River Towne Center
5131 Warm Springs Rd, Columbus, GA 31909 · For profit - Corporation · 210 certified beds · (706) 561-1371 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $24,387 in federal fines (most recent 2023-10-12)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (60%) 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 2.6% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.2% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.2% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.2% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.4% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 0.0% | 15.2% | 16.1% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 15.3% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 99.2% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 14.9% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 6.9% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.1% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.3% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.9% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 12.0% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 3.12 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.85 | 1.90 | 1.80 | worse |
* 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.
40.0% 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 82 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 43.8% 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 64 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 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 40.0%CMS range 29.8–55.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.3%CMS range 8.1–14.7 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 43.8% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 39.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 29.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.8%CMS range 5.6–12.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 210 beds and averages 133.5 residents a day — about 64% occupied, or roughly 76 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 4.14 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.54 hrs/resident/day on weekends vs 4.39 on weekdays — 19% thinner on weekends. RN hours go from 0.87 to 0.73 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 60% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.
- Immediate jeopardy · J2023-10-12 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the job description for the Administrator, the facility Administration failed to ensure the health and safety of the residents by not maintaining an effective Infection Prevention Control Program (IPCP) that would identify and investigate an infection outbreak to prevent or reduce the spread of Covid-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing). This failure resulted in a total of five residents and two staff members who tested positive for COVID-19. The facility census was 131. On 10/4/2023, a determination was made that a situation in which the facilities noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, serious…
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.
- Immediate jeopardy · Jcited before2023-10-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the facility's COVID -19 Response, the facility failed to implement initial and ongoing testing of residents and staff as recommended by the CDC to lessen the exposure of COVID-19 during an outbreak, failed to ensure source control was used during outbreak, ensure the safety of all residents in the facility by not following current guidelines related to COVID-19 for resident and staff testing, infection control, monitoring and documenting COVID-19 symptoms for residents, notification of staff and family of outbreak status during an outbreak and source control that resulted in five residents (R)(R15, R89, R94, R111, and R433) and two staff testing positive for COVID-19. On 10/4/2023, a determination was made that a situation in which the facilities…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 reviews, interviews, and review of the facility policy titled, Medication Therapy, the facility failed to ensure residents or resident representatives were informed in advance of the risks and benefits of a prescribed psychotropic medication or an alternative treatment for two of three residents (Resident (R) 46, and R61) reviewed. This failure had the potential for residents to receive the medication without informed consent or understanding of the treatment, and/or alternative treatment available. Findings include: Review of R46's admission Record, in the electronic medical record (EMR), under the Admissions tab revealed R46 was initially admitted to the facility on [DATE]. Review of R46's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/20/25 and located under the MDS tab of the EMR, revealed R46 had a Brief Interview for Mental Status (BIMS) score of nine of 15, indicating she had moderately impaired cognition. Review of R46's Resident Medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-01 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and facility policy review titled Environment, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for one of one kitchen affecting 103 residents who consume food from the kitchen. This failure had the potential to contribute to contamination and infection control concerns. During a kitchen observation, alongside the Dietary Manager (DM), on 04/01/26 at 6:02 AM, a large section of non-slip flooring in front of the steam table was worn through to show the underneath tile, and some missing grout for the tile.-Two sections of non-slip flooring in front of the three-pan sink were worn through, showing the underneath tile and concrete. The sections were flooded with standing water.-Underneath the steamer, there was broken and worn non-slip flooring to reveal exposed tile.-A long section of broken, worn-through non-slip flooring at the drink station revealed rocky concrete/ tile areas and was flooded with water.-The non-slip flooring in front of the dish machine had broken, worn sections revealing the underneath…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, interviews, and review of the facility's policy titled, Administering Medications, the facility failed to administer medications timely for one of six residents (Resident (R) 141) reviewed for medications out of a total sample of 38 residents. This failure had the potential to alter the effectiveness of the medication with the potential for overdosing if medications were given too close together. Findings include: Review of R141's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed the resident was admitted on [DATE] and discharged on 06/21/25. The resident had diagnoses which included anemia, encounter for orthopedic aftercare following surgical amputation, and muscle weakness. Review of R141's discharge Minimum Data Set (MDS), with an assessment reference date (ARD) date of 06/21/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) was not conducted and the staff assessment for mental status…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 reviews, and interviews, the facility pharmacy services failed to ensure medication irregularities were identified and addressed when ordered medications were not available for administration for one resident (Resident (R) 147) out of four newly admitted residents reviewed for medication irregularities. This failure had the potential to result in a decline of the resident's condition due to missed medication. Findings include: Review of R147's Admissions Record, located under the Admissions tab of the electronic medical record (EMR), revealed R147 was initially admitted to the facility on [DATE] and expired in the facility on [DATE], with diagnoses to include acute respiratory failure with hypoxia, hyperlipidemia, and tracheostomy. Review of R147's Physician Orders, dated [DATE] and located under the Orders tab of the EMR, revealed R147 was prescribed Budesonide Inhalation Suspension 9.5 via trach two times a day for the diagnosis of respiratory failure. The physician orders also…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 policy titled Food Receiving and Storage, the facility failed to ensure food items were discarded upon expiration. This deficient practice had the potential to promote foodborne illnesses in the 110 residents receiving an oral diet from the kitchen. Findings include: Review of the facility's policy titled Food Receiving and Storage, dated November 2022, revealed that the Policy Statement stated, Foods shall be received and stored in a manner that complies with safe food handling practices. During a tour of the kitchen on 4/22/2025, beginning at 9:50 am with the Dietary Manager (DM), observations revealed: One container of ground allspice seasoning with an expiration date of 7/19/2024. One container of ground ginger seasoning with an expiration date of 8/31/2023. One box of French-style dressing packets with an expiration date of 2/24/2025. One box of gelatin expired 9/5/2024. Observations of the walk-in cooler with the DM revealed: Two boxes of cabbage with expiration dates of 3/18/2025 and 4/17/2025. One container…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff and family interviews, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive, person-centered care plan for two of 49 sampled residents (R) (R70 and R385). This deficient practice had the potential to place R70 and R385 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the Policy Statement stated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation section included, . 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment . 7. The comprehensive, person-centered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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
Based on observations, resident interviews, staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to ensure that two of 49 sampled residents (R) (R12 and R43) received activities of daily living (ADL) care related to receiving scheduled showers to maintain good personal hygiene. This deficient practice had the potential to place R12 and R43 at risk of being unclean and feeling insecure about their appearance. Findings include: Review of the facility policy titled Activities of Daily Living (ADL), Supporting, revised 3/2018, revealed the Policy Statement stated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included, . 2. Appropriate care and services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident interviews, and staff interviews, the facility failed to ensure an environment free from accident hazards on one of seven medication carts and in three of 49 sampled residents' (R) (R12, R87, and R36) rooms. This deficient practice had the potential to place the residents at risk of accident hazards. Findings include: 1. Observation 4/22/2025 9:37 am of the medication cart located on the 200 Hall revealed an unpackaged three cubic centimeter (cc) syringe, with an uncapped needle attached, lying on top of a biohazard container attached to the medication cart. In a concurrent observation and interview on 4/22/2025 at 9:46 am, Registered Nurse (RN) MM verified the syringe location. She stated the syringe should have been placed completely in the biohazard container. She further stated there was a potential for a resident to pick up the syringe with the attached needle and have an adverse outcome. In an interview on 4/22/2025 at 9:50 am, Unit Manager (UM) CC revealed that syringes and needles should be disposed of by placing them completely inside the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, resident family interviews, record review, and review of the facility policy titled Pain Assessment and Management, the facility failed to provide pain management for one of 49 sampled residents (R) (R385). Findings include: Review of the facility's policy titled Pain Assessment and Management, revised 10/2022, revealed the General Guidelines section included, 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The Steps in the Procedure section included, Assessing Pain 1. Assess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-24 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policy titled Medication Labeling and Storage, the facility failed to ensure expired medications were discarded after the expiration date in one of two medication rooms. This deficient practice had the potential to place residents at risk of receiving medications with altered effectiveness. Findings include: Review of the facility policy titled Medication Labeling and Storage, revised February 2023, revealed the Policy Interpretation and Implementation Medication Storage section included, . 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Observations on 4/23/2025 at 4:53 pm in the [NAME] Side Medication Storage Room revealed three boxes of bisacodyl suppositories expired 1/2025, one opened container of Tylenol 325 milligrams (mg) expired 11/25/2024, and three containers of Renavite expired 10/2023 were stored with other unexpired medications on the storage shelves. In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · Dcited before2025-04-24 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I the facility failed to ensure the safe handling, labeling, and storage of nebulizer equipment to prevent contamination for one Resident(R)(R1) of 23 sampled residents. This deficient practice had the potential to contribute to the spread of infection and respiratory illness. Findings include: A review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I Purpose-The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 2.Take care not to contaminate internal nebulizer tubes. 3.Wipe the mouthpiece with damp paper towel or gauze sponge. 4.Store the circuit in plastic bag, marked with date and residents.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to implement care plan interventions for pressure ulcer treatments as ordered and provide descriptive wound documentation for two of 12 sampled Residents (R) (R2 and R6). These failures increased the potential for the residents not to receive treatment and/or care according to their needs. Findings include: 1. Review of R2's care plan dated on 12/13/2023 revealed the resident had a care plan for a declining unstageable pressure wound to the sacrum with interventions for weekly treatment documentation to include measurements of each area skin breakdown's width, length, depth, type of tissue and exudate. Review of medical records revealed R2 was admitted to the facility on [DATE] with a Stage two (2) pressure ulcer to the sacrum. Review of the Wound Summary report revealed the pressure ulcer to the resident's sacrum was not assessed until 12/6/2023 and noted the wound was a Stage four (4) that measured 7.1 centimeters(cm) x 8.5 cm x 0.1cm. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-14 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 staff interview and record review, the facility failed to provide treatment timely for one of 12 sampled Residents (R) (R10) with a venous stasis ulcer. Findings include: Review of medical records revealed R10 was admitted to the facility on [DATE] with a venous stasis ulcer to the right rear knee. There was no documentation of treatment being initiated until 2/5/2024 when orders were obtained to clean with normal saline, apply collagen and cover with dry dressing every Monday, Wednesday, and Friday. Review of R10's physician's order dated 2/8/2024 revealed orders were changed to clean with normal saline, apply Santyl to slough and dry protective dressing every day. Review of the 2/2024 Treatment Administration Record (TAR) revealed there was no documentation that the treatment was done as ordered on 2/10/2024 and 2/11/2024. During an interview with the Treatment nurse on 2/14/2024 at 3:25 pm, she stated it must have been an oversight pertaining to the lack of documentation for treatment until 2/5/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review and review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, the facility failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three of 12 sampled Residents (R) (R2, R6 and R10). Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol dated March 2014 under the section titled Assessment and Recognition revealed, 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin. 1. Review of medical records revealed R2 was admitted to the facility on [DATE] with a Stage two (2) pressure ulcer to the sacrum. Review of the Wound Summary report revealed the pressure ulcer to the resident's sacrum was not assessed until 12/6/2023 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.
- Potential for harm · D2023-10-12 · tag F0557 — isolatedHonor 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, resident and staff interviews, record reviews, and the review of the facility policy titled Resident Rights, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one resident (R) (R11) of 59 sampled residents. Findings include: A review of the facility policy titled Resident Rights, last revised February 2021, revealed Policy Interpretation and Implementation 1., a. A dignified existence and b., be treated with respect kindness and dignity. Record review revealed R11 admitted to the facility on [DATE]. R11 has diagnoses that include but are not limited to major depressive disorder, generalized muscle weakness, and unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. R11 is also noted as being dependent on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record reviews, and review of the policy titled Residents Rights, the facility failed to allow four residents (R) (75, 86, 105, and 125) of 59 sampled residents the choice to take showers instead of bed baths. Findings include: Based on the facility's policy Residents Rights last revised February 2021, Policy Interpretation and Implementation 1., e. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination. 1.Record review revealed that R125 admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) with a completion date of 9/15/2023 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated an intact cognition. The facility's shower list revealed that all residents in even room numbers on the 400 hall were scheduled to receive a shower or bed bath every Monday. Further review of the medical record revealed R125 had been receiving a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy titled Care Plans - Baseline revealed the facility failed to ensure the baseline care plan for one resident (R) (R98) of 59 sampled residents was completed to include goals and interventions for fall risk. Findings include: Review of the facility policy titled Care Plans-Baseline last revised December 2016 revealed Policy Interpretation and Implementation (1.) To ensure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. (2.) The Interdisciplinary Team will review the health care practitioner's orders and implement a baseline care plan to meet the resident's immediate care needs. Review of hospital records for her hospital stay from 6/10/2023 -6/22/2023 revealed R98 had fallen out of the bed during the night on 6/16/2023. Further review of the medical record revealed that R98 was admitted to the facility on [DATE]. R98 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.
- Potential for harm · Dcited before2023-10-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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, record reviews, resident and staff interviews, and review of facility policy titled Shower/Tub Bath, the facility failed to ensure Activities of Daily Living (ADL) was provided related to bathing for one resident, (R) (R80), of 59 sampled residents. Findings include: Review of the facility policy titled Shower/Tub Bath last revised October 2010, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Record review revealed R80 had resided in room [ROOM NUMBER]A since her admission to the facility on 9/13/2023. The facility's Shower List revealed all residents in even room numbers on the 400 hall were scheduled to receive a shower or bed bath every Monday. The admission Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental status (BIMS) score of 99, which indicated the assessment was unable to be completed due to cognitive impairment. It further indicated that R80 is dependent on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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, interviews, review of facility documentation, and review of facility policies titled Medication Administration,, the facility failed to administer medication as ordered by the Physician for two residents (R) (R105 and R86) of 59 sampled residents. Specifically, the facility failed to treat diabetes and weight management for resident R105 and failed to have neuropathy medication available for R86. Findings include: 1. Review of the facility policy titled, Medication Administration, revised December 2012 revealed the following: a. Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. b. Policy Interpretation and Implementation #9: The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. In an observation and interview with R105 in his room on 10/4/2023 at 2:20 pm, he was alert and oriented with a tracheostomy (trach) tube…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, the facility failed to provide oxygen therapy as ordered for one resident (R) (R27) of 14 residents who were on oxygen therapy and failed to contain BiPAP tubing in a clean plastic bag when not in use for one resident (R27) out of four residents. Findings include: During a review of the medical record for R27 it was revealed that the medical diagnosis included sleep apnea, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, personal history of transient ischemia attach and cerebral infarction, and insomnia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R27 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review orders for R27 included oxygen at 2 liters(L)/minute (min) via nasal cannula with a start date of 2/23/2023. There also was an order to check oxygen flow at eye level and document accordingly, one time a day. There was an order with a start…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-12 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the policy titled Storage of Medications, the facility failed to discard discontinued and outdated supplements, tube feedings, and Covid-19 test stored in one of two medication storage areas. Findings include: Review of the policy titled Storage of Medication, dated February/2007, revealed the Policy Interpretation and Implementation 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 10/6/2023 at 11:25 am with Licensed Practical Nurse (LPN) CC during tour of the [NAME] Unit medication storage room revealed one container of Osmolite 1.5 calories per 8 ounces supplement with an expiration date of 9/2023, three bags of Nutren 1.5 Kilo calories per cubic centimeter (Kcal/cc), 1000 milliliter (ml) in each bag, with a use by date of 8/29/2023, and one box of partially…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-12 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
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, review of facility documentation, failed to get labs administer treatment for infection in a timely manner for one resident (R) (R102) of 59 sampled residents. Review of the electronic medical record of resident R102, revealed that he was admitted to the facility on [DATE]. R102 admission diagnoses included but are not limited to cerebral infarction, gastrostomy status, tracheostomy status, obstructive and reflex uropathy with chronic use of indwelling catheter, and dependence on respirator status. Review of Section G of the quarterly minimum data set (MDS), dated [DATE], revealed that R102 is total dependence with all activities of daily living. Section H revealed that the resident was admitted with and still has a foley catheter. Review of the electronic medical record that included progress notes from the Nurse Practitioner, revealed that the resident had abnormal urine and ordered for staff to collect urine and blood work on 6/7/2023. The blood work never resulted and 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$24,387 in federal fines across 1 penalty. 1 Medicare payment denial on record.
- $24,387 — penalty dated 2023-10-12
- Medicare payment denial — starting 2025-07-09 for 2 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GEORGIA PYRAMID VENTURE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2017 |
| FISCHMAN, ARNOLD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 10/01/2017 |
| FISCHMAN, ISAAC | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | 50% | since 10/01/2017 |
| DWIGHT CAPITAL LLC | Organization | 5% OR GREATER SECURITY INTEREST | — | since 01/30/2024 |
| ROCO CARE LLC | Organization | 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 01/30/2024 |
| PYRAMID HEALTHCARE MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/02/2017 |
| BROWERS, PATRICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/15/2022 |
| DUNN, JEFFREY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/12/2021 |
| GROSSMAN, GERSHON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2018 |
| GUY, ADRIENNE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/17/2021 |
| HENDERSON, JOHN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/31/2018 |
| HILLIARD, RAVEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/12/2025 |
| LEWIS, IYSHA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/29/2024 |
| ONEAL, GARY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/09/2024 |
| PARKER, CRAIG | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/25/2021 |
| PARKER, TASHIKA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/01/2021 |
| RICHMAN, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/17/2023 |
| WHITEAD, SARA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/12/2025 |
| WILKINSON, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/28/2021 |
| 5131 REALTY LLC | Organization | ADP OF THE SNF | — | since 10/01/2017 |
CMS files one row per role, so the 38 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.
5 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.
This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115566. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.