No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Carrollton Crossing of Journey LLC

2327 North Highway 27, Carrollton, GA 30117 · For profit - Corporation · 159 certified beds · (770) 834-4404 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseResident-funds citation (F0567)Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$3,728 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2026
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has a citation for mishandling residents’ money or property (F0567)
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $3,728 in federal fines (most recent 2023-12-07)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (100%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
Urgent care / clinic
1735 S Highway 27 · (770) 809-7002 · Call to confirm hours
Pharmacy
1355 S Park St · (770) 832-9015 · Call to confirm hours
Grocery
1735 S Highway 27 · (770) 687-1058 · Call to confirm hours
Park
Bob White Ln, Newnan, GA 30263 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased26.1%15.3%15.4%worse
Long-stay residents who lose too much weight4.9%5.6%5.4%typical
Long-stay residents with a catheter left in their bladder2.0%0.9%0.9%worse
Long-stay residents with a urinary tract infection3.0%2.5%2.0%worse
Long-stay residents with depressive symptoms0.0%11.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%3.2%3.3%better
Long-stay residents whose ability to walk worsened28.4%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication22.7%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine96.1%95.0%95.3%typical
Long-stay residents with pressure ulcers7.5%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control23.2%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table19.3%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.1%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine63.6%78.4%79.4%worse
Short-stay residents rehospitalized after admission22.1%25.0%22.6%typical
Short-stay residents with an outpatient ER visit22.9%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.052.151.67worse
Long-stay outpatient ER visits per 1,000 resident days2.901.901.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.1%U.S. median 51.5%
Got home and stayed home
10.4%U.S. median 10.7%
Went back to hospital
30.8%U.S. median 56.6%
Met the expected recovery
0.01U.S. median 0.31
Therapy hours / resident / day
<0.01hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy

Met the expected recovery: 30.8% 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 39 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 0.01 therapist hours per resident per day in 2026Q1 — more than 0% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.1%CMS range 33.5–50.651.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.4%CMS range 7.3–14.510.7%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 discharge30.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge28.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified91.1%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting95.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.4–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.40
RN hours/ resident / day
1.13
LPN hours/ resident / day
1.68
Aide hours/ resident / day
3.22
Total nurse hours/ resident / day
0.49
RN hoursweekends
100.0%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 159 beds and averages 98.3 residents a day — about 62% occupied, or roughly 61 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.22 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 2.84 hrs/resident/day on weekends vs 3.37 on weekdays — 16% thinner on weekends. RN hours go from 0.36 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 100% is well above 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

8
deficiencies at the latest standard inspection (2026-04-09)
15
at the previous standard inspection (2025-03-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-03-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to act upon a change of condition for one of 28 sampled residents (R) (263) related to low blood sugar, which resulted in being transferred to the hospital for treatment. This failure to provide quick intervention led to harm being identified on 12/29/2023, when R263's blood sugar went so low, to the point where the resident was unresponsive and slow to respond to the emergency use of Glucagon intramuscular when administered at the facility. R263 had to be transferred to the emergency room (ER). Findings included: 1. A review of the electronic medical record (EMR) revealed that R263 had been admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus. A review of R263's quarterly Minimum Data Set (MDS) assessment with an assessment Reference Date (ARD) of 12/6/2023 indicated a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R263 was severely cognitively impaired. R263 was also coded as taking…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-04 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect one of three sampled residents' (R) (R1) rights to be free from physical and verbal abuse by a staff member when Certified Nursing Assistant (CNA) NN struck R1 while providing care. Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 03/05/2024, included, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further review revealed the Definitions section included Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured…

    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 · Past Non-Compliance
  • Potential for harm · Fcited before2026-04-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled, Food Safety Requirements, the facility failed to store, handle, and serve food in a safe and sanitary manner by failing to: ensure expired food items were discarded; ensure food items were properly labeled and dated; properly store raw meat to prevent cross-contamination; maintain food storage areas in a clean condition; properly store food off the floor; ensure equipment and surfaces were maintained in a sanitary condition; and ensure meal tray carts were covered during transport. This deficient practice had the potential to affect all 94 residents who receive food orally by placing them at increased risk for foodborne illness, contamination, and infection.Findings included:A review of the facility's policy titled, Food Safety Requirements, revealed the policy, dated revised 1/4/2024, to read in part:Regarding food labeling, dating, and storage: Labeling, dating, and monitoring refrigerated food, including, but not limited to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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, record review, and a review of the facility policy titled Routine Cleaning and Disinfection, the facility failed to maintain a safe, clean, and comfortable home-like environment related to dusty grayish buildup on packaged terminal air conditioner (PTAC) units in one of four halls (300 Hall).Findings included:During an observation on the 300 Hall on 4/7/2026 from 10:40 am until 11:40 am and on 4/8/2026 at 8:55 am, two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with an excessive amount of dusty grayish buildup on PTAC units. During an interview on 4/8/2026 at 11:38 am, the Maintenance Director (MD) confirmed that the maintenance department services the PTAC units. He stated that he has one maintenance assistant tasked with cleaning the PTAC units throughout the facility, and cleaning the units should occur monthly. The MD verified that he does not implement any procedures in the electronic maintenance system. He utilizes a paper log.During an interview…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Consulting Physician/Practitioner Orders and Provision of Quality of Care, the facility failed to provide treatment and care in accordance with professional standards of practice for two of 48 sampled resdients (R) (R2 and R48) related to ensuring that physician orders were in place to provide standard of care concerning: 1) catheter care, in that a physician order was not in place for indwelling Foley catheter and catheter care for R2 resulting in approximately 85 days of catheter care provided without a corresponding physician order; and 2) documentation and assessment of bowel movements and risk for bowel impaction for R48 resulting in the resident to be hospitalized for a 24-hour period for nausea and vomiting that was caused by a bowel impaction. These deficient practices had the potential to place residents at increased risk for catheter-associated urinary tract infection (UTI),…

    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 · D2026-04-09 · 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, record review, staff interviews, and the facility policy titled Restorative Nursing Program, the facility failed to provide restorative services for one of three sampled residents (R) (R86) related to splinting and range of motion (ROM) services.Findings included:During an observation on 4/7/2026 at 8:30 am, R86 was observed resting in bed with her left hand resting on her stomach. Her hand was closed and appeared to be contracted. No splint was observed.During an observation on 4/8/2026 at 10:30 am, R86 was observed in a reclining chair near the nursing station. Her left hand was contracted, and she was holding it on her lap. No splint was observed.During an observation on 4/9/2026 at 2:00 pm, R86 was observed in a reclining chair. Her left hand was in her lap. The left hand was closed in toward her palm, her fingernails were pressing into skin, and her wrist was turned inward. No splint was observed. A review of the electronic medical record (EMR) revealed that R86 was admitted to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · 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 observation, interview, and record review, the facility failed to ensure appropriate safety interventions were implemented and followed for one of 48 sampled residents (R) (R11) by failure to ensure the resident wore a smoking apron while smoking. This deficient practice placed the resident at risk for burns and other accident hazards related to smoking injuries.Findings included:A review of facility policy titled Protocol: Smoking, undated, revealed in the designated smoking area section, fire extinguishers/smoking blanket will be available in designated smoking areas. Smoke-Free Facility -Grandfathered in Policy Acknowledgement provided dating 4/9/2026.A review of R11's electronic medical record (EMR) revealed the resident was initially admitted to the facility on [DATE] with diagnoses of intracapsular fracture of the right femur, chronic obstructive pulmonary disease, dementia, major depressive disorder, acute respiratory failure, and contracture of the right ankle.A review of R11's EMR titled Smoker…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policies titled Oxygen Administration and Oxygen Concentrator, the facility failed to ensure that three of 11 sampled residents (R) (R45, R104, and R56) received respiratory care as ordered related to oxygen therapy and a Bilevel Positive Airway Pressure (BIPAP) machine.Findings included:1. During an observation on 4/7/2026 at 11:41 am and on 4/8/2026 at 8:55 am, R45 was observed receiving oxygen therapy via a nasal canula at the flow rate of between 3.0 and 3.5 liters (L). In addition, the oxygen concentrator filter was observed to have a gray-like dust build-up. During an observation and interview on 4/8/2026, at 9:52 am, Registered Nurse (RN) BB confirmed the concentrator filter had a considerable accumulation of dust-like particles. RN BB stated that R45 has been diagnosed with chronic obstructive pulmonary disease (COPD), which includes symptoms of shortness of breath and hypoxia. She stated that the concentrator filters…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews, the facility failed to ensure the medication rate was less than 5 percent (%) related to four errors with thirty-two opportunities. The medication error rate was 12.5%.Findings included:During an observation on 4/8/2026 at 7:50 am, Registered Nurse (RN) FF was observed administering R2 scheduled 9:00 am medications through her gastrostomy tube (G-tube). RN FF prepared two medications; three were scheduled at this time. The 325 milligrams (mg) aspirin enteric coated (EC) could not be crushed, and a non-EC aspirin was not available. RN FF confirmed that she did notify the Director of Nursing (DON), and that a new order was obtained for a chewable aspirin that was given late.During an observation on 4/8/2026 at 8:23 am, Licensed Practical Nurse (LPN) AA was in 300 Hall. LPN AA was observed obtaining medication for R23. Three medications for R23 were unavailable: Bumex (diuretic), metoprolol (blood pressure), and citalopram (antidepressant). LPN AA stated that it looks like the medications had been ordered prior. Overflow…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-09 · 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 and resident interviews, record review, and review of the facility's policies titled Hand Hygiene, the facility failed to perform hand hygiene when performing resident care, including Foley catheter care and wound care, for one of 48 sampled residents (R) (R2). This deficient practice had the potential to cause the spread of infection to other areas of the residents' bodies and infection to staff.Findings included:During a review of the electronic medical record (EMR), it was revealed that resident R2 was admitted to the facility on [DATE], and pertinent diagnoses, including but not limited to Cerebral infarction, type 2 diabetes, chronic kidney disease, atherosclerotic heart disease, depression, bipolar disorder, and schizoaffective disorder.During a review of R2's quarterly Minimum Data Set (MDS) assessment, it was revealed that a Brief Interview for Mental Status (BIMS) score was not attempted, which indicated R2 was severely cognitively impaired; that R2 is dependent on staff 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 · Dcited before2025-09-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, the facility failed to protect one of 14 sampled residents (R) (R3) right to be free from sexual abuse from R5. This deficient practice created the potential for R3 and other residents to experience further potential abuse. Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, reviewed 9/2024, read, in pertinent part, It is the policy of the facility to prevent abuse.1. Review of R3's admission Record, dated 9/9/2025 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia and type 2 diabetes. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/8/2025 and found in the EMR under the MDS…

    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
Show the remaining 18 citations
  • Potential for harm · Fcited before2025-03-20 · 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, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, large manual can opener, and the main dining room's ice machine and microwave oven clean and sanitized. Additionally, the dietary staff failed to label, date, and/or cover food and beverages stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses, which could affect 101 residents who consumed food prepared from the facility's kitchen. Findings included: A review of the facility's policy titled Sanitation dated October 2008 indicated Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen area and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 3. All equipment, food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-03-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to ensure that the soiled and clean sides of the laundry room were in good repair. Specifically, the facility failed to repair a gap under the exterior door that opens into the soiled laundry area; failed to repair broken wallboard with exposed insulation; failed to clean the air vents in the soiled side of the laundry that had debris build up; the doorless opening between the sorting area and the room with the washing machines was trimmed with unfinished molding, rendering the surface uncleanable; the floor where the washing machine was located had heavy debris build up; reusable rubber gloves were on the floor in the drying area; and the floor (standing) fan had heavy debris build-up on the fan grate. This deficient practice had the potential for the clean linen for all residents to be contaminated. Findings included: During an observation and interview on 3/18/2025 at 8:47 am with the Laundry Supervisor and the Infection Preventionist (IP) nurse revealed the following: 1. A three-fourth-inch gap under the exterior door that…

    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 · E2025-03-20 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and facility policy review, the facility failed to serve food that was palatable and hot to four of seven residents (R) (R22, R77, R83, and R105) reviewed. Findings included: A review of the facility's undated policy titled Assistance with Meals indicated, . All foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that the delivery of food to serving areas accommodates this requirement. A review of the facility's policy titled, Food Temperatures and Test Tray Audits dated 04/05/24, indicated, Policy Test trays will be audited periodically to ensure that food temperatures, food quality, and overall dining experience are at optimal levels. Procedure . 11. Minimum temperatures at the time of service are defined below: a. Soups >[above]135 degrees F [Fahrenheit]. b. Milk & Milk Products < [below] 45 degrees F., Cold Entrees < 55 degrees F., Hot Entrees > 135 degrees F., Starches > 135 degrees F.,…

    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 · D2025-03-20 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and a review of the facility policy titled Resident Self-Administration of Medication, the facility failed to ensure that one of 28 sampled residents (R) (R89) was assessed for self-administration of medications before medications were left at the bedside. This failure had the potential for the residents to overmedicate themselves or for medications to be accessed by other residents. Findings included: A review of the facility's policy titled Resident Self-Administration of Medication and dated November 2017 revealed that if the resident desires to self-administer medications, an assessment will be conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. A review of the Electronic Medical Record (EMR) revealed that R89 was admitted to the facility on [DATE] with the diagnosis of dementia, anxiety disorder, hypertension, and major depressive disorder. A review of R89's quarterly 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to notify one of 28 sampled resident's (R) (R89) responsible party (RP) of a new medication order before the administration of the medication to the resident. This failure had the potential for R89 to be administered with medication that the RP may not want the resident to receive. Findings included: A review of the Electronic Medical Record (EMR) revealed that R89 was admitted to the facility on [DATE] with the diagnoses of dementia and anxiety disorder. A review of R89's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/17/2024, coded R89 as having a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R89 was severely cognitively impaired. A review of R89's physician orders revealed an order dated 8/8/2024 for Naltrexone 50 mg (milligrams), give one tablet by mouth one time a day for OCD (obsessive-compulsive disorder) related behaviors. A review of R89's psychotherapy summary dated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policy titled Abuse Prevention Program, the facility failed to ensure one of three sampled residents (R) (R33) reviewed for abuse was free from abuse. This failure had the potential for psychosocial impairment from being physically abused by another resident. Findings included: A review of the facility's policy titled Abuse Prevention Program, with a revised date of May 2023, indicated, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone, including . other residents. Physical Abuse includes, but is not limited to, hitting, slapping, pinching, and kicking . A review of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, anxiety disorder, bipolar disorder, and depression A review of R33's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/1/2025 revealed a Brief Interview for 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 · D2025-03-20 · 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 record review, interviews, and a review of the facility policies titled Abuse, Neglect and Exploitation and Abuse Prevention Program, the facility failed to ensure allegations of abuse were reported to the facility's abuse coordinator/administrator promptly for one of four residents (R) (R62) with allegations of abuse. The facility failed to notify the State Agency (SA) promptly. This deficient practice placed the resident at risk for uninvestigated abuse allegations. Findings included: A review of the facility's policy titled Abuse, Neglect and Exploitation dated December 2017 indicated, .staff to report abuse to the abuse coordinator/administrator immediately when a resident reports an allegation of abuse, and an investigation is to begin immediately . A review of the facility policy titled Abuse Prevention Program, revised May 2023, indicated, .the abuse coordinator will report allegations or suspected abuse . immediately to .State Survey and Certification agency . A review of R62's Electronic Medical Record (EMR) revealed an admission date of 3/3/2022 with diagnoses 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · 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 record review, staff interview, and a review of the facility's policy titled Care Plans, the facility failed to develop and implement a comprehensive care plan for two of 28 sampled residents (R) (R44 and R263). This failure had the potential for R44 to not receive the appropriate treatment needed, and R263 did not have the newly identified pressure ulcer treatment ordered to prevent the area from becoming larger. Findings included: A review of the facility's policy Care Plans, Comprehensive Person-Centered dated September 2023 stated, .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. A review of the electronic medical record (EMR) revealed that R44 had been admitted to the facility on [DATE] with the diagnosis of dementia. A review of R44's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/21/2024 revealed a Brief Interview for Mental Status (BIMS) score of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · 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 the record review and interviews, the facility failed to investigate a fall for one of three residents (R) (R70) reviewed for falls. This failure had the potential for the fall not to be investigated thoroughly, and allowed R70 to experience another fall. Findings included: A review of the electronic medical record revealed that R70 was admitted to the facility on [DATE] with the diagnosis of Huntington's Disease. A review of R70's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/8/2024 indicated R70 had short-term and long-term memory loss and was severely impaired in cognitive skills for daily decision-making. R70 was coded as being independent in bed mobility. A review of R70's care plan dated 1/25/2024 revealed that R70 was at risk for falls related to Huntington's Disease with Chorea and decreased mobility. The interventions indicated, .Educate the me/my family/caregiver about safety reminders and what to do if a fall occurs [sic] . A review of R70's nursing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · 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, record review, and a review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, the facility failed to complete a Dialysis Communication Form for one of 28 sampled residents (R) (R77) to ensure effective communication regarding the provision of care and medication administration for dialysis. The failure had the potential for R77 to have unmet care needs and complications with her dialysis treatments. Findings included: A review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with, dated September 2010, indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Agreements between this facility and the contracted ESRD facility include all aspects of how the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and a review of the facility policy titled Behavioral Assessment, Intervention and Monitoring, the facility failed to implement policies and procedures to monitor response to psychoactive medications, including specific behaviors to monitor, non-pharmacological interventions, and response to the interventions for two of five residents (R) (R62 and R66). The facility's failure to identify specific targeted behaviors and non-pharmacological interventions to address the behaviors placed the R62 and R66 at risk of inappropriate psychoactive medication use. Findings included: A review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring dated September 2022 indicated, Assessment .3. the nursing staff shall identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including b. Any precipitating or relevant factors . Management 2. The care plan shall incorporate…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy titled Administering Medications,, the facility failed to ensure a medication error rate below five percent. During medication administration, two medication errors for one of 25 residents (R) (R5) opportunities resulted in a medication error rate of eight percent (%). These failures had the potential to increase or decrease the effectiveness of these medications. Findings included: A review of the facility's policy Administering Medications dated February 2020 indicated, . The individual administering the medication should check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . A review of R5's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) revealed R5 had been admitted to the facility on [DATE] with the diagnosis of gout and schizoaffective disorder. A review of R5's 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, facility menu review, and facility policy review, the facility failed to ensure that menus were followed as planned for one (R) (R105) of seven sampled residents reviewed for food in a total sample of 28 residents. This failure had the potential to cause nutritional needs to go unmet for 110 residents who consumed food prepared from the facility's kitchen. Findings included: A Review of the facility's policy titled, Menu Planning and Nutrition Adequacy dated 4/5/2024 indicated, Purpose The dining services department shall serve meals that meet the nutritional needs of the resident in accordance with the recommended dietary allowances (RDAs) of the Food and Nutrition Board of the National Research Council, of the National Academy of Sciences. A review of R105's undated admission Record located in the electronic medical record (EMR) under the Profile tab indicated R105 was admitted to the facility on [DATE], with a diagnosis of diabetes mellitus. A review of R105'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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-20 · tag F0809 — failed to serve meals on a reasonable schedule — isolated
    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
    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, record review, and facility policy review, the facility failed to provide a bedtime snack each night for three of three diabetic residents (R) (R76, R77, and R83). This failure had the potential to cause unmet nutritional needs for residents who received meals and snacks from the facility's kitchen. Findings included: A review of the facility's undated policy titled, Snacks (Between Meals and Bedtime) Serving indicated, The purpose of this procedure is to provide the residents with adequate nutrition . A review of the facility's undated policy titled, Food Preferences indicated, . 10. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 1. A review of R77's undated admission Record, located in the electronic medical record (EMR) under the Profile tab, indicated R77 was admitted to the facility on [DATE], with diagnoses including end-stage renal disease (ESRD) and diabetes mellitus. A 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-07 · 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, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to ensure residents' room were in good repair in five of 70 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) observed for a safe, homelike environment. Specifically, a black substance was observed next to the air conditioning unit next to bed C in room [ROOM NUMBER], the bathroom door would not close in room [ROOM NUMBER], a large hole was observed in room [ROOM NUMBER]'s bathroom, the drywall was damaged with a hole in room [ROOM NUMBER]'s bathroom, and the caulking was dirty and needed replacement and drywall patching was left unpainted in room [ROOM NUMBER]'s bathroom and next to bed C. Findings include: Review of the undated facility policy titled, Safe and Homelike Environment, revealed, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable 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 · D2023-12-07 · tag F0567 — failed to protect residents' money held by the home — isolated
    Honor the resident's right to manage his or her financial affairs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record review, and review of the facility policy titled, Resident Trust Fund, the facility failed to allow two of 74 residents (R) (R74 and R59) with personal funds accounts to take out an amount greater than $20.00 a day. This deficient practice had the potential to not allow a resident to make purchases greater than $20.00 a day affecting 74 residents with personal funds. Findings include: Review of the facility policy titled, Resident Trust Fund with a date of September 2022 revealed, Policy . The resident has a right to manage his or her financial affairs . 1. Review of R74's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed diagnoses that included chronic obstructive pulmonary disease (COPD), bipolar disorder, and adjustment disorder. Review of R74's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 8/17/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognitive capacity.…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · 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, resident and staff interviews, record review, and review of the facility policy titled, CPAP/BIPAP Support, the facility failed to ensure appropriate respiratory services for one of two residents (R) (R59) reviewed for respiratory services. Specifically, the facility failed to ensure clean filters were in the Continuous Positive Airway Pressure (CPAP) machine. The deficient practice had the potential for respiratory infections for R59. Findings include: Review of the facility policy titled CPAP/BIPAP Support, with a revised date of March 2015, revealed, Purpose, 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety . General Guidelines for Cleaning . 6. Filter cleaning: a. Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year.…

    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 before2023-12-07 · 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 observations, staff interviews, record review, and review of the facility policy titled, Handwashing/Hand Hygiene, the facility failed to follow the facility's policy regarding the wearing of Personal Protective Equipment (PPE) for two of three residents (R) (R360 and R84). Specifically, facility staff failed to don (put on) PPE prior to entering the isolation room of R360, and to perform hand hygiene after doffing (removing) gloves for R84 during pressure ulcer treatment observations. Findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2015, revealed, .7. Use an alcohol-based hand rub and water for the following situation: .m. After removing gloves . 1. Observation on 12/6/2023 at 8:19 am, Licensed Practical Nurse (LPN) 1 was standing by the medication cart outside of R360's room preparing for medication administration. LPN1 informed the surveyor that about 10 minutes ago she was notified by the lab of a critical lab result that R360 had extended-spectrum beta-lactamase (ESBL) in her urine. LPN1 stated that she notified the Unit…

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

    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

$3,728 in federal fines across 1 penalty.

  • $3,728 — penalty dated 2023-12-07

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.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$10.7M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$533K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 11%Other / private 15%

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 $533K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$280per resident / day
operating cost
$8,497per month
≈ monthly operating cost
$278per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.

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

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115368. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-09, 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.

What to do next