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

Blue Ridge Care Center LLC

600 West Memorial Drive, Dallas, GA 30132 · For profit - Limited Liability company · 182 certified beds · (770) 445-4411 Medicare & Medicaid certified

Call the home — (770) 445-4411 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Dec 2025
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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

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

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
600 W Memorial Dr · (770) 443-4757 · Call to confirm hours
Pharmacy
Grocery
Lucky's1.1 mi
514 Hardee St · (770) 443-2941 · Call to confirm hours
Park
240 Constitution Blvd · (770) 445-8065 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 3 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 rating3★
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 increased8.1%15.3%15.4%better
Long-stay residents who lose too much weight1.1%5.6%5.4%better
Long-stay residents with a catheter left in their bladder0.4%0.9%0.9%better
Long-stay residents with a urinary tract infection0.4%2.5%2.0%better
Long-stay residents with depressive symptoms6.8%11.3%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury4.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened9.6%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.0%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers2.6%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control18.9%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.8%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%2.6%1.4%typical
Short-stay residents given the seasonal flu vaccine97.2%78.4%79.4%better
Short-stay residents rehospitalized after admission18.5%25.0%22.6%better
Short-stay residents with an outpatient ER visit6.6%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.042.151.67worse
Long-stay outpatient ER visits per 1,000 resident days1.461.901.80better

§ 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.

57.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 139 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

57.0%U.S. median 51.5%
Got home and stayed home
11.4%U.S. median 10.7%
Went back to hospital
56.5%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 56.5% 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 62 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 0.30 therapist hours per resident per day in 2026Q1 — more than 47% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 33% 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 SNF57.0%CMS range 49.7–64.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.4%CMS range 8.9–14.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.5%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 discharge59.7%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 discharge43.5%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 identified96.4%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 setting95.7%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 discharge96.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.2%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 worsened0.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.3%CMS range 2.5–9.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.671.02Oct 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

0.48
RN hours/ resident / day
1.16
LPN hours/ resident / day
2.47
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.39
RN hoursweekends
37.2%
Total nursing turnover
12.5%
RN turnover

How full it usually is: this home is certified for 182 beds and averages 167.4 residents a day — about 92% occupied, or roughly 15 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 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.56 hrs/resident/day on weekends vs 4.32 on weekdays — 18% thinner on weekends. RN hours go from 0.51 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

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

Inspection trend

9
deficiencies at the latest standard inspection (2025-12-07)
1
at the previous standard inspection (2024-05-23)

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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · Fcited before2025-12-07 · 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 policy titled, Food Storage, the facility dietary staff failed to label and date opened food items and failed to properly discard expired milk. The facility census was 163 and 162 residents were receiving an oral diet. Findings include:Review of the facility policy titled Food Storage revealed under B. Refrigerated Storage: . Label all opened items with the date opened and use by date (per facility policy or manufacture guidance). The policy also revealed under 6. Labeling Requirements: All opened, repackaged, or leftover items must include date opened/prepared and use by/discard date.1. Observation on 12/5/2025 at 8:40 am revealed the kitchen had two walk-in refrigerators and the walk-in refrigerator to the far left had a five-pound bag of shredded cheddar cheese that had been open and stored with no open date.During an interview on 12/5/2025 at 8:40 am, the Dietary of Dietary (DOD) confirmed that the bag of shredded cheddar cheese had been…

    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 · F2025-12-07 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility policy titled, Dishwasher Temperature, the facility failed to demonstrate a properly functioning dish machine to sanitize dishware to prevent food borne illness. The facility census was 163 and 162 residents were receiving an oral diet.Findings include:Review of the facility policy titled Dishwasher Temperature revealed for low temperature dishwashers (chemical sanitization) the wash temperature shall be 120 degrees Fahrenheit (F) and the sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.Observation on 12/5/2025 of the facility dish machine was first conducted at 9:10 am until 9:30 am. The facility has a large conveyor belt type dish machine and was a low temperature machine that used a chemical for sanitizing dishware. Dietary aide FF assisted with demonstrating the use of the dish machine. Dietary aide FF placed several empty dish racks on the conveyor belt and observation of the temperature gauges located on the front of the dish machine revealed 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-07 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, family and staff interviews, record review, and review of the facility's policy titled, Promoting/Maintaining Residents Dignity, the facility failed to protect the privacy of health information for one of three residents (R) (R19) reviewed for privacy. Specifically, the facility posted instructions on R19's wall that disclosed birthday, gender, medical identification, and picture. The deficient practice had the potential to place R19 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's dignity.Findings include:Review of the facility policy titled, Promoting/Maintaining Residents Dignity dated 1/8/2025 documented under Policy: It is the practice of this facility to protect and promote resident rights and threat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident individually. Under 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
  • Potential for harm · D2025-12-07 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of a policy titled, Use of Psychotropic Medication(s), the facility failed to ensure as needed psychotropic medication were ordered and limited to 14 days for one of five residents (R) (R 123) reviewed for un-necessary medications, The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include:Review of the policy titled Use of Psychotropic Medication(s) date implemented 1/8/2025 revealed the Policy was to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Under the section titled Policy Explanation and Compliance Guidelines under number 16 revealed psychotropic medications used as needed are limited to no more than 14 days unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days and documentation is included from the physician or prescriber for the rationale to extend the time period 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-07 · 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 observation, record review, staff interviews, and review of the facility policy's titled, Comprehensive Care Plans, Oxygen Administration, and Use of Psychotropic Medications, the facility failed to develop a person-centered comprehensive care plan for four of 48 sampled residents (R) (R71, R90, R21, and R123) out of 48 sampled residents. Specifically, the facility failed to develop a care plan for R71 related to an indwelling urinary catheter, failed to develop a care plan for R21 and R90 related to oxygen, and failed to develop a care plan for R123 related to psychotropic medication. The deficient practice had the potential to cause R71, R90, R21, and R123 not to receive necessary care and services. Findings include: Review of the facility policy, Comprehensive Care Plans dated 1/8/2025 revealed 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…

    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 · D2025-12-07 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident family interviews, record review and review of the facility policy titled, Nutritional and Dietary Supplements, the facility failed to provide one of 48 sampled residents (R) (R15) a nutrition supplement as ordered.Findings include:Review of the facility policy titled Nutritional and Dietary Supplements revealed that the facility will provide nutritional and dietary supplements to each resident, consistent with the residents' assessed needs.Review of the admission record revealed R15 was admitted to the facility with a medical diagnosis of but not limited to unspecified protein calorie malnutrition.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R15 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating cognition is severely impaired.Review of the electronic medical record (EMR) revealed R15 had a physician order for a frozen nutritional supplement with meals for supplemental related to unspecified protein…

    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 before2025-12-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure oxygen was administered as ordered by the physician for two of 14 residents (R) (R90 and R21) receiving oxygen. This deficient practice had the potential to place R90 and R21 at increased risk of respiratory complications.Findings include: Review of the facility's policy titled Oxygen Administration, dated 1/8/2025, revealed the Policy section stated Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The Policy Explanation and Compliance Guidelines section included, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders are obtained as soon as practicable when the situation is under control. 1. Review of the admission Record for R90 revealed…

    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 · D2025-12-07 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of 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 observations, staff and family interviews, and review of the facility menu, the facility failed to serve the lunch meal as written on the menu for one of 48 sampled residents (R) (R15).Findings include:R15 was admitted to the facility with a medical diagnosis of but not limited to unspecified protein calorie malnutrition.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R15 had a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating cognition is severely impaired.Review of the electronic medical record (EMR) revealed R15 had a physician order for a regular diet, regular texture, regular consistency.Review of the facility Week 2 Saturday lunch meal revealed residents were to be served chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll. margarine, Italian ice, and whole milk.Review of R15's lunch meal tray slip revealed he was to receive three ounce chicken parmesan, one half cup mashed potatoes, four ounces Italian vegetable blend,…

    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 before2025-12-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interview, record review, and review of the facility policy titled, Catheter Care, the facility failed to follow proper infection control practices related to hand washing during catheter care for one of seven residents (R) (R71) with indwelling urinary catheters. The deficient practice had the potential to cause R71 increased risk for urinary tract infections. Findings include:Review of the facility policy titled Catheter Care dated 1/8/2025 revealed under Compliance Guidelines . 7. Perform hand hygiene.R71 was admitted to the facility with diagnoses that include but is not limited to, retention of urine.Review of the 11/22/2025 admission Minimum Data Set (MDS) assessment for R71 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition, is dependent with all Activities of Daily Living (ADLs), and has an indwelling urinary catheter, Review of the Person-Centered Comprehensive Care Plan for R71 revealed no care plan in place for an indwelling urinary catheter. Review of the physician orders for R71 revealed…

    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 · F2025-07-10 · tag F0770 — failed to provide lab services — widespread
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to revise their CLIA (Clinical Laboratory Improvement Amendments) certificate within 30 days after new ownership. The facility does not have a current CLIA certificate appropriate for the level of testing it conducts after approximately seven months of ownership.Findings include:Review of the CLIA Certificate of Waiver with Effective Date of 5/6/2024 and Expiration Date of 5/5/2026 is in the name of the previous owner hospital.Review of the CLIA Certificate of Compliance with Effective Date of 8/19/2023 and Expiration Date of 8/18/2025 is in the name of the previous laboratory service owner. In an interview on 7/8/2025 at 12:21 pm with the facility's Administrator, they stated, We are still operating under that (Previous Owner) waiver as part of the transition. The new owner purchased the facility from the hospital in January 2025.On 7/8/2025 the State CLIA Department was consulted, and they confirmed the following, The facility is out of compliance and should request a revised CLIA certificate using the attached CMS-116…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2025-07-10 · 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 record review, observations, and resident and staff interviews, the facility failed to provide bath linen in good condition on seven of nine hallways (C hall, 600 hall, 200 hall, 400 hall, 500 hall, 800 hall and 900 hall).Findings include:On 7/7/2025 beginning at 10:55 am, during a brief tour of C hall, one linen cart revealed no towels or washcloths, a second linen cart has a torn washcloth and a few hand towels in disrepair. On 7/7/2025 at 11:22 am, in the secured hall, a staff member came out of room [ROOM NUMBER] with an arm full of linens, some washcloths tattered, and said, they were not dirty, I promise and put them in soiled laundry bin. On 7/7/2025 at 11:26 am, on the 600-hall linen cart had 10 wash cloths, a few were tattered and 13 bath towels.During an interview on 7/7/2025 at 11:37 am, Resident R12 said, they tore up larger towels and made it into washcloths when the new company took over. I had a few yesterday that were torn.During an interview with R11, on 7/8/2025 at 10:14 am, R11 said,…

    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 before2025-07-10 · 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 facility policy titled, Food Storage, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility had expired food in storage areas reserved for resident snacks. This practice affected two of three units (Middle Unit and the Nursing Unit) observed in the facility for resident food storage. Findings include:Review of the facility policy titled Food Storage with a date of January 2025 revealed under 5. Storage Guidelines. D. Perishable and Leftover Foods, Label with preparation date and discard date (typically within 3-7 days based on item type). Observation on 7/7/2025 at 11:30 am of the snack cabinet for residents on the Nursing Unit revealed the cabinet contained an unopened loaf of bread that had an expiration date of 4/24/2025. The bread was hard and had areas of green discoloration in several areas.An interview, on 7/7/2025 at 11:33 am with Certified Nursing Assistant (CNA) II revealed the bread should have been discarded back in April…

    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 before2025-07-10 · 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 policy titled, Hand Hygiene, the facility failed to ensure proper hand hygiene during the lunch meal in the Nursing Unit Main Dining Room for three of 14 residents (R) (R4, R5, and R6). The deficient practice had the potential to cause foodborne illnesses for residents eating in the Nursing Unit Main Dining room.Findings include:Review of the facility policy titled Hand Hygiene with an effective date of January 2025 revealed under Policy: This facility considers hand hygiene the primary means to prevent the spread of infections. Under Guidelines: . 5) Use an alcohol-based hand rub for the following situations: . o) Before and after assisting a resident with meals.On 7/7/2025 at 12:49 pm, Certified Nursing Assistant (CNA) AA entered the Nursing Unit Dining Room, sat down without performing hand hygiene and started to assist R4 to eat. CNA AA touched the spaghetti on R4s fork with her bare hands and then brought that fork up to R4s mouth for them to eat the now contaminated food. Using the same hand, CNA AA twirled…

    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 · Dcited before2025-07-10 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and resident and staff interviews, the facility failed to promote dignity for one of 14 residents (R) (R 6) who ate in the main dining room. Specifically, R6 was seated at a table with inappropriate height.Findings Include:1. Observation on 7/7/2025 at 12:43 pm, at the second table, two of six residents had meal trays and were eating. R6 was seated at that table, but R6 was upset about not having food and Certified Nursing Assistant (CNA) AA moved R6 to the third empty table that was also upper lip height. Observation on 7/7/2025 at 12:59 pm, R6 was observed sitting in a lowered seat wheelchair eating independently with her upper lip at table height. Observation on 7/7/2025 at 1:18 pm, R6 was seated at a single table at eye level. R6 introduced herself.Interview on 7/7/2025 at 1:33 pm, CNA AA said R6 eats all her food, but her upper lip is almost at table height. R6 should be seated at a smaller table so she can see her food.During an interview with the Director of Nursing (DON) on 7/10/2025 at 10:01 am, she said, We heard through the grapevine that this was a…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the policy titled, Oxygen (O2) Administration, the facility failed to maintain a clean O2 concentrator filter consistent with professional standards of practice for two of 23 residents (R) (R56 and R119) who use O2. The deficient practice had the potential to cause respiratory distress for R56 and R119. Findings include: A review of the facility policy titled Oxygen Administration dated 5/12/2022 and revised on 11/16/2022 revealed in the section titled Care of Concentrator Equipment, number five revealed remove and wash the air filter every seven days, documenting on resident's Medication Administration Record (MAR), Change oxygen (O2) tubing every seven days, documenting on resident's MAR, Wash concentrator with WellStar approved cleaning solution, Change humidifying water bottle weekly, Replace facility approved storage bag once a month or (as needed) PRN, and Check connections and flow setting to assure resident oxygenation every shift 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 · Fcited before2022-10-20 · 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 interview, and review of facility documents titled Food Storage and Distribution and Department Policy and Procedure, the facility failed to ensure that the piping under one of one hood and over the stove was without rust and failed to ensure cleanliness of this area underneath the hood over the stove in the kitchen. Findings include: The initial kitchen tour began on 10/1/22 at 8:55 a.m. with the Certified Dietary Manager (CDM) and revealed the following: The pipes that were underneath the hood over the stove were with white sediment on them and with brown corrosion looking material observed on them and not maintained well. During an interview with the CDM on 10/14/22 at 10:10 a.m. it was reported that she expected the area to be cleaned with the hood cleaning that is done once a quarter. Dietary Manager, CDM acknowledged what was seen in the kitchen in regard to pipes over the hood in need of cleaning/repair, but was unable to identify who exactly was responsible for checking to assure that the pipes over the hood in the kitchen were clean and well…

    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 before2022-10-20 · 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 observation, record review, and staff interview, the facility failed to individualize and/or implement a resident-centered care plan for six of 41 sampled residents (R) (R#97, R#45, R#70, R#117, R#20, and R#486) related to: activities for R#97; Activities of Daily Living (ADL) for R#45; and related to the restorative services for (R#70) (R#117) (R#20) and (R#486). Findings include: 1. Review of R#97's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the staff did not assess his activity preferences. Review of R#97's care plan revealed a care plan description for a need for customary routine choices to be met with the goal that the resident will have preferences for customary routine offered by staff. The approaches listed in the care plan included participating in favorite activities, participating in religious activities or practices, reading books, newspapers, or magazines, and that the resident enjoys listening to music that he likes. It further noted that he likes to be around…

    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 · D2022-10-20 · 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 observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) were provided for two of 41 sampled residents (R) (R#45 and R#68) related to nail and hair care. Findings include: 1. Review to the clinical record for Resident R#45 revealed the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she required total assistance for baths and extensive assistance for personal hygiene. Review of the care plan dated 5/6/21 indicated that R #45 requires assistance with ADLs. Approaches include resident needs extensive assist with bed mobility, dressing, and personal care. Observation and interview with R#45 on 10/18/22 at 11:00 a.m., 10/19/22 at 9:46 a.m. and 4/11/18 at 9:33 a.m. and 11:03 a.m. after a.m. care was provided, revealed that fingernails on both hands are long and untrimmed. She asked surveyor to cut them for her. R#45 told surveyor that she does not desire her fingernails to be that long. She further stated that a girl…

    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 · D2022-10-20 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to provide an ongoing program of activities for one resident (R) (R #97), who needed extensive to total assistance by staff for provision of all care. The sample size was 42 residents. Findings include: Review of R #97's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the staff did not assess his activity preferences and required extensive to total assistance with activity of daily living (ADL) care. Review of his care plan revealed a care plan description for a need for customary routine choices to be met with the goal resident will have preferences for customary routine offered by staff. The approaches listed n the care plan includes participating in favorite activities, participating in religious activities or practices, reading books, newspapers or magazines, Resident enjoys listening to music that he likes. Likes to be around animals and enjoys his favorite activities. Review of his clinical record revealed that he had…

    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 · D2022-10-20 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of the policy titled Restorative Nursing, the facility failed to follow Occupational Therapy (OT) and Physical Therapy (PT) Restorative Nursing Treatment Plan recommendations for range of motion (ROM) and orthotic application for four residents (R), (R#20), (R#70), (R#117) and (R#486) reviewed for ROM and mobility. The sample size was 41. Review of the policy titled Restorative Nursing revised 9/29/22 revealed: Purpose: To establish uniform guidelines concerning restorative care. Definition: General rehabilitative/restorative nursing care is that which does not require the use of a qualified professional therapist to render such care. Policy: Rehabilitative nursing is provided for each resident admitted . Philosophy: WellStar [NAME] Nursing Center uses an integrated model where staff, resident, and family ar trained in the philosophy and concepts of restorative care. The facility's policy is that restorative nursing is integrated in all activities of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-20 · 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, resident interviews, staff interviews, record review and review of policies titled Control of Medications and Medication Self Administration, the facility failed to provide an environment that was free from potential accidents and hazards for two of 41 sampled residents (R) (R#47 and R#437) related to properly storing medications which were located on the bedside tables in residents rooms. Findings include: 1. A review of the facility policy titled Control of Medications dated 7/8/21 revealed: Purpose: To define a process for maintaining the security and storage of medications on the nursing unit. Procedure: Never leave controlled or non-controlled medications unsecured or unattended. 1.2 Store non-controlled medications in the medication cart. A review of the policy titled Medication Self Administration dated 7/8/21 revealed: Policy statement: It is WellStar's policy that residents have the right to self-administer medications if the Interdisciplinary Team has determined that it is…

    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 before2022-10-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews and review of policy titled Oxygen Administration, the facility failed to obtain a physician order to administer oxygen to one of 41 sampled residents (R) (R#437) that required oxygen. Findings include: During initial observation of R#437 on 10/18/22 at 1:29 p.m., revealed that resident was on oxygen 4 liters. No labels and not dated. Resident had blue lips. R#437 stated that she admitted on 4 liters and that is the amount that she uses all the time. On 10/19/22 at 8:35 a.m., observation of resident found her sitting on the bedside commode. Oxygen 4 liters on and lips were not blue at the time of observation. Tubing, and/or humidity bottle not dated or labeled. Observation of another resident on oxygen on the rehab side of 200 hall revealed that he was on 2 liters and had no date or label on tubing/humidity bottle. Per the care plan for R#437 dated 10/11/22, resident receiving oxygen therapy. The goals included: exhibits no shortness of breath, provide 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.

    Quality of Life and Care 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 THE ROSENBERG FAMILY — 16 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 3 of 52.7+0.3 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 4 of 53.9+0.1 vs chain
Quality measures 5 of 54.0+1.0 vs chain
The other 15 homes this chain runs (chain average 2.7★, 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
BLUE RIDGE 2 LLCOrganizationDIRECT OWNERSHIP INTERESTsince 01/08/2025
AZ 22 TROrganizationINDIRECT OWNERSHIP INTERESTsince 01/08/2025
ZA 22OrganizationINDIRECT OWNERSHIP INTERESTsince 01/08/2025
ROSENBERG, AVRAHAMIndividualINDIRECT OWNERSHIP INTEREST; TRUSTEE OF THE SNF; ADP OF THE SNFsince 01/08/2025
ROSENBERG, ZVIIndividualINDIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; MANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNF; ADP OF THE SNFsince 01/08/2025
600 BLUE LLCOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 01/08/2025
ROSENBERG, JONATHANIndividual5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 01/08/2025
ROSENBERG, MOSHEIndividual5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNFsince 01/08/2025
OLAYEYE, IWAYEMIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/08/2025
SMITH, SHAWNAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/08/2025

CMS files one row per role, so the 25 rows in the source record cover these 10 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.

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

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 115258. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

What to do next