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Murray Woods Of Journey LLC

102 Hospital Drive, Chatsworth, GA 30705 · For profit - Corporation · 120 certified beds · (706) 695-8313 Medicare & Medicaid certified

Call the home — (706) 695-8313 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Feb 2026$15,092 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (18% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Feb 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,092 in federal fines (most recent 2024-05-30)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS
Urgent care / clinic
100 Hospital Dr · (706) 695-4546 · Call to confirm hours
Pharmacy
824 Gi Maddox Pkwy · (706) 517-1901 · Call to confirm hours
Grocery
964 GI Maddox Pkwy
Park
Fort Mountain Park Rd · 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 2 of 5
Long-stay residentspeople who live here 3 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 increased12.0%15.3%15.4%better
Long-stay residents who lose too much weight8.1%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.0%2.5%2.0%better
Long-stay residents with depressive symptoms73.1%11.3%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.8%3.2%3.3%worse
Long-stay residents whose ability to walk worsened3.1%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication23.3%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.9%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control4.3%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table37.3%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication4.5%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine87.7%78.4%79.4%better
Short-stay residents rehospitalized after admission27.5%25.0%22.6%worse
Short-stay residents with an outpatient ER visit15.1%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.292.151.67worse
Long-stay outpatient ER visits per 1,000 resident days3.051.901.80worse

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

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

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

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

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

41.0% 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 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.0%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
66.2%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.04hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 66.2% 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 80 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 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF41.0%CMS range 30.7–54.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.2–14.010.7%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 discharge66.2%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 discharge68.8%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge67.5%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 identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.8%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%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 hospitalization11.2%CMS range 7.3–17.37.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.461.02Oct 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

0.18
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.15
Aide hours/ resident / day
3.27
Total nurse hours/ resident / day
0.20
RN hoursweekends
18.4%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 113.2 residents a day — about 94% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 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 2.81 hrs/resident/day on weekends vs 3.45 on weekdays — 19% thinner on weekends. RN hours go from 0.18 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 18% is below the national median of 45%.

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

Inspection trend

15
deficiencies at the latest standard inspection (2025-10-02)
6
at the previous standard inspection (2024-05-30)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · Dcited before2026-02-19 · 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, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to prevent sexual abuse by another resident for one of three residents (R) (R2 and R1) reviewed. This failure allowed R1 to continue to potentially sexually abuse other residents after his behavior of getting in bed with other residents was first identified.Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation revised 3/5/2024 revealed under Definitions: Non-consensual sexual contact of any type with a resident. Under Policy: It is the policy of this facility to provide protections 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. 1. Review of the electronic medical records (EMR) for R1 revealed he was admitted with diagnoses of major depressive disorder,…

    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 · Fcited before2025-10-02 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, document review and review of the facility policy titled, the facility failed to provide sufficient staff to meet the residents' needs timely. This failure to provide Activities of Daily Living (ADL) care, assistance with dressing and transported to the dining room for meals, timely incontinence care, program of activities, services to prevent further decrease in range of motion/mobility for a resident with contracture had the potential to negatively impact quality of life for all residents.Findings include:Review of the undated Facility Assessment revealed, .Staffing plan: staffing is based on the consideration of all or some of the following: diagnoses, conditions, physical and psychosocial limitations, resident acuity, or any other factor that may affect the services the facility must provide. 1.During the initial tour on 9/28/2025 at 9:00 am, there were no residents in the dining room. [NAME] 1 was asked why no residents were eating in the dining room and stated that the residents had to eat in their rooms because there wasn't…

    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
  • Potential for harm · Fcited before2025-10-02 · 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 observation, interview, and review of the facility policy titled, the facility failed to ensure refrigerated foods in the walk-in cooler were stored and labeled correctly and dish wear stored under the air conditioner [NAME] were covered and the dish wear inverted. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen. Findings include:Review of the facility's policy titled, Food Procurement and Storage dated 03/02/23 revealed all leftover food in the cold storage should be dated with an open and discard date, clearly identifying the container contents.During an initial kitchen tour observation on 9/28/2025 at 9:15 am, with the weekend dietary aid , the walk-in cooler contained a large bowl that appeared to be a lettuce salad that was not labeled and/or dated, an open container that appeared to be cream of chicken soup with no label or date, large containers with what appeared to be leftover vegetable soup and leftover tomato…

    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 · F2025-10-02 · tag F0835 — failed to run the facility competently — widespread
    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

    Based on observations, interviews, record review and facility policy, Administration failed to ensure residents' environment on two of four halls (200, and 400) was clean, in good repair and homelike. Administration failed to ensure residents (R33 and R14) were free from sexual and physical abuse. Administration failed to ensure allegations of sexual abuse were thoroughly investigated for R33 and reported timely to the State Survey Agency (SSA) (R14 and R12). Administration failed to ensure residents (R53, R59, R12 and R2) care plans were developed for activities with interventions for residents that required diversional activities, activities in their rooms and activities that were appropriate for residents with dementia on the secure unit. Administration failed to ensure residents were provided with activities to meet their needs (R53, R60, R74 and R97). Administration failed to ensure the facility's ice machine and range oven were repaired and functioning which had the potential to affect all residents' mental, physical psychosocial outcomes.Findings include: 1.The facility…

    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 · F2025-10-02 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of the facility policy titled, Equipment the facility to maintain the ice machine and primary oven in working order. Specifically, the ice machine did not provide the ice needed to meet the needs of the residents and family members had to buy ice for the residents, and the primary range oven did not work and could not be used. This deficient practice had the potential to affect 107 of 111 residents who received meals prepared in the facility's only kitchen.Findings include:Review of the undated facility policy titled Equipment, stipulated that all foodservice equipment will be clean, sanitary, and in proper working order.During an initial kitchen tour interview on 9/28/2025 at 9:15 am, the weekend Dietary Aid reported that the ice machine had been broken and that many times, staff or family members had purchased bagged ice for the residents' the Dietary Aid also stated that the primary range oven in the kitchen was not working for several months and did not know when or if it would be repaired.During an interview on 9/30/2025 at 10:35 am, the Dietary…

    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 · E2025-10-02 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the facility policy titled, Activities the facility failed to provide, based on the comprehensive assessment and care plan and the preferences, a program of activities to support residents in their choice of activities for four of four residents (Resident (R)53, R60, R74, and R97) in the sample of 31 residents and failed to provide an ongoing program of activities designed to support the physical, mental, and psychosocial well-being of residents in the facility. This failure had the potential to negatively impact quality of life for the affected residents.Findings include:Review of the facility's policy titled, Activities dated 2/28/2023 indicated, .facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their…

    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 · D2025-10-02 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of 31 Residents (R)(R39 and R41) were treated with dignity and respect. Specifically, the facility failed to ensure R39 was provided with incontinence care when requested and allowed to remain in a soiled brief for over two hours, the facility also failed to ensure R41 was able to have visitation in her room that was free from offensive odors. Findings include:Review of the facility policy Abuse, Neglect and Exploitation revised 3/5/2024 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident.Review of R39's undated face sheet, found under the ''admission Record'' tab located in the Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] for short-term rehabilitation after a traumatic fall at home with fractures and operative repair of her right elbow, wrist and right knee. Review…

    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 before2025-10-02 · 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, interviews and review of the facility policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on two of four halls (200 and 400) in the facility. This failure could negatively impact resident due to not having a sanitary, homelike living environment. Findings include:Review of the facility's policy titled, Resident Environmental Quality dated 2/16/2024 indicated, .facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for resident.During a tour of the facility on 9/28/2025 at 10:25 am the following was observed: 1. room [ROOM NUMBER] in the bedroom, the baseboard was missing on the wall that held the sink leaving an open space between the floor and the sheetrock,2. room [ROOM NUMBER] bathroom had floor tile around the base of the toilet that was stained black in color and there were floor tiles that were missing,3. Secure 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-02 · 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

    Based on observations, interviews, record review and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to ensure two of four residents (R) (R33 and R14) were free from abuse; R33 from sexual abuse by R57 and R14 from physical abuse by R2.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 03/2024 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of all residents.'Abuse' means the willful infliction of injury, confinement, or punishment with resulting harm or mental anguish.Instances of abuse, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.This includes verbal abuse, physical, mental or sexual abuse.this includes sexual abuse with a resident who does not have the capacity to decline to participate in the sexual act.1.Review of the Administrator's investigation file revealed a written statement by Licensed Practical Nurse (LPN5) which indicated that on the secure unit on 3/25/2025 at 6:30 am, LPN5…

    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 · D2025-10-02 · 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 interviews, record reviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of resident-to-resident abuse to the State Survey Agency (SSA) within the two hours once the facility was aware of the abuse allegation for two of four residents, Resident (R) (R14 and R12). The failure of the facility to report these incidents timely has the likelihood to lead to future unreported allegations of resident abuse.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised on 3/5/2024, revealed the facility would implement policies and procedures to prohibit and prevent all types of abuse and neglect, Notify the appropriate agencies immediately: as soon as possible, but no later than.2 hours after discovery or forming suspicion.1.Review of R2's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R2 was admitted to the facility on [DATE] with diagnoses of cognitive…

    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 13 citations
  • Potential for harm · D2025-10-02 · 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 resident record reviews, interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an alleged allegation of sexual abuse for one of one resident (R) (R33) and physical abuse for one of one resident (R14) in the sample of 31 residents. The failure by the facility to failure to thoroughly investigate allegations of abuse had the potential to negatively impact residents in the facility.Findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation revised 3/2024 revealed, It is the policy of this facility to provide protections for the health, welfare, and rights of all residents.Instances of abuse, irrespective of any mental or physical condition, can cause physical harm, pain or mental anguish.this includes sexual abuse with a resident who does not have the capacity to decline to participate in the sexual act.V: Investigating abuse: An immediate investigation is warranted with any report or allegation 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 · D2025-10-02 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policies titled, Transfer and Discharge, and Bed Hold Policy, the facility failed to ensure for two of two Resident (R) (R59 and R74) and Resident Representative (RR) received a written notice of transfer, and a written bed hold notice that included all the required information. In addition, the facility failed to ensure the Long-Term Care Ombudsman was notified of R59 and R74's hospital transfers.Findings include:Review of the facility's policy titled, Transfer and discharge date d 3/20/2025 indicated, .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include the following at the time it is provided: a. The specific reason and basis for transfer or discharge.The specific location.to which the resident is to be transferred.d. An explanation of the right to appeal the transfer.to the State. e. The name, address.and telephone…

    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 · D2025-10-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and review of the facility policy titled, Resident Assessment- RAI, the facility failed to ensure the comprehensive assessment accurately reflected Pre-admission Screening and Resident Review (PASSR) level II for one (Resident (R) 1) of two residents reviewed for PASSR level II and to ensure the comprehensive assessment accurately reflected contractures for one resident (R59) of one resident reviewed for contractures in the sample of 31 residents. R1's annual Minimum Data Set (MDS) assessment failed to document PASSAR level II. This failure had the potential to lead to a lack of services. R59's quarterly MDS assessment failed to document limited range of motion in upper extremity. This failure had the potential to lead to further worsening of contractureFindings include:Review of the facility's policy titled, Resident Assessment- RAI dated 12/24/2023 noted, this facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS.1.Review…

    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 · D2025-10-02 · 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 interview, record review and review of the facility policy titled, Comprehensive Care Plans , the facility failed to develop a comprehensive care plan for four of 31 Resident (R) (R53, R59, R12 and R2). This failure placed the resident at risk for unmet care needs, and the inability to meet their maximum practicable level of functioning.Findings include:Review of facility's policy titled, Comprehensive Care Plans with a revision date of 03/20/2025 noted, .facility to develop and implement a comprehensive person-centered care plan for each resident.ALL services that are identified in the resident's comprehensive assessment.other factors identified by the-interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.5. The comprehensive…

    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 · D2025-10-02 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of the facility policy titled, Activities of Daily Living (ADL), the facility failed to provide timely incontinence care for two of three Residents (R) (R39 and R8) reviewed for Activities of Daily Living (ADL) in the sample of 31 residents. The facility's failure could negatively impact residents' overall feelings of wellbeing, and their willingness to socialize or participate in activities and other residents and/or staff.Findings include:Review of the facility's policy titled, Activities of Daily Living (ADL) dated 3/2025 revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate.3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal hygiene.1. Review of R39's undated face sheet under the ''admission Record'' tab located in…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-02 · 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, interviews, and record review, the facility failed to ensure residents admitted to the facility with a contracture were provided with the services to prevent further decrease in range of motion/mobility for one of two Resident (R) (R59).Findings include:During an observation of R59 on 9/28/0225 at 2:12 pm and on 9/29/2025 at 9:58 am, R59's right hand was contracted without a device in the palm of his hand. During an interview with R59 on 9/28/2025 at 2:12 pm, he confirmed that staff do not put a device in his contracted right hand.Review of R59's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with complete paralysis (hemiplegia) and partial weakness or paralysis (hemiparesis) on his right dominant side.Review of the R59's Care Plan located under the Care Plan tab in the EMR dated 4/24/2023 revealed there was not a care plan for resident's right-hand contracture.Review of R59'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-30 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff and family interviews, and review of facility documents titled, Facility Assessment Tool 2024 and the PBJ (payroll-based journal) Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023), the facility failed to ensure that the facility had adequate nursing staff. The deficient practice had the potential to affect the care provided to the 116 residents that resided in the facility. Findings include: Review of The Facility Assessment Tool (FAT) 2024 revealed the average daily census in the facility was 112 residents. The FAT revealed the average hourly staffing needs per day were 84 hours of licensed nurses providing direct care, 233 hours for nurses' aides. Review of the PBJ Staffing Data Report Quarter 1 2024 (October 1, 2023, through December 31, 2023) revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing and for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation…

    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
  • Potential for harm · F2024-05-30 · tag F0803 — failed to meet residents' dietary needs — widespread
    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

    Based on observations, staff interviews, record review, and review of the facility policy titled, Menus, the facility failed to serve the meal listed on the cycled menu for residents who received an oral diet from the kitchen. Specifically, the cycled menu stated ham and California vegetable blend was to be served for dinner, but instead, a sloppy joe was served. The deficient practice affected 115 of 116 residents who received an oral diet from the kitchen. Findings include: 1. Review of facility policy titled Menus updated February 2017 revealed under Policy: All residents are to receive the meal stated on the weekly menu. Meals should be prepared and served based on the cycled menu. Review of the weekly menu cycle for the week of Sunday, 5/26/2024, revealed residents were to receive glazed baked ham, pinto beans, broccoli, and cornbread. Interview on 5/29/2024 at 11:33 am with the Regional Dietitian revealed that she was aware of the residents in the facility not liking the food. 2. Review of the quarterly Minimum Data Set (MDS) assessment from 4/30/2024 for R85 revealed a Brief…

    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 before2024-05-30 · 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 policy titled, Resident Environmental Quality, the facility failed to provide a safe, clean, comfortable, and homelike environment in nine of 53 resident rooms on two of four halls, and in the lobby media common area. Specifically, these rooms and halls contained pests (flies), damaged floor fall strips, dirty wall sheetrock, dirty privacy curtain with missing hanging hooks, stained, brown, and damaged floor tiles, damaged bathroom toilet commodes, damaged baseboard, dirty, broken packaged terminal air conditioner (PTAC) unit vent covers, damaged soap dispensers, and crowded furniture (beds with crank adjustment) in the lobby media common area. Review of the facility policy titled Resident Environmental Quality dated 2/1/2022 indicated under Policy: It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Policy…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · 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

    Based on observations, staff interviews, record review, and review of the facility policy titled, Resident Smoking, the facility failed to enforce its smoking policy adequately for one of 23 sampled residents (R) (R68) reviewed for smoking compliance. Specifically, this failure allowed R68 to vape unsupervised in his room. The deficient practice had the potential to cause safety issues, including fire. Findings include: Review of the facility policy titled Resident Smoking dated 2/11/2022 indicated under Policy: It is the policy of this facility to provide a safe and healthy environment for all residents, visitors, and employees, including safety as related to smoking. Under Policy Explanation and Compliance Guidelines revealed under number 5. Electronic cigarettes (e-cigarettes/vape/vapor pens) could catch on fire and explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include, but are not limited to: a. Use of e-cigarettes in designated smoking areas only. Review of the electronic medical record (EMR) revealed R68 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-30 · 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 observations, staff interviews, record review, and review of the facility policies titled, Administration of Dry Powder Inhalers and Peripherally Inserted Central Catheter Flushing, Locking, Removal, the facility failed to ensure that residents were free of medication administration errors of more than 5 percent (%) for two of 41 sampled residents (R) (R36 and R111). Specifically, one of three nurses observed failed to have R36 rinse their mouth after administration of an inhaler, and one of three nurses observed failed to properly disinfect the lumen (inside space) of the peripherally inserted central catheter (PICC) line of R111. Findings include: Review of the facility policy dated 2/1/2022 titled Administration of Dry Powder Inhalers revealed under Policy: Medications are administered as prescribed, in accordance with current nursing principles and practices and only by persons legally authorized to do so.under Compliance Guidelines . 13. Allow residents to rinse mouth with water when required per…

    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 · D2024-05-30 · 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 review of the facility policy titled, Peripherally Inserted Central Catheter Flushing, Locking, Removal, the facility failed to use proper infection control practice when flushing a needleless connector of a peripherally inserted central catheter (PICC) for one of three Residents (R) (R111) observed during medication administration. The deficient practice had the potential to cause infection for R111. Findings include: Review of the facility policy titled Peripherally Inserted Central Catheter Flushing, Locking, Removal, it states under Policy: It is the policy of the facility to ensure that peripherally inserted central catheters (PICC) are flushed, locked, and removed consistent with current standards of practice.under Flushing Compliance Guidelines: 4. Disinfect needleless connector with an antiseptic solution using a vigorous mechanical scrub for five (5) seconds and allow it to dry completely. Review of the electronic medical record (EMR) for R111…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-12-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    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 observations, staff interviews, and review of the facility policies titled, Dietary Employee Personal Hygiene and Staff Attire, the facility failed to ensure food was prepared, distributed, and served in accordance with professional standards for food service quality. Specifically, the facility failed to ensure four of six staff members observed (Dietary Manager (DM), Kitchen Staff (1), Kitchen Staff (2), and the Social Services Director (SSD) had their hair restrained appropriately which had the potential to affect all residents on an oral diet. Facility census was 108 with 107 residents recieiving an oral diet. Findings include: Review of the facility policy titled, Dietary Employee Personal Hygiene, dated 2/01/2022 revealed All dietary staff must wear hair restraints (e.g., hairnet, hat and/or beard restraint) to prevent hair from contacting food. A review of the facility policy titled, Staff Attire, dated October 2019 revealed The Dining Services Director ensures that all staff members have their hair off the shoulders, confined in a hair net or cap and facial hair…

    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

“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

$15,092 in federal fines across 1 penalty.

  • $15,092 — penalty dated 2024-05-30

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 JOURNEY HEALTHCARE — 32 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 1 of 52.3-1.3 vs chain
Staffing 1 of 51.5-0.5 vs chain
Quality measures 2 of 52.7-0.7 vs chain
The other 31 homes this chain runs (chain average 1.9★, per CMS)
1 of 5Calhoun Crossing Of Journey LLCCalhoun, GA 1 of 5Clifton HeightsLouisville, KY 1 of 5Crossroads of Flowery Branch of Journey LLC, TheFlowery Branch, GA 1 of 5Fairburn Heights Of Journey LLCFairburn, GA 1 of 5Jasper Point Of Journey LLCJasper, GA 1 of 5Jesup Ridge of Journey LLCJesup, GA 1 of 5Kirtland Woods Of JourneyKirtland, OH 1 of 5Morgantown Heights Of JourneyMorgantown, WV 1 of 5Reserve at Appling of Journey LLC, TheAppling, GA 1 of 5Stanford CrossingStanford, KY 1 of 5Stone Mountain Run Of Journey LLCStone Mountain, GA 1 of 5Thomasville Vistas of Journey LLCThomasville, GA 1 of 5Tucker Park Crossing of Journey LLCTucker, GA 2 of 5Crossings At East Lake Of Journey Llc, TheDecatur, GA 2 of 5Fort Valley Crossing of Journey LLCFort Valley, GA 2 of 5Frankfort TrailsFrankfort, KY 2 of 5Glasgow Hills Of JourneyGlasgow, WV 2 of 5Reserve at Fort Gaines of Journey LLC, TheFort Gaines, GA 2 of 5Warrenton Woods of Journey LLCWarrenton, GA 2 of 5Woods at Lumber City of Journey LLC, TheLumber City, GA 3 of 5Bainbridge Landing of Journey LLCBainbridge, GA 3 of 5Cartersville Crossing Of Journey LLCCartersville, GA 3 of 5Chardon WoodsChardon, OH 3 of 5Dublin Trails Of Journey LLCDublin, GA 3 of 5LaGrange Trails of Journey LLCLagrange, GA 3 of 5Riverside Valley Of JourneySaint Albans, WV 3 of 5Twin City Trails of Journey LLCTwin City, GA 3 of 5Vanceburg HillsVanceburg, KY 4 of 5Green River TrailsGreensburg, KY 4 of 5Roberta Trails of Journey LLCRoberta, GANot rated (Special Focus)Lyndon Crossing, LLCLouisville, KY

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
JOURNEY OX OF GA LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2024
3 BEES HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
AJOJ HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
BEES FAMILY IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
BLUE OCEAN TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
JOURNEY OX GA HEALTHCARE HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
SHASAM FAMILY TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
SHASAM HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
MCGUINNESS, BERNARDIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF; ADP OF THE SNFsince 11/01/2024
JOURNEY OX GA MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
BILBO, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/20/2024
BLACKWELL, HAILEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/08/2025
CONRAD, CAMERONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
COOK, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
DODD, ANGELAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
FERENTI, LEONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
JOHNSON, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
JONES, ANTONIOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/18/2024
OMARA, JODYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
ROOPNAUTH, LLOYDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
SILLINGS, NIKKIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2025
TRAMMELL, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
SEGALL, SARAHIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 09/12/2025
SUMMIT CHATSWORTH LLCOrganizationADP OF THE SNFsince 11/01/2024

CMS files one row per role, so the 41 rows in the source record cover these 24 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

10 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.

$10.2M
Net patient revenuemost recent cost report
-39.8%
Operating marginrevenue minus expenses
$513K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 74%Medicare 14%Other / private 12%

About 74% 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 $513K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$354per resident / day
operating cost
$10,763per month
≈ monthly operating cost
$253per 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 115280. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-10-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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