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Chestnut Ridge Nsg & Rehab Ctr

125 Samaritan Drive, Cumming, GA 30040 · For profit - Limited Liability company · 150 certified beds · (770) 889-0120 Medicare & Medicaid certified

Call the home — (770) 889-0120 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Mar 2026
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 an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
  • a high number of inspection citations overall (27) — 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 (1/5)
  • nursing-staff turnover (74%) runs well above the national median (45%)

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

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

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

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
214 Canton Rd Ste G · (478) 239-0413 · Call to confirm hours
Pharmacy
116 W Maple St · (770) 887-5040 · Call to confirm hours
Grocery
436 Canton Rd · (770) 889-5868 · Call to confirm hours
Park
Suwanee Mountain · Typically dawn to dusk
Place of worship
212 Canton Rd · (800) 581-4141

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 4 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 held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.6%15.3%15.4%typical
Long-stay residents who lose too much weight5.5%5.6%5.4%typical
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection2.0%2.5%2.0%typical
Long-stay residents with depressive symptoms0.5%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 injury1.7%3.2%3.3%better
Long-stay residents whose ability to walk worsened18.0%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication21.4%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine90.6%95.0%95.3%typical
Long-stay residents with pressure ulcers5.8%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control21.0%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.7%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.6%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine68.5%78.4%79.4%worse
Short-stay residents rehospitalized after admission22.2%25.0%22.6%typical
Short-stay residents with an outpatient ER visit12.7%11.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.672.151.67typical
Long-stay outpatient ER visits per 1,000 resident days1.451.901.80better

§ 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.

54.3% 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 151 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

54.3%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
36.4%U.S. median 56.6%
Met the expected recovery
0.19U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 36.4% 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 77 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 0.19 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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 SNF54.3%CMS range 45.3–63.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.5–15.310.7%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 discharge36.4%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 discharge45.5%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 discharge29.9%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 identified96.3%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 discharge91.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened7.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.3%CMS range 4.7–12.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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
1.39
LPN hours/ resident / day
1.88
Aide hours/ resident / day
3.60
Total nurse hours/ resident / day
0.23
RN hoursweekends
73.8%
Total nursing turnover
57.1%
RN turnover

How full it usually is: this home is certified for 150 beds and averages 130.0 residents a day — about 87% occupied, or roughly 20 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 3.60 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.88 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 3.28 hrs/resident/day on weekends vs 3.72 on weekdays — 12% thinner on weekends. RN hours go from 0.36 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 74% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

12
deficiencies at the latest standard inspection (2026-03-05)
7
at the previous standard inspection (2025-02-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · Ecited before2026-03-05 · 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

    Based on observations, interviews, record review, and facility policy titled Housekeeping Operations Manual, the facility failed to ensure the dining room, and 2 of 2 communal shower rooms were maintained in a safe, clean, comfortable and homelike environment. The deficient practice had the potential to affect patient comfort and safety. Findings include:Review of the undated document titled Housekeeping Operations Manual, documented The main area of concern to a housekeeping department in a healthcare facility is the transmission of bacteria.Observation of the women's communal bathroom on 03/02/2026 at 11:48 AM, 03/04/2026 at 12:18 PM and 2:48 PM, revealed on a shelf: numerous bottles of shampoo, lotion, grooming items scattered across the surface; hairbrush, scissors, wipes, lotions, and cleaning products were observed intermixed and unlabeled. There were small pieces of debris scattered across the shower room floor and appeared unclean and unsanitary with residue along the lower portion of the tile wall. Used washcloths were observed on the hand grab bar, a resident gown was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-05 · tag F0759 — failed to keep medication error rate low — pattern
    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, staff interviews, review of the facility's policies titled Administering Medications, the facility failed to ensure accurate administration of medications for six of 25 medication opportunities observed, resulting in a medication error rate of 24% (percent.) The deficient practice increased the risk of adverse clinical outcomes. Findings Include:Review of the facility's policy titled, Administering Medications, dated 2/2020 documented that Medications shall be administered in a safe and timely manner, and as prescribed.Observation on 03/04/2026 at 9:26 AM on A-Hall with Licensed Practical Nurse (LPN) DD revealed resident (R) R106 had physician orders for Glipizide 10 mg {milligrams}, give 1 tablet by mouth twice daily for Diabetes Mellitus (DM), and Fluticasone-Salmeterol inhalation powder 500/50 mcg {micrograms}, inhale 1 puff orally twice daily for Chronic Obstructive Pulmonary Disease (COPD). These medications were not administered due to lack of availability, and the physician was not notified of the missed doses. During the same 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 · Ecited before2026-03-05 · tag F0880 — failed to prevent and control infections — pattern
    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 and resident interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene, Insulin Administration, Housekeeping-Infection Control Procedures, and Cleaning and Disinfection of Resident-Care Items and Equipment, the facility failed to follow proper infection control practices for one of four nursing units and two of two shower rooms. Specifically, top of an insulin vial not disinfected, blood pressure cuff not disinfected between residents, Housekeeping Aide pouring liquid from resident cup into mop water, and nursing staff exiting resident rooms without removing gloves and performing hand hygiene. In addition, multiple personal items in the communal shower rooms were unlabeled. The deficient practice increased the risk of cross contamination and spread of infection. Facility census was 127.Findings Include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2/2020, revealed that This facility considers hand hygiene the primary means to prevent the spread of infections. Further review of item 5. Hand…

    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 · D2026-03-05 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Personal Property, the facility failed to promote dignity by not exercising reasonable care and protection to prevent damage to the glasses for one resident (R) (R109) from a sample of 47 residents. The deficient practice had the potential to affect R109 from reaching the highest practicable level of function. Findings include:Review of the Personal Property policy dated 03/2023, documented the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.On 03/02/2026 at 10:50 AM, R109 was observed in bed wearing broken glasses. R109 showed the arm broken off one side of the glasses and demonstrated that a staff person broke the glasses when something was placed on top of them. R109 stated she informed the nurse when it happened a couple weeks ago and had not heard if they would be repaired or replaced. On 03/04/2026 at 8:55 AM, R109 was observed in bed,…

    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 · D2026-03-05 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy titled, Abuse Prevention Program, the facility failed to ensure safety and freedom from an act of physical abuse for one resident (R) (R84) from a sample of three residents reviewed for abuse. The deficient practice had the potential to affect the quality of life and safety for other residents. Findings include:Review of the policy titled Preventions of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, revised 7/2025, section titled Policy documented, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Review of R84 quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R84 was admitted to the facility on [DATE] with 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record reviews, and review of the facility's policy titled Transfer of Discharge Notice, the facility failed to ensure two of two sampled residents (R) (R131 and R133) were provided with a written bed hold notice or reason for transfer at the time of transfer. This failure had the potential to place the resident or resident's representative at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility.Findings include:Review of the policy, Transfer or Discharge Notice, revised [DATE], documented Our facility shall provide a resident and/or the resident's representative a notice of transfer or discharge and the reason for the move in writing (Notice Form for Transfer or Discharge). 3. The resident and or representative will be notified in writing of the following information: the reason for the transfer or discharge; the effective date; the location to which the resident is being transferred or discharged ; a statement of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-05 · 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 record review, policy review, and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for two of four residents (R) (R112 and R113) reviewed for elopement risk. This deficient practice had the potential to place R112 and R113 at increased risk of not receiving care and services according to their assessed needs. Findings include: Review of the policy titled Wandering, Unsafe Resident, dated 05/2023, documented Policy Interpretation and Implementation: 3. Monitoring and Managing Residents at Risk for Elopement and Unsafe Wandering: a. Residents shall be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care team. B. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. C. The effectiveness of interventions shall be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated…

    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 before2026-03-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Administering Medications, Provision of Care, and Change in a Resident's Condition or Status, the facility failed to ensure that residents received care in accordance with physician orders and facility policy for five residents (R) (R47, R72, R106, R137, and R128) of 47 sampled residents. Specifically, the facility failed to: ensure a wound vac was applied and connected; ensure medications were administered by the nurse who pulled the medication; notify the physician of deviations from orders; accurately document medication administration; obtain resident weights as ordered; and provide timely pain medication. These deficient practices increased the risk of adverse clinical outcomes. Findings Include: Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed. Further review of item 4.…

    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 · D2026-03-05 · 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, record review, staff interviews, and review of the policy titled, Accidents and Incidents-Investigation and Reporting, the facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision for two residents (R) (R49 and R145) from a sample of 47 residents. The deficient practice increased the risk of avoidable accidents and injury. Findings include: Review of the policy titled, Accidents and Incidents-Investigation and Reporting revised 02/2024 documented The facility shall provide the residents an environment free of accident hazards. Further review of section 7. Supervision item a.Adequacy of supervision is based on the individual's assessed needs and identified hazards in the resident's environment. 1. Review of the electronic medical record (EMR) revealed R145 was admitted to the facility on [DATE], with pertinent diagnoses including but not limited to Alzheimer's disease, unspecified dementia, aphasia, expressive…

    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 before2026-03-05 · 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 and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered according to physician's order for two of 13 residents (R) (R140 and R75) who use O2. This deficient practice had the potential to result in inappropriate respiratory treatment and adverse clinical outcomes.Findings include:Review of the facility policy titled, Oxygen Administration, undated documented Preparation: 1. Verify that there is a physician order for this procedure. Review the physician's or facility protocol for oxygen administration.1.Record review of the Electronic Medical Record (EMR) revealed R140 was admitted to the facility on [DATE] and pertinent diagnoses including but not limited to acute respiratory failure with hypoxia, sleep apnea, chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, atherosclerotic heart disease of native coronary artery without angina, presence 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
Show the remaining 17 citations
  • Potential for harm · D2026-03-05 · 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

    Based on observations, staff interviews, and review of facility policies titled Administering Medications, the facility failed to maintain accurate records on controlled substances for resident (R) (R43) on one of three medication carts. The deficient practice increased the risk of medication error for R43 and the potential for drug diversion. Findings include:Review of the facility's policy titled, Administering Medications, dated 2/2020 revealed that Medications shall be administered in a safe and timely manner, and as prescribed.Review of the Physicians Orders for R43 included but was not limited to:Order dated 01/27/2026 for Methadone HCl {Hydrochloride} Oral Tablet 10 MG (Methadone HCl) *Controlled Drug* Give 2 tablet by mouth every 8 hours as needed for Chronic painReview of the electronic medical record (EMR) revealed R43 received Methadone on 03/04/2026 at 10:47 AM.Observation and interview on 03/04/2026 at 3:22 PM, of the nurse's medication cart with Registered Nurse (RN) HH on C-Hall revealed the following:Controlled Substance Record Book: Multiple pages were torn, loose,…

    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 · D2026-03-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to assure that two residents (R) (R34 and R90) from a sample of 47 residents, received and consumed foods in the appropriate form as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with goals and preferences. The deficient practice increased the risk of adverse clinical outcomes. Findings include:Record review of the facility diet type report dated 03/05/2026, revealed R90's diet was listed as regular, mechanical soft, reduced concentrated sweets, no added salt. The report specified R34 should receive a mechanical soft, regular diet, reduced concentrator sweets, no added salt. 1.R90 was admitted [DATE]. The diagnoses included congestive heart failure, diabetes type 2, dysphagia (difficulty swallowing), and chronic kidney disease. The record also included a history of pneumonitis (aspiration). R90's diet order dated 02/13/2026, documented diet upgraded…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-02 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of the facility's policy titled Competency of Nursing Staff, the facility failed to conduct annual performance reviews to ensure competency for the Certified Nursing Assistants (CNAs) employed by the facility. The census was 135. Findings include: Review of the undated facility's policy titled Competency of Nursing Staff revealed the Policy Statement: Licensed nurses and nursing assistants employed by the facility will participate in facility-specific, competency - based staff development and training program and demonstrate competencies and skill sets necessary to care for the needs of residents, as identified through resident assessments and described in the plan of care. Policy Interpretation and Implementation: Number 5. Facility and resident specific competency evaluations will be conducted upon hire, annually, and as deemed necessary. Number 7. Competency demonstrations will be evaluated based on staff members ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled Food and Nutrition Services, and review of the facility document titled [Name of supply company] TELS (The Equipment Lifecycle System) Ice Machines Preventative Maintenance, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure foods were not left open to air, label and date opened and unopened foods in addition to, serving cold fruit at 68 degrees Fahrenheit (F). Also, the facility failed to ensure that one of two ice machines was clean and sanitary as evidenced by one ice machine had discoloration on the inside middle part of the machine. This deficient practice had the potential to cause a diminished quality of life for 132 out of 135 residents receiving an oral diet. Findings include: Review of the facility's undated policy titled Food and Nutrition Services revealed, that foods that are left without 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-02-02 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility's policy titled Food-Related Garbage and Refuse Disposal, the facility failed to ensure that the area around the dumpster was free from garbage and refuse. This deficient practice had the potential to attract pest. The facility census was 135. Findings include: Review of the facility policy titled Food-Related Garbage and Refuse Disposal with a revision date of October 2017, revealed that garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pets. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Observation on 1/31/2025 at 8:30am during the initial tour of the kitchen with [NAME] II revealed, that the area around the dumpster contained garbage and refuse on the ground. Interview on 1/31/2025 at 8:40 am with [NAME] II revealed, that when the dumpster got too full, they must open the lid, so that they could make more room for garbage. [NAME] II revealed that when the lids were open, the wind would blow garbage out 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 before2025-02-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, review of the facility's policy titled Maintenance Service, and review of documents titled [Name of supply company] TELS (The Equipment Lifecycle System), the facility failed to provide a safe, clean, comfortable, homelike environment related to dirty filters in the Packaged Terminal Air Conditioner (PTAC) units, walls in disrepair and missing paint, missing chair rail, and missing/falling ceiling tiles for nine resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on three of four halls (B,C, and D halls) and falling ceiling tiles the kitchen. The deficient practice had the potential to place the residents at risk for accidents and hazards and diminished quality of life. The facility's census was 135. Findings include: Review of the facility's undated policy titled Maintenance Service revealed, the Policy…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-02 · 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 the facility's policy titled Resident Assessment-Coordination with PASARR (Preadmission Screening and Resident Review) Program, the facility failed to ensure one of one resident (R) (R99) reviewed with a serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R99. Findings include: A review of the facility's undated policy titled Resident Assessment-Coordination with PASARR Program revealed the Policy was The center coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy explanation and Implementation section included . 8. Any resident who…

    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 · D2025-02-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Care Plan, Comprehensive Person Centered, the facility failed to develop and implement care plans for four of 42 (R) (R84, R50, R20, and R90) sampled residents. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Care Plan, Comprehensive Person Centered with a revision date of September 2023 revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of the physician orders revealed that R84 was to receive but was not limited to docusate sodium (a stool softener), and acetaminophen. Review of the nurse's progress notes revealed that on more than one occasion between…

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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure ADL care was provided for three of 42 sampled residents (R) (R20, R90, and R50) related to showers, nail care, and shaving of facial hair. This failure placed R20, R90, and R50 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed the Policy Statement included, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The Policy Interpretation and Implementation section included . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including appropriate support and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-07 · tag F0880 — failed to prevent and control infections — pattern
    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's policy titled Laundry Operations Manual, the facility failed to ensure the soiled linen hampers located in the hallways of the facility, were emptied immediately when full. This failure has the potential to impact 71of 128 residents residing on the A and C Halls. Findings include: Review of the facility's policy titled, Laundry Operation Manual, revised in January 2022, under the section titled Sorting Soiled Linens revealed, Treat all soiled linen as if it were potentially infectious-never treat soiled linen different simply if it does not look dirty and Keep soiled linen covered at all times. During the initial tour of the facility, it was revealed that the facility had four halls, A, B, C and D. Each hall had had two or three soiled linen hampers in the hallways. During an observation on 10/30/2024 at 9:49 am, one soiled linen hamper on the C hall was observed to be full and overflowing as the lid to the hamper was left ajar. During an observation on 11/5/2024 at 11:55 am, two soiled linen hampers were observed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-08-24 · 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, interviews, and review of facility documentation, the facility failed to maintain a functional and sanitary environment in two of 20 sampled resident rooms on the A Hall. Specifically, the facility failed to maintain its packaged terminal air conditioners (PTAC) in a sanitary condition in rooms [ROOM NUMBERS]. In addition, the facility failed to maintain one of 35 resident wardrobes on the B Hall, room [ROOM NUMBER], in a functional condition. Findings include: Observation of room [ROOM NUMBER] on 8/22/2023 at 12:09 p.m. revealed a drawer missing from wardrobe #1 behind the door of the room. Observation of room [ROOM NUMBER] on 8/22/2023 at 2:40 p.m. revealed the PTAC (heating and air unit) had a large amount of a black substance on the grill. Observation of room [ROOM NUMBER] on 8/22/2023 at 3:24 p.m., revealed a large amount of a black substance on the grill of the PTAC. Observation of rooms [ROOM NUMBER] on 8/23/2023 beginning at 12:40 p.m. revealed black substance remained on the PTAC…

    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 · Ecited before2023-08-24 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the Contracted Dietary Company's policies titled, General HACCP Guidelines, Uniform Policy and Personal Hygiene Policy, the facility failed to allow dishes to air dry prior to use, ensure kitchen staff perform hand hygiene and wear gloves when preparing food for residents, to ensure staff entering the kitchen wear hair net and perform hand hygiene upon entering the kitchen. This deficient practice had the potential to affect 128 of 133 residents receiving an oral diet. Review of policy titled General HACCP Guidelines dated January 2022, under subtitle, Policy revealed, Staff must be educated and supervised on all HACCP information and procedures. A good training program and the proper systems and tools will help to assure a successful HACCP /Food Safety program. Under the subtitle, Procedure revealed, Educate and monitor staff on the following: Hand washing -Train staff to wash hands prior to working with food, after using restroom, or soiling hands. 10. Dishwashing -Air Dry: use drying racks if needed; do not stack dishes…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · 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 staff interviews, record review, and review of the facility's policy titled, Bladder and Bowel Evaluation, the facility failed to obtain a physician's order for a urinary catheter for one of five Residents (R) #69. The deficient practice had the potential to affect the needed care and services to meet the resident's needs. Findings include: Review of the facility's policy titled, Bladder and Bowel Evaluation not dated, Policy Statement revealed Based upon the resident's comprehensive assessment, all residents that are incontinent shall receive appropriate treatment and services. Under the subtitle Policy Explanation and Compliance Guidelines revealed 1. The facility shall conduct a bladder and bowel evaluation upon admission, quarterly, and with significant change in condition to determine incontinence and appropriate interventions. 4. Residents that enter the facility with an indwelling catheter, or receives one while in the facility, will be assessed for removal as soon as possible, unless the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of facility documentation, and review of the facility's policy titled, Foot Care, the facility failed to identify and treat four of five wounds on the toes of the left foot for one of seven Residents (R) (R#32). The deficient practice had the potential to affect proper treatment and care to maintain mobility and good foot health. Findings include: Review of the facility's policy, titled Foot Care, undated revealed under the Policy Interpretation and Implementation: 1. Residents shall be provided with foot care and treatment in accordance with professional standards of practice. Review of the clinical record for R#32 revealed he was diagnosed with, but not limited to cerebral infarction, hemiplegia and hemiparesis affecting the left non-dominant side, dementia without behavioral disturbance, and vascular dementia. In addition, he required extensive assistance for bed mobility and transfer. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-24 · 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 interview, review of records, and review of the facility's policy titled, Oxygen Administration, the facility failed to change disposable respiratory supplies and failed to maintain the cleanliness of respiratory supplies for eight of 22 Residents (R) (R#17, R#25, R#35, R#57, R#64, R#97, R#106, and R#108) with physician orders for continuous Oxygen (O2) and/or bilevel positive airway pressure (BiPAP) therapy. The deficient practice had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice. Findings include: Review of the facility policy titled. Oxygen Administration, undated, revealed the following: Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 2. Nasal cannula, nasal catheter, mask (as ordered) 3. Humidifier bottle Steps in the Procedure: 8. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-24 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's document titled, Internal Agreement Request Prep Form; Nursing Home Dialysis Transfer Agreement, the facility failed to secure a contract with the dialysis center. The facilities census was 133. Findings include: Review of the Internal Agreement Request Prep Form, Nursing Home Dialysis Transfer Agreement dated 2/6/2020 under the Agreement Description revealed the agreement type was for nursing home residents who are transferred from a nursing home to a chronic dialysis facility for treatment. The standard process up to 10 business days. 5. Once approved, agreement sent for signatures, you will receive a copy once all parties sign. Date Prep Form Submitted was 2/6/2020 with Date Agreement Needed by on 2/10/2020. Review of the electronic medical record (EMR) revealed R #66 with diagnoses listed but not limited to end stage renal disease (ESRD) and diabetes mellitus. Review of R#66 admission Minimum Data Set (MDS) assessment dated [DATE]…

    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 before2023-08-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain personal use equipment in a sanitary manner for two of six shared bathrooms on the B Hall. Specifically, unlabeled/unbagged wash basins were observed in the bathrooms serving rooms [ROOM NUMBERS]. Findings include: Observations on 8/22/2023 at 3:35 p.m. and 8/23/2023 at 12:40 p.m. of the shared bathroom for room [ROOM NUMBER] revealed two unlabeled/unbagged wash basins. Observations on 8/22/2023 at 3:47 p.m. and 8/23/2023 at 12:45 p.m., of the shared bathroom for room [ROOM NUMBER] revealed four unlabeled/unbagged wash basins and one urinal. Observations on 8/24/2023 beginning at 3:30 p.m. of rooms [ROOM NUMBERS] with the Unit Manager confirmed the unbagged/unlabeled wash basins. Interview during this time with the Unit Manager, stated staff should be labeling and bagging wash basins, urinals, graduates, and toiletries for multiple residents sharing a bathroom.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to CYPRESS SKILLED NURSING — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.0-1.0 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 1 of 51.4-0.4 vs chain
Quality measures 3 of 52.2+0.8 vs chain
The other 4 homes this chain runs (chain average 2.0★, 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 / managerTypeRoleSince
ENIN TROrganizationINDIRECT OWNERSHIP INTERESTsince 11/12/2013
SNF TROrganizationINDIRECT OWNERSHIP INTERESTsince 11/12/2013
OVITS, ISAACIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
PATTERSON, DIANNEIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/07/2018
CYPRESS SKILLED NURSING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
BENDER, SARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/02/2025
MACATULA, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/31/2017
MOSS, BRENTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/05/2025
NARDIELLO, ELIZABETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2018
NORDHOLM, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2014
PATTERSON, TIMOTHYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/06/2022
PHILLIP, KARENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/21/2024
SHAIKH, FAIZANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/06/2025
WHIPPLE, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/08/2001

CMS files one row per role, so the 28 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

$13.6M
Net patient revenuemost recent cost report
-4.3%
Operating marginrevenue minus expenses
$682K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 10%Other / private 25%

This home reported $682K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$295per resident / day
operating cost
$8,972per month
≈ monthly operating cost
$283per day
avg. revenue, all payers

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

What families pay in GA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115423. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, 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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