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Gold City Health And Rehab

222 Moore Drive, Dahlonega, GA 30533 · For profit - Limited Liability company · 102 certified beds · (706) 864-3045 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuseBehavioral-health or dementia-care citation — no harm found (F0758)$52,548 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • CMS has flagged it for abuse
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $52,548 in federal fines (most recent 2025-03-13)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (61%) 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 1 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
24 Alicia Ln · (706) 867-6505 · Call to confirm hours
Pharmacy
70 Memorial Dr · (706) 864-2522 · Call to confirm hours
Grocery
19 E Main St · (706) 482-8421 · Call to confirm hours
Park
Amicalola Falls · Typically dawn to dusk
Place of worship
UNG BCM0.1 mi
166 S Park St · (678) 564-4887

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 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 increased24.0%15.3%15.4%worse
Long-stay residents who lose too much weight9.1%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection5.8%2.5%2.0%worse
Long-stay residents with depressive symptoms12.2%11.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened33.0%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication33.6%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers0.3%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control21.1%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table51.4%19.9%17.1%check this — see note marked dagger below the table
Short-stay residents who newly got an antipsychotic medication17.1%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine87.9%78.4%79.4%better
Short-stay residents rehospitalized after admission29.1%25.0%22.6%worse
Short-stay residents with an outpatient ER visit18.8%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days4.372.151.67worse
Long-stay outpatient ER visits per 1,000 resident days8.571.901.80worse

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

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

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

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

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

14.6%U.S. median 10.7%
Went back to hospital
50.0%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
<0.01hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 50.0% 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 24 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 40% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.6%CMS range 10.8–19.210.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge50.0%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 discharge33.3%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 discharge33.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 worsened0.0%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 hospitalization6.6%CMS range 3.2–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 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

0.19
RN hours/ resident / day
0.87
LPN hours/ resident / day
1.70
Aide hours/ resident / day
2.76
Total nurse hours/ resident / day
0.14
RN hoursweekends
61.4%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 72.0 residents a day — about 71% occupied, or roughly 30 beds typically open. It usually has some room. 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 2.76 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.19 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.70 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.58 hrs/resident/day on weekends vs 2.84 on weekdays — 9% thinner on weekends. RN hours go from 0.21 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% 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

0
deficiencies at the latest standard inspection (2025-09-28)
11
at the previous standard inspection (2024-08-28)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

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

  • Potential for harm · Dcited before2026-02-05 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policies titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation and Use of Restraints, the facility failed to report an allegation of abuse timely involving one of three sampled residents (R) (R1) to the State Survey Agency. This deficient practice resulted in delayed investigation, placing facility residents at risk for continued or unaddressed abuse.Findings include:A review of the facility's policy dated 12/19/2022 titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed under Policy: .all allegations of abuse/neglect.are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current stated and federal regulations within prescribed timeframes.A review of the facility's policy dated April 2017 titled Use of Restraints revealed under Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical…

    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 before2026-02-05 · 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 staff interviews, record review, and review of the facility policy titled, Functional Impairment-Clinical Protocol, the facility failed to ensure that one of three sampled residents (R) (R1) was assessed for use of a medical device (Broda (specialized seating designed for individuals with mobility challenges, physical disabilities, or those requiring enhanced postural support) chair) prior to its use. This deficient practice placed R1 at risk for use of medical equipment without assessment to determine appropriateness, need, and safe use.Findings include:A policy regarding assessment of residents prior to the use of mobility devices was requested but not provided.Review of the facility's policy titled Functional Impairment - Clinical Protocol, dated September 2012 under the section Assessment and Recognition, stated, Upon admission to the facility, at any time a significant change in condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical…

    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 before2025-08-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and facility policy review, the facility failed to prevent resident to resident abuse for one of three residents (Resident (R)10) reviewed in a total sample of 20. This failure resulted in R9 having unsupervised access to R10 providing opportunity for R9 to pull R10's arm inappropriately and attempt to kiss R10's hands. Findings include:Review of the facility's policy Abuse, Neglect and Exploitation with an implementation date of 12/19/2022, provided by the facility indicated under Definitions: Definition of sexual abuse is non-consensual sexual contact of any type with a resident. Under III. Prevention of Abuse, Neglect and Exploitation-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom…

    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 before2025-08-27 · 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 facility policy review, the facility failed to develop a comprehensive person-centered care plan that included specific interventions to ensure psychosocial well-being and safety for one of three residents (Resident (R) 4) reviewed in a sample of 20 residents.Findings include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 4/1/2025 indicated under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Review of R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed an admission date to the facility on [DATE] with…

    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 · D2025-08-27 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure a resident was evaluated for appropriate bed rail use and that alternative measures were attempted prior to installation of bed rails for one of one resident (Resident (R) 4) reviewed for bed rails out of a total sample of 20. The lack of alternate bed rail measures had the potential to lead to safety concerns related to bed rail use. Findings include:Review of the facility's policy titled Bed Safety and Bed Rails, provided by the facility, with a revision date of August 2022 indicated, Use of Bed Rails.The use of bed rails or side rails (including temporarily) raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Review of R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-28 · 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 staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours seven days a week on 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024. This failure had the potential to render all 68 residents without the necessary medical assistance that only an RN could provide, leading to adverse outcomes. Findings include: Review of the Daily Nursing Staff Report(s), dated 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024 that was provided by the Administrator, indicated the absence of RN coverage during each shift of each day listed. The form revealed, report contains nursing staff directly responsible for resident care. The form continued, daily posting of this information is required for nursing homes participating in Medicare and Medicaid programs. During an interview on 8/28/2024 at 11:25 am, the Administrator [interim since July 2024, but familiar with facility] verified that there should have been RN coverage for at least eight consecutive hours every day 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-28 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, record review, and review of the facility's policies titled Dishwashing and Temperature Log Guidelines, the facility failed to ensure the chemical level of the low temperature dishwasher was maintained at a level that would sanitize the soiled dishes with the potential to affect 68 of 68 residents. The deficient practice had the potential to result in the spread of infections/viruses and food borne illness. Findings include: Review of the facility's undated policy titled, Dishwashing revealed the low temperature dishwasher rinse temperature should be in the temperature range of 120 degrees Fahrenheit (F) to 150 degrees F and the chlorine should be 50 part per million concentration minimum to 100 PPM concentration maximum. Review of the facility's undated policy titled, Temperature Log Guidelines revealed the dish machine log should have been completed three times daily to ensure the temperatures and the sanitizer levels were properly maintained and controlled. During an observation on 8/25/2024 at 7:04 pm, Dietary Aide (DA) 3 was 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-28 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    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 observation, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect the residents' right to be free from mental/verbal abuse for four of 13 residents (R) (R53, R11, R122, and R71) and free from physical abuse for one of one resident (R48) reviewed for abuse out of a total sample of 43 residents. Specifically, R19 verbally harassed R53 and verbally insulted R11. Also, R16 verbally harassed R53 and verbally disrespected R122 and R71. This failure had the potential to cause psychosocial harm to the residents. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 12/19/2022, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect,…

    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 · E2024-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of the facility policy Abuse, Neglect, and Exploitation, the facility failed to provide adequate supervision to prevent accidents for four of four residents (R) (R6, R3, R23, and R36) reviewed for supervision out of a total sample of 43. Specifically, R6 had diagnoses of severe dementia, delusions, and paranoid schizophrenia and exhibited aggressive behaviors towards R3, R23, and R36. As a result of this deficient practice the residents in the facility had the potential for harm from the aggressive behaviors from R6. Findings include: Review of the facility policy Abuse, Neglect, and Exploitation, dated 12/19/2022 revealed, The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Identifying, correcting and intervening in situations in which abuse, neglect, . with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Advanced Directives, the facility failed to ensure one of 43 sampled residents (R) (R16) reviewed for advanced directives had a medical record that accurately reflected her request to not have cardiopulmonary resuscitation (CPR) in the event she should experience cardiopulmonary failure. The deficient practice had the potential to result in the resident receiving CPR against her wishes. Findings include: The facility's policy titled, Advanced Directives, dated [DATE] revealed, the resident had a right to formulate an advance directive. The policy revealed the resident's wishes were communicated to the residents' direct care staff and physician by placing the advanced directive documents in a prominent, accessible location in the medical record. Review of R16's the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the electronic medical record (EMR) revealed 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 Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · Dcited before2024-08-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure an allegation of abuse was reported within two hours of occurrence for two of 12 residents (R) (R6 and R36) sampled for abuse out of a total sample of 43. The deficient practice had the potential for timely intervention to not be implemented for the protection of the residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated 12/19/2022 revealed, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of R6's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6…

    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 · D2024-08-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an allegation of staff to resident abuse involving one of 12 residents (R) (R68) reviewed for abuse out of a total sample of 43. This failure increased the risk of ongoing staff to resident abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 12/19/2022, revealed, . Written procedures for investigations include . Providing complete and through documentation of the investigation . Review of R68's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on 5/2/2024 with diagnoses including type 2 diabetes, monoplegia of lower limb, and depression. Review of R68's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/8/2024 and located in the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 resident and staff interviews, record review, and review of the facility's policy titled, Transfer and Discharge, the facility failed to provide the resident and the responsible party with notice of the transfer and the reasons for the transfer in writing and in a language and manner they understand for one of two residents (R) (R4) reviewed for hospitalization out of a total sample of 43. The deficient practice had the potential to result in the resident and/or responsible party not knowing the resident was transferred to the hospital and the reasons for the transfer. Findings include: Review of the facility's policy titled, Transfer and Discharge dated 12/19/2022, revealed a transfer notice would be provided to the resident and representative when a discharge was initiated by the facility for medical reasons to an acute care setting such as a hospital. Review of R4's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R4 was readmitted to the facility on [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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and review of the facility's policy titled, Antipsychotic Medication Use, the facility failed to monitor for adverse consequences and behaviors related to antidepressant use for one of five residents (R) (R24) reviewed for unnecessary medications out of a total sample of 43. The deficient practice had the potential to place the resident at risk of untreated adverse consequences to the medication. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use dated July 2022 revealed, . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation. b. Cardiovascular: orthostatic hypotension, arrhythmias. c. Metabolic: increase in total cholesterol triglycerides,…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-28 · 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 observation and staff interviews, the facility failed to ensure that one of three medication carts (B Hall) was secure when left unattended and out of the site of the nursing staff. The deficient practice had the potential to allow residents and/or visitors unauthorized access to medications. Findings include: Review of the facility's policy titled, Security of Medication Cart dated April 2007 under the section titled Policy Interpretation and Implementation revealed, 4. Medication carts must be securely locked at all times when out of the nurse's view. Observation on 8/27/2024 at 12:20 pm revealed a medication cart on the B hallway between rooms B5 and B78. The cart was out the sight of the nurse. The medication cart was unlocked, and inside the drawer were residents' liquid medications and vials of residents' insulin. The drawers to the cart were easily accessible to anyone walking down the hall. R56 and R61 and were both within 2-3 feet of the unlocked cart. The cart remained unlocked until 12:37 pm, when the Assistant Director of Nursing (ADON) was observed locking it.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of 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 observations, interviews, record review, and policy review, the facility failed to ensure the call light was placed within reach to enable the resident to call for assistance, for one resident (R) (R#61) of 21 sampled residents. Findings included: Review of the policy titled, Call System, Residents, copyright 9/2022, revealed residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Review of the policy titled, Answering the Call Light, copyright 9/2022, revealed under General Guidelines number 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Review of the clinical record revealed R#61 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance and age-related physical debility. The resident's most recent quarterly Minimum Data Set (MDS) 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-02 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Change in a Resident's Condition or Status, the facility failed to ensure the physician was immediately notified of a significant change in condition for one resident (R)(R#69). The sample size was 30. Findings included: Review of the policy titled, Change in a Resident's Condition or Status, revised 5/2017, Revealed the policy is facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition. The policy also indicated, 2. A 'significant change' of condition is a major decline 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of the policy titled Resident Assessments, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurately reflected residents' status for two residents (R) (R#25 and R#46) of 30 sampled residents. Findings included: Review of the policy titled Resident Assessments, revised 11/2019, revealed the policy statement is a comprehensive assessment of every resident's needs is made at intervals designated by OBRA [Omnibus Budget Reconciliation Act] and PPS [Prospective Payment System] requirements. Policy Interpretation and Implementation number 1. The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team conducts timely and appropriate resident assessments and reviews according to the following requirements. 1. Review of the clinical record revealed R#25 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis/weakness on one side of the body)…

    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 before2023-02-02 · 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 record review, interviews, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive person-centered care plan to address the care, treatment, and monitoring of pressure ulcers for one resident (R) (R#172) of four sampled residents reviewed for pressure ulcers. Findings included: Review of the policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed policy statement is 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. Policy Interpretation and Implementation-the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that…

    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 · D2023-02-02 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure one resident (R) (R#17) of two sampled residents was provided the opportunity to participate in care plan meetings. Findings included: Review of policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed 'Policy Interpretation and Implementation' number 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's right to participate in the development and implementation of his or her plan of care, including the right to participate in the planning process; number 5. The resident will be informed of his or her right to participate in his or her treatment; and number 7. The care planning process will facilitate resident and/or representative involvement. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD)…

    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 · D2023-02-02 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, review of Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, and policy review, the facility failed to maintain professional nursing standards of quality evidenced by Licensed Practical Nurse (LPN) CC failing to consult the Director of Nursing or attending physician for one resident (R) (R#69), with an episode of hypoglycemia, low blood sugar of 32. LPN CC administered instant glucose to resident, waited one hour before rechecking the blood sugar and failed to notify the physician of change in condition for R#69. Additionally, licensed nursing staff failed to request the physician define blood sugar parameters to guide the nursing staff on when to notify the physician and/or when and how to provide treatment for hypoglycemia or hyperglycemia (high blood sugar). Findings included: A review of the policy titled, Nursing Professional Standard, revised 8/2001, revealed the policy of this facility is to conform with applicable Laws and Professional Standard…

    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 · D2023-02-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and policy review, the facility failed to maintain an effective Infection Control Program (ICP) to prevent potential cross-contamination which could result in disease or infection, by not ensuring staff removed a urinal and disinfected one resident (R) (R#40) bedside table before placing residents' meal tray on the table. The sample size was 30. Findings included: Review of the policy titled Homelike Environment, revised 2/2021, revealed policy statement is residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation number 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary, and orderly environment. Review of the clinical record revealed resident was admitted to the facility on [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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-08-28 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident family, friends, or other visitors to not know the ratio of nursing staff to residents causing uncertainty of ability and availability of the staff for residents' needs. The facility census was 68 residents. Findings include: Review of the Daily Nursing Staff Report(s) from 7/29/2024 through 8/26/2024 that was provided by the Administrator, presented a space, but the facility census information was not filled in. The form revealed, report contains nursing staff directly responsible for resident care. The form continued, daily posting of this information is required for nursing homes participating in Medicare and Medicaid programs. During an interview on 8/28/2024 at 11:25 am, the Administrator [interim since July 2024, but familiar with facility] verified that the Daily Nursing Staff Report(s) posted daily in the front of the facility should…

    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

“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

$52,548 in federal fines across 1 penalty.

  • $52,548 — penalty dated 2025-03-13

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to C. ROSS MANAGEMENT — 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 51.8-0.8 vs chain
Health inspection 2 of 52.6-0.6 vs chain
Staffing 1 of 51.0≈ chain avg
Quality measures 1 of 52.2-1.2 vs chain
The other 4 homes this chain runs (chain average 1.8★, 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
R DAVIS HOLDINGS INCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2016
MARTIN, LAURAIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2020
WINGET, BRANDONIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2020
WINGET, BYRONIndividualINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 01/01/2020
WINGET, MICHAELIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020
GOLD CITY HR PROPERTIES LLCOrganization5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNFsince 08/28/2019
KEITH, NABILIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2025
SORENSEN, TRIBBIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025
C. ROSS MANAGEMENT LLCOrganizationADP OF THE SNFsince 04/07/2025

CMS files one row per role, so the 18 rows in the source record cover these 9 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.

$5.1M
Net patient revenuemost recent cost report
-36.6%
Operating marginrevenue minus expenses
$321K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 8%Other / private 92%

This home reported $321K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

$274per resident / day
operating cost
$8,323per month
≈ monthly operating cost
$200per 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 115689. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-28, 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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