Cherokee Center for Nursing and Healing LLC

Location & what’s nearby

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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

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.

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.

49.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 100 beds and averages 88.1 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.95 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.76 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 2.60 hrs/resident/day on weekends vs 3.08 on weekdays — 16% thinner on weekends. RN hours go from 0.47 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 53% is about the same as the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 16 most serious are shown; the remaining 11 are one tap away and print in full.

• Immediate jeopardy · K2023-12-05 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility document review, the facility staff failed to prevent, assess, and treat pressure ulcers appropriately for nine out of 10 residents (R) (R291, R293, R65, R3, R63, R50, R21, R292, and R142) with pressure ulcers. These failures present a likelihood of serious harm, serious injury/impairment, or death related to wound infection and wound deterioration and contributed to hospitalization and subsequent cardiac arrest for R291. On 11/29/223 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/4/2023 at 7:35 pm. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/27/2023. At the time of exit on 12/5/2023, an acceptable Immediate Jeopardy Removal Plan had not been…

  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
• Immediate jeopardy · K2023-12-05 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  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 facility policy/job description review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to avoid a system failure with the wound care program and lack of Director of Nursing (DON) supervision over the wound care program. The facility failed to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment. These failures affected nine of 10 residents (R) (R291, R293, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. These failures presented a likelihood…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-12-05 · tag F0841 — pattern
  Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
  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 facility policy/contract review, the facility failed to provide needed physician services to ensure admission assessments were provided by the primary physician (who also served as the facility's Medical Director) rather than the Nurse Practitioner (NP); the primary physician assessed, measured, and treated pressure ulcers; and the primary physician ensured appropriate treatment and services were provided by the wound care consultant for pressure ulcer prevention, assessment, and treatment for nine of 10 resident (R) (R291, R293, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. These failures presented a likelihood of serious harm, serious injury/impairment, or death related to a lack of adequate wound management, which contributed to hospitalization and subsequent cardiac arrest for R291. On 11/29/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Kcited before2023-12-05 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, facility document review, and facility policy review, the facility failed to 1. control measures to prevent the spread of COVID-19 among 17 (Resident (R)83, R79, R51, R291, R73, R52, R80, R86, R57, R77, R81, R26, R8, R74, R66, and R28) of 85 current facility residents; 2. follow infection control guidelines during pressure ulcer dressing change observations for four of seven residents (R142, R21, R292, and R63); 3. perform hand hygiene during meal service; and 4. maintain a urinary catheter bag off the floor. At the time of the survey team's entrance in the facility on 11/27/2023, there were five confirmed cases of COVID-19, with an additional six cases on 11/27/23. On 11/28/2023, the facility reported six more new cases of COVID-19 to the survey team totaling 17 cases of COVID-19 present in the facility. All 17 residents had co-morbid diagnoses which placed them at risk of severe illness or death. On 11/29/2023 a determination was made that a situation in…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-12-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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, resident and staff interviews, record review, and the review of the facility policy titled, Incidents and Accidents the facility failed to properly educate and supervise staff on equipment use resulting in an injury to one of five sampled Residents (R) (R65). Actual harm occurred on 12/21/2023 when R65 suffered a partial thickness burn (2nd degree) to his right foot after the Certified Nursing Assistant (CNA) placed a soft bonnet hair dryer (used to dry hair on an individual's head) on top of the residents sheet next to his feet for 30-45 minutes. Findings included: A review of the undated policy titled Incidents and Accidents revealed: It is the policy of this facility for staff to utilize Risk Management System to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-12-05 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of three residents (R) (R293 and R2) reviewed for pain management. This failure resulted in harm to R293 for wound care treatment and R2 for chronic pain. Findings included: 1. A review of R293's undated admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R293 was admitted to the facility on [DATE] with diagnoses including unstageable pressure ulcer to sacral region, pressure induced deep tissue damage of left heel, osteomyelitis, methicillin resistant staphylococcus aureus, and pneumonia. A review of R293's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2023 and located under the MDS tab of the EMR, revealed…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policies titled, Safe Water Temperatures, and Safe and Homelike Environment, the facility failed to ensure one of two units maintained safe water temperatures for one resident room (room [ROOM NUMBER]) and one Communal Restroom (CR) on the B Hall. In addition, the facility failed to ensure a safe, clean, and comfortable home-like environment for six of 44 occupied rooms, including Rooms 211, 121, 201, 207, 214, and 221. This deficient practice had the potential to affect resident comfort and safety.Findings include: 1. Review of the policy titled, Safe Water Temperatures implemented March 2025, documented under section, Policy Explanation and Compliance Guidelines: .3. Water temperatures will be set to a temperature of no more than 110 degrees F {degrees Fahrenheit}, or the state's allowable maximum water temperature. 4. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits…

  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 · D2025-03-14 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on staff interview, record review, and review of facility policy, the facility failed to coordinate with the proper State-designated authority to ensure residents with a mental disorder, intellectual disability or related condition had the opportunity to receive care and services appropriate to their needs for one (1) of one (1) resident reviewed for Level I and Level II Pre-admission Screening and Record Review (PASARR); Resident (R) #43. Findings include: Review of facility's policy titled, Resident Assessment-Coordination with PASARR Program, with a reviewed/revised date of December 2024, noted the Policy Explanation and Compliance Guidelines to be: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I-initial pre-screening that is completed prior to admission. i Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-14 · 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, staff interview, record review, and policy review, the facility failed to implement a comprehensive person-centered care plan for each resident in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one (1) of 21 sampled residents. Resident #50 sustained a fall from his/her bed and 2. The facility failed to implement a care plan for oxygen therapy as ordered for one (1) of 19 sampled residents, Resident (R)#40 This deficient practice had the potential to put R#40 at risk for medical complications. Findings include: A review of facility policy titled, Care Plans, Comprehensive Person-Centered, dated 12/22 revealed, Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of Resident (R)#50's admission Record revealed the facility admitted him on 3/31/22.…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-03-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure 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 staff interviews, record review, and policy review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of three sampled residents. Resident (R)#50 sustained a fall from a rollover from his/her bed to the floor during activities of daily living (ADL) care. Findings include: A review of the policy titled, Fall Prevention Program dated 6/2023 stated, Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. An observation of R#50 on 3/13/25 at 4:19 p.m., revealed the resident to be alert, and awake and lying in a low bed. During an attempted interview with the resident, the resident could not be fully understood. He appeared clean, and without odor. A pump that delivered enteral feeding directly into R#50's gastrointestinal tract was observed to be at the bedside. A review of R#50's admission Record revealed the facility admitted…

  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 before2025-03-14 · 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 observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that one (1) out of 11 residents receiving oxygen (O2) therapy was administered the therapy in accordance with the physician orders. This deficient practice had the potential to put Resident (R)40 at risk for medical complications. Findings include: Review of the facility's policy titled, Oxygen Administration, undated, outlined the purpose of this procedure was to provide guidelines for safe oxygen administration. Under the section Preparation, outlined the following procedure: 2. Review the resident's care plan to assess any special needs of the resident. Equipment and Supplies outlined that a humidifier bottle would be necessary when performing oxygen administration. Review of the clinical electronic record for R#40, revealed he was admitted to the facility with diagnoses that included, but not limited to, other pulmonary embolism without acute cor pulmonale, anxiety disorder, depression and heart failure. Review of R#40's most recent Minimum Data Set…

  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 before2025-03-14 · 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 observations, staff interviews, record review, and facility policy review, the facility failed to ensure staff: sanitized or washed hands before donning and after doffing gloves, did not stack a medication cup containing liquid medication on top of a medication cup containing pills, and applied gloves before removing a germicidal wipe to clean the glucometer (device that reads blood glugose) after checking a resident's blood sugar. This affected two (2) of five (5) residents, Resident (R)#34 and R#18, observed during medication pass. Findings include: A review of the facility's policy titled, Personal Protective Equipment with a Date Reviewed/Revised of January 2025, revealed the following: Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Definitions: Personal protective equipment, or PPE, . It includes gloves, . Policy Explanation and Compliance Guidelines 4. Indications/considerations for…

  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 · F2023-12-05 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  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 facility policy review, the facility failed to ongoing quality assurance and performance improvement (QAPI) program demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities to address systemic failures to prevent, assess, and treat pressure ulcers appropriately and failed to ensure needed physician services were provided by the primary physician (who also served as the facility's Medical Director). These failures affected nine of 10 residents (R) (R291, R293, R141, R50, R65, R142, R292, R21, R3, and R63) reviewed for pressure ulcers. Findings included: During an interview on 12/2/2023 at 4:57 pm, the Director of Nursing (DON) stated the facility implemented a Performance Improvement Plan (PIP) through their quality assurance and performance improvement (QAPI) program regarding…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-12-05 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
  Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
  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 and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident belongings were stored in a clean room, breaker boxes were properly secured throughout the building, the kitchen maintained a floor that had cleanable surfaces, and outside seating was in good condition. Findings included: 1. An observation on 11/28/2023 at 10:12 am revealed a wardrobe in the bathroom of Resident (R)56. This wardrobe was observed with resident clothing hung from a rack, with no covering. The resident's clothing was not protected from the nearby toilet. 2. An observation on 11/29/2023 at 4:09 pm revealed breaker boxes on the first floor Unit A hallway, near rooms [ROOM NUMBERS]. The breaker boxes had small, unlocked padlocks on the latches. The padlocks were both easily turned, and the breaker box doors opened with the push of a finger. Accessible to residents were breaker switches…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and policy review, the facility failed to ensure abuse allegations were reported in a timely manner for two of three residents (R) (R53 and R40) reviewed for abuse. These failures presented a potential for continued abuse resulting in physical and/or psychosocial harm for R53 and R40. Findings included: 1. A review of R53's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to chronic pain, weakness, fatigue, and a need for assistance with personal care. A review of R53's quarterly Minimum Data Set (MDS) assessment under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 9/11/2023, revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. R53 was able to make himself understood and understand others. He required extensive assistance with toileting. In 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2023-12-05 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility document review, the facility staff failed to thoroughly investigate allegations of abuse for one of three sampled residents (R) (R40) reviewed for abuse. Findings included: A review of R40's undated admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R40 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, atrial fibrillation, first degree heart block, sick sinus syndrome, and cerebral atherosclerosis. A review of R40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/12/2023, revealed R40 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This indicated that R40 was cognitively intact. A review of R40's Progress Notes, dated 7/10/2023 at 2:52 pm and located under the Progress Notes tab of the EMR, revealed, Resident reported to social worker today that on Friday night [R40] was physical struck by charge nurse directly over her…

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

  Freedom from Abuse, Neglect, and Exploitation 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.

Fines & penalties

$185,650 in federal fines across 1 penalty. 1 Medicare payment denial on record.

• $185,650 — penalty dated 2023-12-05
• Medicare payment denial — starting 2023-12-09 for 46 days

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 EMPIRE CARE CENTERS — 20 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 →

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

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $489K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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