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Riverside Health Care Center

5100 West St NW, Covington, GA 30014 · For profit - Corporation · 159 certified beds · (770) 787-0211 Medicare & Medicaid certified

Call the home — (770) 787-0211 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0602, F0606) — most recent Jan 2024Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

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

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0602, F0606) — most recent Jan 2024
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
6238 Turner Lake Rd NW · (470) 971-2118 · Call to confirm hours
Pharmacy
3188 Highway 278 NE · (770) 784-8090 · Call to confirm hours
Grocery
6169 Highway 278 NW · (770) 787-2622 · Call to confirm hours
Park
3123 W Alexander St · (770) 786-4373 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 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 fell from 2 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.2%15.3%15.4%typical
Long-stay residents who lose too much weight8.3%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.9%0.9%better
Long-stay residents with a urinary tract infection0.9%2.5%2.0%better
Long-stay residents with depressive symptoms5.4%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 injury2.7%3.2%3.3%better
Long-stay residents whose ability to walk worsened13.6%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication21.0%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine99.3%95.0%95.3%typical
Long-stay residents with pressure ulcers6.6%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control13.9%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table16.0%19.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication2.0%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine54.6%78.4%79.4%worse
Short-stay residents rehospitalized after admission23.6%25.0%22.6%typical
Short-stay residents with an outpatient ER visit12.4%11.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.472.151.67better
Long-stay outpatient ER visits per 1,000 resident days2.031.901.80worse

§ 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.

44.8% 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 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.8%U.S. median 51.5%
Got home and stayed home
10.2%U.S. median 10.7%
Went back to hospital
45.3%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.11hours / resident / day
Speech therapy

Met the expected recovery: 45.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 75 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 42% 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 SNF44.8%CMS range 34.7–57.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.2%CMS range 7.5–14.110.7%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 discharge45.3%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 discharge44.0%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 discharge34.7%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 identified82.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge86.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%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 worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization11.0%CMS range 7.5–15.77.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.361.02Oct 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

0.25
RN hours/ resident / day
0.69
LPN hours/ resident / day
2.55
Aide hours/ resident / day
3.49
Total nurse hours/ resident / day
0.15
RN hoursweekends
46.4%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 159 beds and averages 152.8 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.25 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above 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 3.19 hrs/resident/day on weekends vs 3.61 on weekdays — 12% thinner on weekends. RN hours go from 0.29 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2026-05-14)
5
at the previous standard inspection (2025-04-03)

Deficiencies are unchanged from the previous inspection. 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.

30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · Gcited before2025-10-28 · 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, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur. Findings include:A review of the facility's policy titled, Care Plan- Comprehensive, dated September 2025 under Policy revealed: A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Under the section Policy Interpretation and Implementation number 2 (e) identify the professional services that are responsible…

    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 · G2025-10-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur. Findings include:A review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, dated July 2025 under Purpose: To ensure a safe environment for all residents by minimizing accidents hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 staff interviews, record review, and review of policies titled, Preadmission Screening PASARR/PASSR, the facility failed to refer one of 10 residents (R)(R7) for level two pre-admission screening and resident review (PASARR) out of 10 residents identified with level two PASARR. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include:Review of the policy titled Preadmission Screening (PASSAR/PASSR) dated June 2025 revealed the policy of the facility was to follow the Federal and State regulations with regards to prescreening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center, with the Procedure: 1. A level II PASSR must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, or a suspicion or diagnosis of serious mental illness, intellectual disability, or…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff, record review and review of the facility policies titled, Activities of Daily Living and Prevention of Pressure Injuries, the facility failed to ensure one of six sampled residents (R13), who required assistance with repositioning, was repositioned in accordance with the resident's turning schedule and interventions. This deficient practice placed the resident at risk for poor hygiene, decreased quality of life, and worsening pressure ulcers.Review of the facility's policy titled, Activities of Daily Living revised December, 2025 revealed the following: 1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that the resident's abilities in activities of daily living do not diminish unless circumstances of the individual's condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-14 · 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, interviews with staff, record review and review of the facility policy titled, Activities of Daily Living, the facility failed to follow physician orders related to diet by failing to provide a meal tray to one of 150 residents on an oral diet (R13). This deficient practice placed the resident at risk for decreased quality of life.Findings include:Review of the facility's policy titled, Activities of Daily Living revised December 2025 revealed the following: 3. The facility will provide care and services for the following activities of daily living: d. Dining-eating, including meals and snacks.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the Electronic Medical Records (EMR) revealed R13 iresident admitted to the facility on [DATE] with diagnoses including traumatic cerebral hemorrhage, obstructive hydrocephalus, epilepsy, dysphagia following cerebral…

    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 before2026-05-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory Therapy Equipment, the facility failed to ensure proper maintenance and monitoring of oxygen equipment in accordance with professional standards of practice for two of 28 sampled residents (R) (R109 and R1) reviewed for respiratory care related to maintaining a clean oxygen concentrator and filter. This deficient practice had the potential to result in decreased oxygen delivery, increased risk of respiratory compromise, and exposure to contaminants, which could adversely affect the residents' health and safety.Findings include:Record review of the facility policy titled Respiratory Therapy Equipment, which was undated, revealed procedure guidelines for oxygen administration directing staff to wash oxygen concentrator filters weekly, rinse the filters, and squeeze dry prior to reuse.1. Review of the EMR revealed R109 had diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, congestive heart failure…

    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 before2026-05-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to perform appropriate hand hygiene while passing lunch meal trays between each resident on one of three units. The deficient practice had the potential to place residents at risk of cross-contamination and the transmission of infectionsFindings include:Review of the facility policy titled, Hand Hygiene, dated February, 2026, revealed that handwashing /hand hygiene shall be regarded by this Center as a means of preventing the spread of infections. The subsection titled, Policy Interpretation and Implementation revealed under number 2. e. stated, Associates must perform appropriate handwashing procedures under the following conditions, between passing out meal trays at lunch.Observations made on 05/11/2026 at 12:33 AM in the Unit 2 dining hall revealed two employees, Certified Nursing Assistants (CNAs) PP and QQ, not performing proper hand hygiene between passing out lunch meal trays.In an interview on 05/11/2026 at 12:33 PM with Licensed Practical Nurse (LPN) FF, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-03 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure 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 interview, and review of the facility's policy titled, Medication Storage, the facility failed to ensure all medication labels were legible and that expired medications were disposed of after expiration date on one of five medication carts and in two of three medication storage rooms on (100 Hall and 300 Hall). Findings include: A review of the facility's policy titled, Medication Storage, revision date of November 2020 revealed under policy statement, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Observation on 4/2/2025 at 9:36 am Certified Medication Aide (CMA) GG was observed during 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · 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, record review, resident and staff interviews, and review of the facility's policy titled, Self-Administration of Medication, the facility failed to ensure one of 56 sampled residents (R) (R150) was assessed for self-administration of medications prior to leaving medications at her bedside. This deficient practice had the potential to place R150 at risk of medical complications and a diminished quality of life. Findings Include: A review of the facility's policy titled, Self-Administration of Medication, dated April 2022, revealed 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 R150's electronic health record (EHR) for R150 revealed diagnoses including, but not limited to, chronic respiratory failure with hypoxia, acute chronic diastolic congestive heart failure (CHF), acute pulmonary…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-03 · 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's policy titled Care Plan Policy, the facility failed to develop a comprehensive person-centered care plan for one of 12 residents (R) (R120) with an indwelling urinary catheter and one of 26 R (R147) receiving oxygen (O2). This deficient practice had the potential to place R120 and R147 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised 11/15/2022, revealed the Policy Statement included, 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. The Standards of Practice section included, . 9. A comprehensive plan of care will be developed by the interdisciplinary team, resident and/or resident representative as applicable. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · 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 observations, staff interviews, and a review of the facility's, Care Plan policy, the facility failed to revise the comprehensive care plan to include a new sacral pressure injury with measurable goals and interventions for one of three residents (R) (R206) reviewed with pressure ulcers. The facility also failed to update the care plan for R47, whose oxygen treatment had been discontinued but was still listed on the care plan. Findings include: Review of the facility policy titled, Care plan policy updated 11/15/2022 revealed the policy statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how facility staff will provide services to attain or maintain the resident highest practicable physical, mental and psychosocial wellbeing. Further review of the Policy revealed under 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 5 .Upon 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
  • Potential for harm · Dcited before2025-04-03 · 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, records reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure a physicians order for oxygen administration was obtained for one residents R (R147), the facility also failed to ensure two of 26 residents (R254 and R69) oxygen was administered as ordered by the physician. Findings include: Review of undated facility policy titled Oxygen Administration revised date of October 2010 revealed under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1.Review of the Electronic Medical Record (EMR) for R147 revealed resident was admitted to the facility with diagnoses of but not limited to pneumonia, anxiety, and cough. Continued review of the residents' physicians' orders did not reveal an order for oxygen therapy administration. Review of the 5-day admission Minimum Data Set (MDS) dated [DATE] documented R147 had a Brief…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 18 citations
  • Potential for harm · F2023-01-19 · tag F0727 — failed to provide required RN coverage — widespread
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, document review, and interviews, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours per day seven days a week. This had the potential to affect all 134 residents residing in the facility. Findings include: Review the [NAME] Payroll Based Journal (PBJ) dated July 1, 2022, through September 30, 2022 revealed during the fourth quarter reporting, the facility was identified as not having a RN working on the dates of 7/3/2022 and 8/21/2022, for 8 consecutive hours each day. Interview on 1/18/2023 at 4:14 p.m., Human Resource (HR) confirmed that eight consecutive hours of RN coverage was not provided for the dates of 7/3/2202 and 8/21/2022. Interview on 1/19/2023 at 1:35 p.m., the Staffing Coordinator (SC), revealed they have not been without RN coverage. She stated the ADON will come in and work when RN coverage is needed. The SC stated she gave the information to HR as a missed punch and stated it must have not gotten entered. Interview on 1/19/2023 at 1:47 p.m., both the Administrator and Director of Nursing (DON), state…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-01-19 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interview, policy review and review of Centers for Disease Control (CDC) guidelines and Quality Safety and Oversight Group (QSO) memo, the facility failed to implement an effective Infection Control Program to prevent the spread of infections, including COVID-19 virus by not posting signage related to the current COVID-19 outbreak upon entering the facility. In addition, the facility failed to ensure staff changed gloves during wound care for one resident (R) (R#60) of 10 residents reviewed for infection control. Findings include: 1. Review of the CDC guidelines in Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic include: Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-01-19 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and document review, the facility failed to ensure an effective pest control program was in place to maintain the facility free of pests. The census was 134. Findings include: Review of the policy titled, Pest Control Policy, revised 11/2022 indicated this facility ensures that, as far as possible, pests (rats, mice, roaches, ants, fruit flies, silver fish, etc.) within the premises are kept to an absolute minimum with the ideal being eradication but due to the resilience and persistence of some species this ideal is impossible to achieve. Review of the contract to provide pest elimination services revealed on 10/23/2020, the facility entered a contract with [name of provider] to provide pest elimination services to the facility for the control of cockroaches, ants, rodents, silverfish, drain flies, and other structural pest infestations, by periodic treatment using appropriate products according to approved label procedures. Review of [provider] service records revealed the exterminator had been to the facility and treated 10 resident rooms on 400…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-01-19 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and document review, the facility failed to provide comfortable water temperatures in the residents' bathrooms and shower rooms in 11 of 38 rooms, and one broken shower head. The census was 134. Findings include: Review of the facility's Maintenance Log History from 8/1/2022 - 1/19/2023 revealed the following rooms had reported issues with water temperatures: *On 10/4/2022 in room [ROOM NUMBER]-A, resident complained to family that her hot water is not working in her room. *On 10/7/2022 on Unit 300 H, reports of having no hot water in several rooms on the unit. *On 10/24/2022 in room [ROOM NUMBER], no hot water. *On 11/2/2022, shower room unit 2 with shower head reported to be broken, CNA [Certified Nursing Assistant] reported it is leaking everywhere like it has been dropped. *On 11/18/2022, Unit 300 H hot water is not working. *On 1/5/2023 in room [ROOM NUMBER]-A, no water in bathroom. *On 1/16/2023 in room [ROOM NUMBER], water is not working in the bathroom.…

    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 · D2023-01-19 · 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, interviews, record review and policy review, the facility failed to ensure two residents (R) (R#60 and R#101) were treated with dignity. Specifically, staff failed to sit while feeding R#60, and served R#101 meals on Styrofoam plates with plastic silverware. The sample size was 33. Findings include: Review of the facility policy titled, Resident Rights, revised 10/20/22, indicated, . The resident has the right to a dignified existence . 1. Review of the clinical record for R#60 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's, cerebral infarction, and unspecified severe protein calorie malnutrition. The resident's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 4, which indicated severe cognitive impairment. Section G revealed resident was dependent on staff for eating. Observation on 1/16/23 at 12:46 p.m. Licensed Practical Nurse (LPN) AA was feeding R#60…

    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 · D2023-01-19 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of the policy titled Social Service - Respect and Dignity Policy, the facility failed to ensure that one resident (R) (R#125) was free from misappropriation of resident's property of 33 sampled residents. Findings include: Review of the facility's policy titled Social Service - Respect and Dignity Policy revised November 2022 revealed respecting resident's private space and property, not moving, or inspecting resident's personal possessions without permission; Process: Residents are encouraged to have and to use personal possessions. Review of the clinical record revealed R#125 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/15/2022 documented a BIMS score of 7, indicating severe cognitive impairment and no signs of delirium present at time of assessment. Interview on 1/16/2023 at 3:50 p.m. R#125 stated that she had some items that were broken or missing since…

    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 · Dcited before2023-01-19 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Care Plan Policy, the facility failed to develop a person-centered comprehensive care plan related to behaviors for one resident (R) (R#58) of 33 sampled residents. Findings include: Review of the policy titled Care Plan Policy, reviewed 11/15/2022 revealed policy statement is 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. Review of the clinical record for R#58 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), depression, and schizophrenia. Resident's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/2022, revealed Brief Interview for Mental Status (BIMS) score of three out of 15, which…

    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 · D2023-01-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 policy review, the facility failed to assess one resident (R) (R#102) of 33 sampled residents, for a bladder training program to determine appropriate services to restore or maintain bladder continence. Findings include: Review of the policy titled, Bowel and Bladder Assessment Policy, last reviewed 11/2021, indicated, . Residents will function at their highest level of functioning, promoting self-esteem and independence . resident who is incontinent of bladder receives appropriate treatment and services to . restore continence to the extent possible .Resident's .bladder assessment will be completed upon admission, quarterly, and with significant changes . Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, current episode mixed, moderate and type 2 diabetes mellitus without complications. Review of the residents quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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, interviews, and policy review, the facility failed to address significant weight gain for one resident (R) (R#48) of five sampled residents reviewed for nutritional status. Findings include: Review of the policy titled Nutritional Assessment, dated 11/2016, revealed standard of practice 2. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. 3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: e. Current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including diabetes mellitus with other circulatory complications, unspecified protein-calorie…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and policy review, the facility failed to ensure clean oxygen concentrator filters and oxygen tubing and a breathing treatment mask were stored in a sanitary manner for three of six residents (R) (R#68, R#28 and R#116). The sample size was 33. Findings include: Review of the policy titled Oxygen Therapy Policy, revised 11/2022, revealed policy is Oxygen (02) is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress. Standard of practice 5. check that the equipment is functioning properly; 8. change oxygen tubing weekly; 9. date tube when changed (weekly). The policy did not include oxygen concentrator cleaning or maintenance. 1. Review of clinical record for R#68 revealed she was admitted to the facility on [DATE] with a primary diagnosis of chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/2022 revealed a Brief Interview Mental…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 review, interviews, and policy review, the facility failed to ensure prescribed medications were available for administration for one resident (R) (R#112) of five sampled residents. Findings include: Review of the facility's policy titled, Ordering and Receiving of Medications, reviewed 11/2022, indicated, . It is the policy of this facility to complete the required tasks with the ordering and receiving of medications within the electronic medical record system in a timely manner to ensure the consistent availability of physician prescribed medications for the residents that we serve . Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses of dry eye syndrome of bilateral lacrimal glands and punctate keratitis. Review of Physician's Order, revealed an order dated 12/11/22 for resident to receive Xiidra Solution 5% (a medication used for dry eyes) one drop to each eye twice daily. Observation on 1/17/2023 at 8:39 a.m., Licensed Practical…

    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 · D2023-01-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure one resident (R) (R#58) of five sampled residents reviewed for unnecessary medications did not receive an antipsychotic medication without clinical indication for its use. Specifically, the facility failed to identify and implement interventions to aid in the reduction or prevention of behaviors before administering Haldol (an antipsychotic medication). Findings include: Review of the policy titled, Psychotropic Drug Therapy, revised 10/25/2022, indicated non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated, instead of, or in addition to drug therapy. Review of the clinical record for R#58 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and major depressive disorder. It was documented R#58 received a diagnosis of other schizophrenia eleven months after her admission. Resident's most recent annual Minimum Data Set (MDS) with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure there medication error rate was less than 5%. A total number of 28 medication opportunities were observed. There were six errors for two of five sampled residents (R) (R#32 and R#112) observed during medication pass, resulting in a medication error rate of 21.43%. Findings include: 1. Observation on 1/17/2023 at 8:39 a.m., Licensed Practical Nurse (LPN) KK was preparing medications for R#112. LPN KK placed Paxil 40 milligram (mg) one tablet in the resident's medicine cup and administered it to R#112 at 8:44 a.m. Review of the January Order Summary Report revealed resident was to receive the following medications: a. Paxil (an antidepressant) 30 milligrams (mg) one tablet by mouth every day at 9:00 a.m. for depression. b. Symbicort Aerosol (a respiratory inhaler) 160-4.5 mcg (micrograms)/ACT (actuation), two inhalations orally two times a day, at 9:00 a.m. and 9:00 p.m., for chronic obstructive pulmonary disease (COPD). c. Albuterol Sulfate (a respiratory inhaler) 180 mcg/ACT (90 base) one puff orally…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-01-19 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure 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, interviews, and review of the policy titled Storage of Medications and Biologicals, the facility failed to dispose of loose medications found in the drawers of three of three medication carts (Carts A, B, and C) observed out of the six medication carts in the facility. Findings included: Review of the policy titled Storage of Medications and Biologicals revised September 2017, revealed the standard is the facility shall ensure that the medications and biologicals are stored appropriately and securely at any given time. Observations on 1/18/2023 three medication carts were observed with Registered Nurse (RN) JJ. The following was observed: At 3:00 p.m. Cart C - two half pills noted loose on the bottom of the second drawer on the right side. At 3:07 p.m. Cart A - four whole pills and two half pills noted loose on the bottom of the second drawer on the right side: and one whole pill and one-half pill loose on the bottom of the third drawer on the right side. At 3:14 p.m. Cart B - eight whole pills and one-half pill noted loose on the bottom of the second drawer…

    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 · D2023-01-19 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to obtain dental services for two residents (R) (R#132 and R#) reviewed for dental services. The sample is 33. Findings include: 1. Review of the clinical record revealed R#132 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, hypertension (HTN), and anemia. Review of the quarterly Minimum Data Set (MDS) dated with an Assessment Reference Date (ARD) of 11/26/2022, indicated a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Section L revealed no dental status was checked. Review of Physician Orders revealed an order dated 7/19/2022 for Tylenol Extra Strength Tablet 500 mg (Acetaminophen, pain medication) one tablet by mouth every 12 hours as needed (PRN) for tooth pain and decay, dental referral. Review of the care plan revised 12/15/2022 did not include a care plan for oral/dental issues. Observation on 1/16/2023 at 11:52 a.m. revealed R#132 had three…

    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 · D2023-01-19 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 policy titled Infection Control Prevention and Control Antibiotic Stewardship, the facility failed to follow and implement an effective antibiotic stewardship program (ASP) by ensuring one of five residents (R) (R#24) reviewed for antibiotic usage, was prescribed an antibiotic for urinary tract infection (UTI) without having met the criteria for the use of an antibiotic. Findings include: Review of the facility's policy titled, Infection Control Prevention and Control Antibiotic Stewardship revised on 11/29/2022 revealed the policy is antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Standard of Practice number 8. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available: a. signs and symptoms, b. when symptoms were first observed, c. resident's hydration status, f. infection type, i. time of last…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-01-19 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    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, interviews, and review of the policy titled Call System/Light Policy, the facility failed to ensure that the call light communication system was functioning adequately to allow one resident (R) (R#102) to call staff for assistance. The sample size was 33. Findings include: Review of the facility's policy titled, Call System/Light Policy, revised 10/20/2022, indicated to report any defective call lights to charge nurse and the maintenance department immediately. Review of clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including bipolar disorder, diabetes, paranoid schizophrenia, depression, hypertension (HTN), and chronic pain syndrome. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/2022, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident cognitively intact. Observation on 1/16/2023 at 10:50 am. in R#102's room, she was asked to test her call…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-01-24 · tag F0606 — failed to not employ staff found guilty of abuse — widespread
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of facility's policy titled Abuse Prevention Policy, the facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for two [Certified Nursing Assistant (CNA) BB and CNA CC] of ten employee files selected for review. The facility census was one hundred and forty-eight residents. Findings include: Review of the policy titled Abuse Prevention Policy dated 11/1/2021 under the section titled Employee Screening revealed, Background, reference, and credentials' checks should be conducted on employees prior to or at the time of employment by the facility administration, in accordance with applicable state and federal regulations. During a record review of the employee files there was no documentation that a fingerprint records check was conducted on CNA BB and CNA CC. An interview on 1/17/2024 at 10:30 am with the Administrator stated the facility follows the State and Federal requirements for conducting fingerprint checks. The Administrator confirmed CNA BB and CNA CC did not have 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan 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 2 of 52.0≈ chain avg
Staffing 2 of 52.0≈ chain avg
Quality measures 2 of 52.1-0.1 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 INTEREST100%since 07/31/2007
ANDWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/10/2012
SENIOR CARE HOLDINGS INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/01/2015
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 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$17.7M
Net patient revenuemost recent cost report
+15.5%
Operating marginrevenue minus expenses
$874K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 8%Other / private 92%

This home reported $874K 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

$275per resident / day
operating cost
$8,356per month
≈ monthly operating cost
$325per 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 115375. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-14, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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