care of the Resident with a Urinary Catheter with revised date of 10/2014, revealed under Procedure: 5. Maintain tension free catheter by taping securely but still allowing movement. Never allow bag to touch the floor. 1. Review of the admission record revealed R2 was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis, vascular dementia, urogenital implants, hypertension, neuromuscular dysfunction of bladder, and dysphagia. Review of the Order Summary Report as of 10/22/2024 revealed an order for, catheter to bedside drainage bag. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-09 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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, interviews, record reviews, and review of the facility policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities the facility failed to provide ADL Care for three of three Residents (R) (R# 6, R#29, and R#49). Specificall, the facility failed to ensure nail care was provided for R#6 and R#49. The facility also failed to ensure that R#29 received foot care from podiatrist ( Physician that specialises in foot care)on a regular basis. Findings include : Review of the facility undated policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities Procedure: #1 revealed the following information: 1.Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 1.Review of the admission…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-09 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, family interview, and review of the facility policy titled, Change in Condition Notification, the facility failed to notify the designated resident representative or family member of significant changes for one of five Residents (R) R#22. Specifically, the facility failed to notify the responsible party (R/P) for R#22 of the transfer to the Acute hospital from the dialysis clinic on January 11, 2023. Findings: Review of the facility undated policy titled, Change in Condition Notification under Procedure: revealed the facility must inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there is a change requiring such notification. (Situations Requiring Notification include:) 2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 4. A decision to transfer or discharge the resident from the facility. A review of the progress…

    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 9 citations
  • Potential for harm · Dcited before2023-02-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and review of the facility policy titled, Nursing Care Plan the facility failed to develop a care plan which addressed the podiatric and diabetic care needs for one Resident (R) #29. The deficient practice had the potential to affect the residents' care regimen by not ensure all care needs were addressed in the person-centered Plan of Care for R#29. Findings: Review of the facility policy titled, Nursing Care Plan dated 10/2014 under purpose, revealed the following information: The plan shows what the nurse should know about the resident and includes: 1. Name, date of admission, diagnosis, and age. 2. Basic needs: A. Nutrition D. Safety G. ADL's B. Fluids E. Activity C. Vital signs F. Emotional status Information concerning basic needs is obtained from coordinated effort of all personnel caring for the resident, through observation, interviewing, inspection and MDS CAA's. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that R#29 was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2020-02-06 · 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, staff interview, review of facility documentation, and review of the policies titled, Food Storage and Food Contamination, the facility failed to monitor dishwasher temperature (temp) daily to ensure proper wash and rinse temps were in a safe range; failed to discard expired foods in the dry storage area; failed to ensure opened food items in the walk-in cooler were properly labeled and dated; failed to ensure opened food in the walk-in freezer were securely wrapped, labeled and dated; and failed to maintain sanitary conditions of the two-compartment sink. This had the potential to affect 88 of 95 residents receiving an oral diet. Findings include: Review of the facility policies titled, Food Storage, and Food Contamination dated 1/20/2020 revealed: 1.) Food items should be stored, thawed, and prepared in accordance with good sanitary practice. 2.) All products should be dated upon receipt and when they are prepared, use by dates are put on products, leftovers should be dated according to policy. 3.) Food to be frozen should be stored in airtight containers 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2020-02-06 · tag F0582 — pattern
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview the facility failed to provide a Notice of Medicare Non-coverage (NOMNC) to two of three residents (R) (#17 and #58) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of records for R#17 indicated that services were initiated on 11/1/19 with services ending 11/27/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. Review of records for R#58 indicated that services were initiated on 9/19/19 with services ending 10/23/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. During an interview on 2/6/2020 at 10:25 a.m. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF it was reported that she has never given the NOMNC to residents remaining in the facility unless the insurance company provided it. RN MDS Coordinator FF reported that she was not aware that the NOMNC was required 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
  • Potential for harm · E2020-02-06 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to develop a baseline care plan for three residents (R), (#53, #83, and #142) of 44 sampled residents. Findings include: 1. R#53 admitted to the facility with principal diagnosis of iron deficiency anemia, and other diagnoses included peripheral vascular disease, muscle spasms, malignant neoplasm of prostrate, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of left knee, white matter disease, unspecified, and limitation of activities due to disability. R#53 was initially admitted for short term rehabilitation for knee contracture. Review of the clinical electronic record, facility documentation, and Minimum Data Set (MDS) Assessment at entry, 5-day, 14-day, and 30-day, revealed R#54 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Review of the Interim Care Plan (ICP) dated 12/5/18 revealed there was 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for one resident (R) (#51) related to the use of restraints and for one resident (R#27) related to receiving dialysis services of 44 sampled residents. Findings include: 1. A review of the MDS indicator for R#51 revealed the use of a restraint. An observation on 2/4/2020 at 8:11 a.m. revealed the resident was in bed unrestrained. A review of the Quarterly MDS dated [DATE] documented that the resident utilized a chair that prevented rising. An observation on 2/5/2020 at 8:58 a.m. revealed the resident was sitting up in a wheelchair in the activity area with no sign of a seat belt, lap buddy or cushion that would restrain the resident. An observation on 2/5/2020 at 4:49 p.m., and on 2/6/2020 at 8:44 a.m. revealed the resident was in bed unrestrained. An interview on 2/6/2020 at 9:55 a.m. with the Registered Nurse (RN)/MDS Coordinator FF revealed she thought that staff had used 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-06 · 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, record review, and staff interviews the facility failed to follow the care plan related to oxygen therapy for one of 44 residents (R) (#75) reviewed for care plans. Findings include: Review of the medical record for R#75 revealed a diagnosis of respiratory failure, unspecified with hypoxia and hypoxemia. Review of the Physician Orders revealed an order for oxygen at 2 liters per minute (LPM) continuously per nasal cannula with a start date of 1/1/2020. Further review of the medical record revealed a care plan date 12/31/19 indicating that resident had returned from a hospital stay for aspiration pneumonia and hypoxia with an intervention of oxygen at 2 LPM via nasal cannula continuously initiated on 1/1/2020. Observations on 2/4/2020 at 1:23 p.m., 2/5/2020 at 7:56 a.m., and 2/6/2020 at 7:15 a.m. revealed R#75 receiving oxygen therapy via nasal cannula ranging from 3 and/or 3.5 LPM. During an interview and observation on 2/6/2020 at 9:32 a.m., the Director of Nursing (DON) confirmed that R#75 was receiving oxygen at 3 LPM. However, when the order was checked by…

    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 · D2020-02-06 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility failed to ensure appropriate services and assistance were provided to maintain or improve mobility when the residents demonstrated a limited mobility for one of 44 sampled residents (R) (#142). Findings include: Record review revealed that R#142 admitted to the facility on [DATE] with diagnosis of but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. During interview on 2/4/2020 at 1:20 p.m. R#142 was observed in bed leaning towards the left side. R#142 denied receiving any therapy services at this time. During an interview with the Physical Therapy (PT) Director on 2/5/2020 at 2:16 p.m. it was reported that a therapy referral is not automatic for new admissions. PT director went on to report that the therapy department does not screen everyone that is admitted into the facility. The PT Director reported that nursing has to refer residents to be seen by therapy. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2020-02-06 · 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

    Based on observation, record review, staff interviews, and review of the facility policy titled Monitoring Oxygen Therapy the facility failed to follow the Physician's Order for one resident (R) (#75) of 20 residents receiving oxygen. Findings include: Review of the policy titled Monitoring Oxygen Therapy dated with a revision date of 1/31/2019 revealed to review the patient's chart for current oxygen therapy order and to check equipment for liter flow. Review of the medical record for R#75 revealed a diagnosis of respiratory failure, unspecified with hypoxia and hypoxemia. Review of the Physician Orders revealed an order for oxygen at 2 liters per minute (LPM) continuously per nasal cannula with a start date of 1/1/2020. Observations on 2/4/2020 at 1:23 p.m., 2/5/2020 at 7:56 a.m., and 2/6/2020 at 7:15 a.m. revealed R#75 receiving oxygen therapy via nasal cannula ranging from 3 and/or 3.5 LPM. During an interview and observation on 2/6/2020 at 9:32 a.m., the Director of Nursing (DON) confirmed that R#75 was receiving oxygen at 3 LPM. However, when the order was checked by Licensed…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-06 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#65) of two residents observed, failed to ensure that one resident room of 56 resident rooms had sanitizer available for staff usage, failed to ensure clean linen was not contaminated in the laundry area, and failed to ensure that one of three shower rooms was maintained in a sanitary manner to prevent the spread of disease. Findings include: 1. An observation on 2/5/2020 at 12:17 p.m. revealed that the sanitizer was out in room [ROOM NUMBER] and was verbally reported by Licensed Practical Nurse (LPN) GG to the housekeeping staff. An interview with the LPN revealed that she had verbally reported to housekeeping over several days that the sanitizer was empty. An observation on 2/5/2020 at 2:58 p.m. revealed that LPN GG administered eye drops to R#65 without putting a barrier down on the medication cart while preparing the resident's oral medication or in 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.

    Infection Control 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.

Who owns this facility

Owner / managerTypeRoleSince
KIRBO, BRUCEIndividualDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODYsince 02/13/2025
BAILEY, CHARLESIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
BARBER, DONALDIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
BENCH, GLENNIEIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
CARROLL, MARVALYNNIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
DAVIS, THOMASIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
YARBROUGH, ANNALEEIndividualMANAGING CONTROL - GOVERNING BODYsince 02/13/2025
TOOLE, LADONIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 02/13/2025
FAIRCLOTH, KARENIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/13/2025
COCHRAN, JAMESIndividualADP OF THE SNFsince 03/04/2025
FERGUSON, ANDREAIndividualADP OF THE SNFsince 02/13/2025

CMS files one row per role, so the 13 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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 115711. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-01, 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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