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

Rockdale Healthcare Center

1510 Reniassance Drive, Conyers, GA 30012 · For profit - Partnership · 103 certified beds · (770) 483-4480 Medicare & Medicaid certified

Call the home — (770) 483-4480 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jul 2025Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
  • 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
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS
Urgent care / clinic
Pharmacy
405 Sigman Rd NW Ste B · (770) 648-7868 · Call to confirm hours
Grocery
425 Sigman Rd NW · (470) 886-1318 · Call to confirm hours
Park
1665 Main St NE · Typically dawn to dusk
Place of worship
2505 Highway 20 NE · (678) 806-3158

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 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 improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased24.3%15.3%15.4%worse
Long-stay residents who lose too much weight6.9%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder1.7%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.0%2.5%2.0%better
Long-stay residents with depressive symptoms2.2%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.3%3.2%3.3%better
Long-stay residents whose ability to walk worsened48.1%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.6%20.5%18.9%typical
Long-stay residents given the seasonal flu vaccine96.5%95.0%95.3%typical
Long-stay residents with pressure ulcers7.4%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control22.3%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.4%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication3.6%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine73.9%78.4%79.4%typical
Short-stay residents rehospitalized after admission23.1%25.0%22.6%typical
Short-stay residents with an outpatient ER visit13.3%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.152.151.67worse
Long-stay outpatient ER visits per 1,000 resident days1.691.901.80typical

§ 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.

50.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 231 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.8%U.S. median 51.5%
Got home and stayed home
10.7%U.S. median 10.7%
Went back to hospital
31.8%U.S. median 56.6%
Met the expected recovery
0.57U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 31.8% 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 126 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 0.57 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 45% 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 SNF50.8%CMS range 43.6–56.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.7%CMS range 7.9–13.610.7%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 discharge31.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge25.4%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 discharge37.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified84.0%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 setting83.6%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 discharge94.2%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 stay1.7%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 worsened5.8%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 hospitalization12.9%CMS range 9.2–18.07.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 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

0.32
RN hours/ resident / day
1.04
LPN hours/ resident / day
2.11
Aide hours/ resident / day
3.47
Total nurse hours/ resident / day
0.28
RN hoursweekends
21.7%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 103 beds and averages 97.7 residents a day — about 95% occupied, or roughly 5 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 3.47 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.11 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 3.18 hrs/resident/day on weekends vs 3.59 on weekdays — 11% thinner on weekends. RN hours go from 0.33 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 22% is below 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

1
deficiencies at the latest standard inspection (2026-01-29)
10
at the previous standard inspection (2024-10-31)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 13 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2023-06-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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 policy titled Care Plan Policy, the facility failed to update and revise the comprehensive person-centered care plan related to unwitnessed falls for one resident (R) (R#306). The sample size was 35 residents. Findings include: Review of the Care Plan Policy reviewed October 25, 2022, revealed each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standard of Practice: Number 1: Each resident will be assessed by the interdisciplinary team on admission, quarterly, annually, and with a significant change in status. Number 12. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representatives party if so desired. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policies, the facility failed to ensure proper assessment and followup for one resident (R) (R#306) post fall on 1/20/2023. Specifically, facility failed to complete a fall assessment after an unwitnessed fall, failed to complete neuro-checks on 1/20/2023, and failed to provide Radiology services in a timely manner. Actual harm was identified on 1/23/2023 when resident was transferred to the hospital with continued pain. Computerized tomography (CT) of the head indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 residents. Findings include: 1. Review of the policy titled Fall Prevention Protocol Policy revised 10/18/2021 revealed Action number 4. After an incident of a fall: a. Complete the Post Fall Risk Assessment (electronic medical record-EMR); b. Notify Medical Doctor (MD) and Resident Representative. c. Start Neuro check if there is a suspected head injury or for an unwitnessed fall as per facility protocol. d.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-06-25 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interview, and review of the policy titled Pain Management - Acute and Chronic, the facility failed to manage pain for one resident (R) (R#306) after a fall. Actual harm occurred on 1/20/2023 when R#306 had an unwitnessed fall, hitting his head, with complaints of pain in bilateral hips and back. Resident was transferred to hospital on 1/23/2023 with continued pain. Computerized tomography (CT) of the head without contrast indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 Residents. Findings include: Review of the facility policy Pain Management - Acute and Chronic reviewed November 2022 revealed the facility will have an effective pain recognition and management that is on-going and committed to resident's comfort, identifying, and addressing barriers to managing pain and addressing any misconceptions that the residents, family, and staff may have about managing pain. Review of the clinical record revealed resident was admitted to…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review,staff interviews and a review of the facility policy title Accident and Incident Prevention, Reporting, and Response and Care Plan-Comprehensive, the facility failed to ensure that appropriate care plan interventions were developed and implemented to meet the needs of two of three residents care plan reviewed. Specifically, the facility failed to develop post fall interventions for one Resident (R1) following three separate falls. In addition, the facility failed to implement and establish care plan interventions for Activities of Daily Living (ADL) for R3.Review of the policy titled Accident and Incident Prevention, Reporting, and Response, dated 05/2026. Purpose: To ensure a safe environment for all residents by implementing a proactive and systematic approach to preventing accidents and incidents in accordance with federal regulations, facility policies, and resident-centered care principles. D. Corrective Actions and Prevention: Develop and implement interventions based…

    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 plan of correction
  • Potential for harm · D2026-06-17 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    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, record review, including a review of the Certified Medication Aide job description, the facility failed to ensure that professional standards of practice were maintained with one of three sampled Resident (R) (R2) during a scheduled medication pass. Specifically, the Certified Medication Aide (CMA) DD failed to maintain direct visual observation during the medication administration process, resulting in the resident being discovered holding a white pill that was actively dissolving in their hand. Findings include: A review of the Certified Medication Aide job description revealed: observe and verify that medication is ingested as directed. Review of R2's Electronic Medical Record (EMR) revealed an admission date of 4/29/2026 with diagnoses of but not limited to Alzheimer's Disease and type 2 diabetes mellitus without complications. Review of the resident's most recent Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS)…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-17 · 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, resident, family and staff interviews, record review and a review of the facility's policy titled Accommodation Of Needs the facility failed to provide activities of daily living (ADL) for one resident (R) (R3) out of three dependent on staff for care.Findings include:Review of the policy titled Accommodation Of Needs, dated 12/2025. Policy: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. Procedure: 1. The resident's individual needs and preferences are accommodated to the extent possible. In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in accordance with the residents' wishes. B. Arranging toiletries and personal items so that they are in easy reach of the resident.Review of the document titled Grievance/Complaint Form dated 04/15/2026 revealed the family of R3 filed a grievance…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and the facility policy titled Accident and Incident Prevention, Reporting, and Response, the facility failed to ensure that an environment free from accident hazards was maintained, and failed to provide adequate supervision and sufficient individualized interventions to prevent accidents for one Resident (R) (R1) who was identified as a high risk for falls and a history of recurrent falls. Specifically, the facility failed to develop and implement effective post-fall safety interventions following three separate falls sustained by R1 resulting in a major injury including a lumbar two (L2) compression fracture and a left distal femur fracture.Findings include: Review of the policy titled Accident and Incident Prevention, Reporting, and Response, dated 05/2026. Purpose: To ensure a safe environment for all residents by minimizing accident hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing,…

    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 plan of correction
  • Potential for harm · D2026-01-29 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    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 Advance Directives, the facility failed to ensure the Advance Directive status was consistently documented in the clinical record for one of 45 sampled residents (R) (R71). This deficient practice had the potential to place R71 at risk of not receiving life-sustaining treatment in accordance with the resident's wishes. Findings include:Review of the facility's policy titled Advance Directives dated 7/2025 documented Policy: A resident's choice about Advance Directives will be respected. Policy Interpretation and Implementation: 3b; Do Not Resuscitate-Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health-care proxy, or representative have directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used.Review of the admission Record for R71 revealed R71 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including, but not…

    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 · D2025-07-03 · tag F0576 — isolated
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policy, the facility failed to ensure the residents were allowed to receive mail/packages without staff opening and obtaining copies of the documents without the resident's/resident's representative's permission for one of 14 Residents (R) (R3) interviewed about receiving mail unopened.Findings include:Review of the facility's policy titled, Mail, dated 11/2017, revealed, . residents are allowed to communicate privately with the persons of their choice and may send and receive their personal mail unopened unless otherwise advised by the attending physician or resident and documented in the residents' medical records . Review of R3's admission Packet, signed by the resident on 2/6/2024, revealed under the section titled Mail that the resident shall be afforded reasonable privacy in communications, including the timely sending and receiving of mail and electronic communications.Review of R3's Diag (Diagnosis) tab of the EMR revealed R3 had diagnoses which included cerebral infarction and slurred speech.Review of R3's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-03 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview and review of the facility's policy titled, Discharging/Transferring the Resident, the facility failed to notify the resident's responsible party on the day the resident was discharged and transported out of the facility for one of three Residents (R) (R7) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy titled, Discharging/Transferring the Resident, dated 6/2025, revealed it was the facility's policy to notify the responsible party of the transfer or discharge.Review of R7's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/19/2025 and located in the Aspen MDS Viewer, revealed R7 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, dementia, and aphasia.Review of R7's Progress Note, dated 6/10/2025 at 4:39 pm and located under the Progress Notes tab of the electronic medical record (EMR), revealed a progress note written by the previous Social Worker…

    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 · D2025-07-03 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to ensure the resident's right to be free from verbal/mental abuse for one of eight Residents (R) (R) (R11) reviewed for abuse out of a total sample of 20.Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility that each resident be free from verbal, sexual, physical, and mental abuse, and mistreatment of any kind. Under the Definitions section of the policy, it defined mental abuse as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.Review of R11's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/7/2025 and located in 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-03 · 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 interview, record review, and facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to report an allegation of verbal/mental abuse to the State Survey Agency within two hours after the allegation was made for one of eight Residents (R) (R11) reviewed for abuse out of a total sample of 20.Findings include:Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility that each resident be free from verbal, sexual, physical, and mental abuse, and mistreatment of any kind. The policy indicated abuse is to be reported to the Administrator and the State Survey Agency within two hours of the allegation being made.Review of R11's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 4/7/2025 and located in the ASPEN MDS Viewer, revealed R11 was readmitted to the facility on [DATE]. It…

    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 · D2025-07-03 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property, the facility failed to ensure allegations of abuse were thoroughly investigated for two of eight Residents (R) (R1 and R14) reviewed for a total sample of 20. Findings include: Review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property, dated 8/22/2022, revealed it was the policy of the facility to ensure all suspected cases of abuse be fully investigated by the Administrator, Abuse Coordinator, or designee. Under the investigation section of the policy, it stated to . Interview all associates, residents, and family members involved . 1. Review of R1's admission tab in the electronic medical record (EMR) revealed she was admitted to the facility with diagnoses that included dementia, psychotic disturbance, mood disturbance, anxiety, mental disorder, depression, muscle weakness,…

    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 16 citations
  • Potential for harm · D2025-07-03 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to ensure residents were not inappropriately transferred or discharged against the resident's/residents' representatives wishes for two of three Residents (R) (R7 and R4) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, dated 6/2025, revealed, . when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken . The policy indicated should the resident be transferred or discharged because the safety of individuals in the facility would be endangered the basis of the discharge . must be documented in the resident's clinical record by a physician . The policy indicated the documentation must include at minimum: the reason for the discharge, that an appropriate notice be provided to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-03 · 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

    Based on interview, record review, and review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to notify the resident and the resident's representative of the reasons for a discharge/transfer, failed to notify the Office of State Long-Term Care Ombudsman of the discharge/transfer, and failed to record the reasons for the transfer/discharge in the resident's medical record for two of three Resident (R) (R7 and R4) reviewed for discharge out of a total sample of 20.Findings include:Review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, dated 6/202025, revealed, . when a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken . The policy recorded should the resident be transferred or discharged because the safety of individuals in the facility would be endangered the basis of the discharge . must be documented in the resident's clinical record by a physician . The policy stated the documentation must include at…

    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 · F2024-10-31 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to ensure notifications of discontinuation of Medicare Part A benefits were issued in a timely manner for three of three residents (R) (R36, R81, and R605) reviewed for beneficiary notification. This failure had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes. Findings include: 1. Review of R36's Part A Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed section A (Identification Information) documented the Medicare stay had a start date of 7/1/2024 and an end date of 8/17/2024. Review of R36's Occupational Therapy Discharge Summary dated 5/11/2024 to 8/16/2024 revealed R36 had reached her maximal potential and was discharged to long-term care at this facility. The Occupational Therapist (OT) signed the note on 8/21/2024. Review of R36's medical record revealed no evidence that a (Skilled Nursing Facility Advance…

    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 · Fcited before2024-10-31 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and review of the facility's policy titled, Food Service Director, the facility failed to maintain sanitary practices in the kitchen in regard to food handling and hair coverings. The deficient practice had the potential to affect 101 of 103 residents receiving an oral diet from the kitchen. Findings include: Review of the facility's policy titled Food Service Director revealed under Procedure: 6. Food is prepared in a manner that prevents food borne illness. Staff follow proper sanitation and food handling practices. Food is served as soon as possible after it has been prepared, and at the proper safe temperature. Observation on 10/29/2024 at 9:30 am revealed [NAME] NN without a beard net in the kitchen food preparation area. Observation on 10/29/2024 at 9:35 am revealed a fan blowing debris that was accumulated on the fan blades and wire cage towards the food preparation area. Observation on 10/29/2024 at 9:40 am in the dry storage room revealed an unsealed bag of instant food thickener. The bag was left open in the box with the top of 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-31 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and interviews, record review, and review of the facility's policies titled Activities of Daily Living (ADLs)/Maintain Abilities, and Care of Fingernails, the facility failed to ensure that Activities of Daily Living (ADL) was provided for two of three residents (R) R72 and R83 reviewed for ADL. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs)/Maintain Abilities under the section titled Intent revealed, It is the facility's responsibility to ensure all staff understand the principles of quality of life and honor and support these principles for each resident; and that the care and services provided are person-centered. Under the section titled Procedure revealed, 3. The facility will provide care and services for the following activities of daily living, hygiene which is bathing dressing, grooming and oral care. 4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good…

    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 · D2024-10-31 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medication, the facility failed to adequately assess one of 50 sampled residents (R) (R24) for self-administration of medication. This failure placed R24 at risk for inappropriate and unsafe medication use. Findings Include: A review of the facility policy titled Self-Administration of Medication, dated 4/2022, revealed the Policy was, The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs. The General Guidelines section included 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of R24's electronic medical record (EMR) revealed diagnoses including, but not limited to, cognitive-communication deficit, dementia, major depressive disorder, mild cognitive impairment,…

    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 before2024-10-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of the facility policy titled Environmental Services, and review of the manufacturer recommendations titled Monthly Maintenance Front Filters, the facility failed to maintain a clean, homelike environment by not ensuring that packaged terminal air conditioner (PTAC) filters were free of debris in 2 of 42 resident rooms. This failure had the potential to compromise the hygiene and safety of the room environments, increasing the risk of infection and negatively impacting the health and well-being of the residents residing in the rooms.The census was 103 residents. Findings Include: Review of the facility policy titled Environmental Services, dated 4/2022, revealed the Policy stated, It is the primary responsibility of the Housekeeping, Laundry and Maintenance Departments to ensure a safe, sanitary, orderly and comfortable environment. The Policy Interpretation and Implementation section included . 2. Preventative maintenance will be conducted. 7. A…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility's policy titled Resident Assessment, the facility failed to ensure that all high-risk medications were coded on the admission assessment for one of 50 sampled residents (R) R309. This deficient practice had the potential to cause resident not to receive person centered care. Findings include: Review of the undated facility's policy titled Resident Assessment, under the section titled Intent revealed, It is the policy of the facility to provide, and services related to Resident Assessment/Instrument and process in accordance with State and Federal regulation. Under the section titled Procedure revealed, This policy will include: 1. admission Physician orders for Immediate care .7. Accuracy of Assessments. Review of the Electronic Medical Record (EMR) for R309 revealed, she was admitted with diagnoses that included but were not limited to acute respiratory failure, acute embolism and thrombosis of deep veins or right lower extremity, sepsis…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-31 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Care Plan -Comprehensive, the facility failed to develop a comprehensive person-centered care plan that addressed all high-risk medications for two of 50 sampled residents (R) (R309 and R83). This failure had the potential for residents to not receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Care Plan-Comprehensive, dated January 2023, revealed the Policy stated, A comprehensive care plan that includes measuring objectives and timetables to meet the residents medical, nursing, mental and psychological needs shall be developed for each resident. The Policy Interpretation and Implementation section included 2. The Comprehensive Care Plan has been designed to do the following but was not limited to b. Incorporate risk factors associated with identified problems; d. Reflect treatment goals and objectives in measurable outcomes. 4. Care plans are revised as…

    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 · D2024-10-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, resident family and staff interviews, record review, and review of the facility's policies titled, Medication Administration and Activities of Daily Living (ADLs)/Maintain Abilities, the facility failed to give ordered medications that were readily available for one of 50 sampled residents (R) (R553) and failed to implement resident-directed care and treatment consistent with the resident's orders as directed by podiatrist and professional standards of practice for one of 50 sampled R (R50). The deficient practices had the potential to cause R553 to be at risk for medical complications, unmet needs, and a diminished quality of life and cause pain and possible open skin which can lead to infection for R50. Findings include: Review of the facility policy titled Medical Administration dated April 2022 revealed under Policy Interpretation and Implementation: 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Administration of Drugs, the facility failed to administer oxygen to one of five residents (R) (R28) who received oxygen and failed to secure the oxygen canister. The deficient practice had the potential to place R28 at risk of respiratory complications. Findings include: Review of the facility policy titled Administration of Drugs, dated April 2022, revealed the Policy stated, Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Review of R28's electronic medical record (EMR) revealed diagnoses included, but not limited to, chronic obstruction pulmonary disease (COPD) and chronic respiratory failure with hypoxia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented impairment on both sides of upper extremities, and Section O (Special Treatments and Programs)…

    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 · D2024-10-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, staff interviews, and review of the facility's policy titled, Psychopharmacologic Drugs, the facility failed to add a 14-day stop for as-needed (PRN) psychotropic medication for one of five residents (R) (R10) reviewed for unnecessary psychotropic medication. The deficient practice had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. The facility census was 103 residents. Findings include: Review of the facility policy titled Psychopharmacologic Drugs dated April 2022, documented under section titled, Policy, The purpose of this procedure is to provide guidelines for the psychopharmacologic drug treatment of a resident with a specific condition as diagnosed and documented in the clinical record. Under section titled, Procedural Guidelines, it documented, 1.Psychopharmacologic drugs include antianxiety agents, antidepressants, sedatives, hypnotics, antipsychotics and other drugs that affect behaviors. 9. PRN orders for psychotropic drugs are limited to 14 days. Excluding Antipsychotic…

    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 · Fcited before2023-06-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the policies titled Use and Storage of Food and Beverage Brought in for Residents, Food Procurement and Dishwashing Procedures, the facility failed to label and date opened food items in the walk-in cooler, the walk-in freezer, and the dry storage pantry; failed to discard food items by the discard date; and failed to maintain sanitary conditions by not stacking wet drinking cups. This deficient practice had the potential to affect all 89 residents receiving an oral diet. Findings include: 1. Review of the policy titled Use and Storage of Food and Beverage Brought in for Residents, Food Procurement reviewed 11/18/2021 indicated the policy was to provide safe and sanitary storage, handling, and consumption of all food. This includes the storage, preparations, distributions, and serving food in accordance with professional standards for food service safety. The food service workers, cooks, dietary aides, food prep aides, or any person(s) who are in the kitchen working with any type of food are responsible to adhere to the food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-06-25 · 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 observation, family and staff interviews, and review of the facility policies titled Cleaning and Disinfection of Environmental Surfaces and Cleaning and Disinfecting Resident's Rooms, the facility failed to maintain a clean and comfortable homelike environment in eight resident rooms (449, 454, 455, 457,458, 460, 461, and 463) on one of two halls, including black scuff marks on walls and dirty and dusty air vents in the bathrooms. Findings include: Review of the policy titled Cleaning and Disinfection of Environmental Surfaces reviewed November 20, 2020, revealed Policy Statement is environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: number 11. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Review of the policy titled Cleaning and Disinfecting Resident's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident representative and staff interviews, and review of the policy titled Urinary Catheter Care, Anchoring and Changing, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of seven residents (R) (R#100) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of the policy titled Urinary Catheter Care, Anchoring and Changing reviewed 11/15/2022 revealed the policy statement is each resident who is incontinent of bladder and has an indwelling catheter receives appropriate treatment of services to prevent urinary tract infections and to restore as much bladder function as possible. Standard of Practice: step 16. secure foley catheter drainage bag below level of bladder and above the floor. Catheter drainage bags will be covered when residents are in a public…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-06-25 · tag F0776 — isolated
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the policy titled Laboratory, Radiology and Other Diagnostic Services, the facility failed to provide radiology services in a timely manner for one resident (R) (R#306). The sample size was 35 residents. Findings include: Review of the policy titled Laboratory, Radiology and Other Diagnostic Services reviewed November 2022, revealed facility will provide laboratory and diagnostic services to meet the needs of the residents in a timely manner. Standard of Practice Radiology or Other Diagnostic Services revealed results from radiology or other diagnostic services will be obtained and acted upon in a timely manner by the physician, physician assistant, nurse practitioner or clinical nurse specialist or the facility staff as ordered. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, dysphagia, diabetes, hypertension (HTN), and gastroesophageal reflux disease (GERD). Review of 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.

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to WELLINGTON HEALTH CARE SERVICES — 14 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 2 of 51.9+0.1 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 1 of 52.1-1.1 vs chain
The other 13 homes this chain runs (chain average 1.9★, per CMS)

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 / managerTypeRoleShareSince
WELLINGTON HEALTHCARE SERVICES LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST100%since 07/31/2007
ANDWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/10/2012
ANDREWS, JAMESIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/10/2012
BAILEY, TERESAIndividualW-2 MANAGING EMPLOYEEsince 07/01/2023
KELMAN, MOSHEIndividualCORPORATE OFFICERsince 07/01/2023
ELKINS ROAD ASSOCIATES LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 07/31/2007

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$12.5M
Net patient revenuemost recent cost report
+9.4%
Operating marginrevenue minus expenses
$623K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 17%Other / private 83%

This home reported $623K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$325per resident / day
operating cost
$9,884per month
≈ monthly operating cost
$359per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

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 115670. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next