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Decatur Center For Nursing And Healing LLC

2722 North Decatur Road, Decatur, GA 30033 · For profit - Limited Liability company · 140 certified beds · (404) 296-5440 Medicare & Medicaid certified

Call the home — (404) 296-5440 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 27 lower-level deficiencies on record (see below)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing 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) 2 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 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 — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS
Urgent care / clinic
2712 N Decatur Rd · (404) 299-0187 · Call to confirm hours
Pharmacy
2738 N Decatur Rd · (404) 508-8058 · Call to confirm hours
Grocery
1555 Church St · (470) 237-7340 · Call to confirm hours
Park
Glenlake Park · 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 held steady at 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 increased13.6%15.3%15.4%better
Long-stay residents who lose too much weight6.5%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 infection0.7%2.5%2.0%better
Long-stay residents with depressive symptoms0.0%11.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.0%3.2%3.3%better
Long-stay residents whose ability to walk worsened9.6%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication2.0%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine95.2%95.0%95.3%typical
Long-stay residents with pressure ulcers4.1%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control19.7%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table2.8%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.3%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine86.0%78.4%79.4%typical
Short-stay residents rehospitalized after admission22.0%25.0%22.6%typical
Short-stay residents with an outpatient ER visit9.0%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.332.151.67better
Long-stay outpatient ER visits per 1,000 resident days0.731.901.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.

59.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 242 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

59.3%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
67.2%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.26hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 67.2% 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 67 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 34% 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 SNF59.3%CMS range 50.9–64.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.8–12.410.7%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 discharge67.2%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 discharge52.2%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 discharge64.2%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 identified88.8%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 setting97.8%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 discharge98.6%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 stay2.6%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 worsened3.3%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 hospitalization5.9%CMS range 3.7–9.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.181.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.59
RN hours/ resident / day
0.88
LPN hours/ resident / day
1.81
Aide hours/ resident / day
3.27
Total nurse hours/ resident / day
0.42
RN hoursweekends
40.0%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 140 beds and averages 117.9 residents a day — about 84% occupied, or roughly 22 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 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.81 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 2.96 hrs/resident/day on weekends vs 3.40 on weekdays — 13% thinner on weekends. RN hours go from 0.66 to 0.42 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% 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

4
deficiencies at the latest standard inspection (2026-04-01)
9
at the previous standard inspection (2025-04-24)

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.

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

  • Potential for harm · Fcited before2026-04-01 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff Interviews, and review of the facility policy titled, Disposal of Garbage and Refuse, the facility failed to ensure garbage and waste refuse was properly disposed of at the Dumpster site; failed to ensure garbage and refuge receptacle containers were covered and failed to ensure dumpster area was clean and free of debris. These failures posed a sanitation hazard with the potential for insect and rodent attractions. Findings include:Review of the Facility's Policy titled Disposal of Garbage and Refuse dated January 2022, and revised April 2024, Policy Statement revealed The facility shall properly dispose of kitchen garbage and refuse. The Policy Section Explanation and Compliance Guidelines .7. Refuse and dumpsters shall be kept outside the facility, shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. The Policy Section Explanation 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-01 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, and review of the facility policies titled, Preventative Maintenance Program and Linen Operations and Management: The Linen Operation, the facility failed to ensure the environment was maintained in a safe, sanitary, and functional condition. Specifically, Packaged Terminal Air Conditioner (PTAC) air filters in two of ten rooms (rooms [ROOM NUMBERS] on Team A Hall) were observed to contain a significant amount of gray, fuzzy particulate matter. Additionally, clean linens were not consistently available for resident care for six of 47 sampled residents (R) (R39, R8, R101, R89, R90, and R72). The deficient practice had the potential to contribute to respiratory problems for residents due to unclean air filters and to delays in care due to insufficient linen availability.Findings include:Review of the facility policy titled Preventative Maintenance Program revised September 2023, revealed under Policy: A Preventative Maintenance Program shall be developed 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-01 · 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 observations, staff interviews, and review of facility policies titled, Accidents and Incidents and Preventative Maintenance Program, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility failed to maintain environmental surfaces in a safe condition and failed to implement interim measures to mitigate identified hazards, including a broken handrail with exposed, jagged edges on one of two hallways on the first floor, and a loose, rusted heater cover with sharp edges accessible to residents in one of two shower rooms (first floor central shower room). These conditions had the potential to cause injury, including skin tears and lacerations.Findings include:Review of the facility policy titled Accidents and Incidents revised October 2025, revealed under Policy: It is the policy of this facility for staff to utilize Risk Management System to report, investigate, and review any accidents or incidents that occur or allegedly occur, on or off facility property and may involve or allegedly involve a resident.Review of the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-01 · 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 and resident interviews, record review, and review of the facility's policy titled, Hand Hygiene, the facility failed to ensure staff adhered to appropriate infection control practices during the handling and disposal of contaminated waste. This deficient practice had the potential to increase the risk of infection transmission through cross-contamination.Findings include:Review of the facility's policy titled Hand Hygiene revised June 2023 revealed under Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Under Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Observation on 03/31/2026 at 1:28 PM was conducted with the Skin Management Specialist (Regional Nurse) BB and Licensed Practical…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility's policies titled Sanitation, Refrigeration and Freezers, and Food brought by Family/Visitors, the facility failed to maintain cleanliness for two of the two ice machines and failed to properly store food items in two of the two refrigerators and freezers on the units (First and Second Floor). This deficient practice had the potential to affect residents who received an oral diet. Findings include: Review of the facility's policy titled Sanitation, dated April 2024, under the section titled Guidelines: revealed, 12. Ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the facility's policy titled Refrigeration and Freezers, dated April 2024, under the section titled Policy revealed, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. Under section titled Guidelines revealed, 7. All food shall be appropriately dated to ensure proper…

    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 · E2025-04-24 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility's policy titled How to Puree Foods, the facility failed to follow a recipe, use measuring devices, and use utensils when preparing puree food. This deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increase risk of aspiration for seven of seven residents receiving a puree diet. Findings include: Review of the undated facility's policy titled How to Puree Foods, under the section titled Preparation Steps revealed, 1. Depending on the resident's dietary restrictions, follow the proper recipe. 2. Portion out your prepared food according to the number of pureed meals you have. An observation on 4/24/2025 at 10:14 am in the main kitchen revealed [NAME] GG preparing puree baked chicken, green beans, and cornbread for the seven residents on a puree diet. [NAME] GG was observed pulling apart the baked chicken with gloved hands and placing the chicken into the food processor. [NAME] GG then poured an unmeasured amount of chicken broth into the food…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-24 · 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

    Based on staff interviews, record review, and review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, the facility failed to assure that the advance directive status was consistently documented in the clinical record for one out of 43 sampled Residents (R) (R167). Findings include: Review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives, dated February 2024 under Definitions revealed, Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State, relating to the provision of health care when the individual is incapacitated. Under the section titled Policy Explanation and Compliance Guidelines revealed, 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of R167's Physician Orders for Advance Directives…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy titled Heating, Ventilation and Air Conditioner (HVAC) Packaged Terminal Air Conditioner (PTAC): Clean air filters, the facility failed to maintain clean PTAC unit grills for two out of 32 Rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the First floor. This deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections. Findings include: A review of the facility's undated policy titled HVAC (PTAC): Clean air filters, under the section titled Steps revealed, 4. Clean grill on cover. Observations on 4/22/2025 at 11:02 am and 4/23/2025 at 2:24 pm, in room [ROOM NUMBER] revealed, the PTAC unit grills was noted with a black substance. Observations on 4/22/2025 at 11:27 am and 4/23/2025 at 2:26 pm, in room [ROOM NUMBER] revealed, the PTAC unit grills was noted with a black substance. Observations on 4/22/2025 at 11:13 am in room [ROOM NUMBER], and on 4/22/2025…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · 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 observations, record review, staff interviews and review of the facility's policy titled Medication Administration, the facility failed to provide services that meet professional standards by not ensuring one out of eight Residents (R) (R10) received the correct medication dosage that was observed during medication administration. This deficient practice had the potential to cause adverse medication effects and medication error. Findings include: Review of the facility's policy titled Medication Administration dated January 2023 under the section titled Policy revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standard of practice . Review of the Electronic Medical Record (EMR) revealed that R10 was admitted to the facility with diagnoses that included but not limited to paranoid schizophrenia, dementia and behavioral disturbance. Review of R10's Quarterly Minimum…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide nail care for one out of three Residents (R) (R45) reviewed for Activities of Daily Living. This failure had the potential to affect the resident's comfort, body image, and increase the risk of infections. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLS), dated January 2024 under the section titled Policy Explanation and Compliance Guidelines revealed, 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R45's Electronic Medical Record (EMR) revealed R45 was admitted to the facility with diagnoses that included but was not limited to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of R45's Quarterly Minimum Data Set (MDS) assessment…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Dcited before2025-04-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to follow physician orders for oxygen administration one Residents (R) (R45) and to properly store the oxygen nasal cannula when not in use for R96 out of 15 residents on oxygen. This deficient practice had the potential to cause respiratory distress and infection. Findings include: A review of the facility's policy titled Oxygen Administration, dated December 2022 under the section titled Policy Explanation and Compliance Guidelines revealed, 1. Oxygen is administered under orders of a physician, except in the case of an emergency .5. (e.) Keep delivery devices covered in plastic bag when not in use 1. Review of R45's Electronic Medical Record (EMR) revealed R45 was admitted to the facility with diagnoses that included but was not limited to chronic obstructive pulmonary disease (COPD), asthma, chronic respiratory failure with hypoxia, and dependence on…

    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 · D2025-04-24 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Medication Storage, Labeling of Medications and Biologicals, and Use by Dating Guidelines, the facility failed to lock two of six medication carts on the 100 and 200 halls. In addition, the facility failed to have an open date on one bottle of glucometer strips in one of six medication carts on the 200 hall and failed to remove six bottles of expired nutritional supplements from one of two medication rooms. Findings include: Review of the facility's undated policy titled Medication Storage dated June 2023 under the section titled Policy Explanation and Compliance Guidelines revealed, 1. General Guidelines: (a.) All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) .(c.) During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-24 · 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, record review, staff interviews, and review of the facility's policies titled Glucometer Disinfection and Infection Prevention and Control Program, the facility failed to disinfect the glucometer machine after it was used to check blood sugar for one out of eight Residents (R) R50 observed during medication administration. This deficient practice had the potential to increase the risk of infection transmission and compromise the overall health of residents. Findings include: Review of the facility's policy titled Glucometer Disinfection dated 9/12/2022 under the Policy Explanation and Compliance Guidelines section revealed, 5. Procedure: .(i.) Retrieve (2) disinfectant wipes from container. (j.) Using first wipe, clean first to remove heavy soil, blood and/or contamination left on the surface of the glucometer. (k.) After cleaning, use second wipe to disinfect the glucometer thoroughly, with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. (l.) Discard disinfectant wipes in waste receptacle. (m.) Perform hand…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-12-11 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility's policy titled, Disposal of Garbage Refuse, the facility failed to ensure one of one garbage dumpsters had a tightly fitted lid. In addition, the facility failed to ensure the sliding door was kept close when not in use. The facility census was 123 residents. Findings include: Review of the undated facility's policy titled Disposal of Garbage Refuse, dated April 2024, documented that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded litter. Observation on 12/2/2024 at 9:02 am revealed, the facility's garbage dumpsters were observed overflowing with stacks of garbage bags. Observation on 12/5/2024 at 9:33 am during a tour of the kitchen with the Dietary Manager (DM) revealed, the garbage dumpster outside was missing a lid and the sliding door was open. The DM attempted to shut the sliding door, but it was stuck and difficult to close. The DM then stated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-11 · 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 observation, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure that opened food stored in one walk-in cooler was covered, labeled and dated. This failure had the potential to affect 121 of 123 residents who received an oral diet from the kitchen. Findings include: Review of the undated facility's policy titled, Food Receiving and Storage dated April 2024 revealed, all foods stored in the refrigerator or freezer will be covered, labeled and dated. Observation on 12/5/2024 at 9:33 am during a tour of the kitchen with the Dietary Manager (DM) revealed, one of the walk-in coolers had an open bag of cabbage with no open date on the bag. The DM stated, it was probably left open from when the salads were being made for lunch. However, the lettuce did not match the premade salads. During the observation, [NAME] EE stated, it may have been left open from the day before. Interview on 12/10/2024 at 10:09 am with [NAME] EE revealed, the bag of cabbage was used for cole slaw. [NAME] EE stated staff must have needed to…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-11 · 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 interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one of four sampled residents (R) (R12) reviewed for falls. Findings include: Review of the Electronic Medical Record (EMR) revealed, R12 admitted to the facility on [DATE] with multiple diagnoses that included but not limited to type II diabetes mellitus without complications, sepsis, morbid (severe) obesity with alveolar hypoventilation, edema, indwelling urethral catheter, pressure ulcer of sacral region, stage IV hypertension and chronic pain. Review of R12's admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition; Section J (Health conditions) revealed, Fall since Admit/prior Assessment, was marked no' Review of a fall incident report dated 7/26/2024 revealed that R12 was trying to get from my chair into the bed and it rolled from underneath me. Review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · 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 interviews, record review and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medication within 60 minutes before or after the scheduled medication time for one of sampled three residents (R) (R13) reviewed for medication administration. Findings include: Review of the facility's policy titled Medication Administration dated January 2023 under the section titled Policy Explanation and Compliance Guidelines revealed, 11. (b) Administer within 60 minutes prior or after scheduled time unless otherwise ordered by physician. Review of the Electronic Medical Record (EMR) revealed R13 admitted to the facility with multiple diagnoses that included but not limited to type II diabetes, chronic kidney disease, hearing loss, pulmonary hypertension, chronic pain and of automatic (implantable) cardiac defibrillator. Review of R13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitve Pattern) a Brief Interview for Mental…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-11 · 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 resident and staff interviews and record review, the facility failed to provide showers/baths for one of six sampled residents (R) (R12) reviewed for Activities of Daily Living (ADLs). Findings include: Review of the Electronic Medical Record (EMR) revealed, R12 admitted to the facility on [DATE] with multiple diagnoses that included but not limited to type II diabetes mellitus without complications, sepsis, morbid (severe) obesity with alveolar hypoventilation, edema, indwelling urethral catheter, pressure ulcer of sacral region, stage IV hypertension and chronic pain. Review of R12's admission Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 15 which indicated intact cognition. Review of R12's Care plan, initiated on 7/23/2024 revealed, R12 required extensive assistance by one staff when bathing. Review of the Facility's shower schedule revealed, residents receive two showers per week; Mondays and Thursdays; Tuesdays…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews the facility failed to provide a safe homelike environment for residents on two of two floors. The tour of the facility revealed trash debris in residents' rooms and bedroom furniture in disrepair. This failure had the potential to place residents at risk for use of unsanitary and a unsafe environment and a potential for diminished quality of life. Findings include: During the initial tour of the facility conducted on 03/21/2023, observations of the following concerns were identified: Observation in the room of R#63 a black 1 inch by 1/2-inch pest that was crawling over the resident's bed. Observation in the room of R#22 a strong musty odor coming from residents' bathroom. Observation in the room of R#17 the wallpaper peeling off the wall. Observation in the room of R#92 the nightstand missing the middle drawer and nicks and scratches were observed on the nightstand. Observation in the room of R#49 the emergency outlet not covered, and the electrical outlet over the resident's bed with multi plugs is not completely covered the outlet. Observation…

    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 · E2023-03-24 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 and resident interviews, record reviews, and a review of facility's policy titled, Care Plans - Baseline, the facility failed to develop base line care plans for six residents of 35 sampled residents (R) (#67, #92, #105, #117, #279, and #280). This failure had the potential to place newly admitted residents at risk of not receiving necessary care and services. Finding include: Review of the facility's document titled Care Plans - Baseline updated 12/2022 states the facility's policy interpretation and implementation includes the following: A baseline care plan will be developed within 48 hours of the resident's admission. The resident and their representative will be provided a summary of the baseline care plan . 1. Record review of the admission Record for R#67 located in the electronic medical record (EMR) under section Profile revealed the resident was admitted on [DATE] with diagnoses that included malignant poorly differentiated neuroendocrine tumors, protein calorie nutrition, and drug…

    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 · D2023-03-24 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, record review, and a review of the facility's policy titled, Resident Rights, and Care Planning-Interdisciplinary Team, the facility failed to ensure a care conference was held on a regular basis with the resident or resident representative for one of three sampled residents (R) (#94) reviewed for care conferences. This failure had the potential to place residents at risk for unmet care needs. Findings include: Review of the facility's undated policy titled, Resident Rights, revealed, . Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment. Including .The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to . The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care . Review of the facility's undated policy titled Care…

    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 · D2023-03-24 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 interview, record review, and a review of the facility's policy titled, Resident Assessment Instrument (RAI), the facility failed to electronically transmit Minimum Data Set (MDS) data to the CMS [Center for Medicare and Medicaid] system for one of 35 sampled residents (R) (#21) whose MDS data was reviewed. The facility failed to transmit an 11/08/2022 Discharge-Return Not Anticipated for R#21. Findings include: According to the Resident Assessment Instrument (RAI), referred to in this citation as the State Operations Manual, dated November 2017, §483.20(f)(2) Transmitting data within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State .'Complete' means that all the items required according to the record type, and in accordance with CMS'…

    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 · D2023-03-24 · 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

    Based on staff and resident interviews, record review, and a review of the facility's policy titled, Comprehensive Care Plans review, the facility failed to ensure that one of 35 sampled residents (R) (#43), care plan was revised to reflect R#43's current full-code status. This failure placed the resident at risk for delayed response time and potential for her life saving preferences not to be followed. Findings included: Review of the facility's policy titled Comprehensive Care Plans revised on 09/12/2022, revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Record review of the admission Minimum Data Set (MDS) for R#43 located in the EMR under the MDS tab, dated 12/24/2022, revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 14, which indicated the resident was cognitively intact for daily decision-making. Record review of the Physicians Orders dated 04/07/2022, located in the Orders tab of the EMR showed R#43 was a Full Code. Further review of the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Urinary Catheter Care the facility failed to ensure one of 35 sampled residents (R) (#117) received the appropriate care to prevent urinary tract infections. While providing incontinent care to R#117 a staff member was observed not to use proper hand hygiene and failed to provide proper catheter care. Findings include: Review of the facility document titled Urinary Catheter Care with a revision date of September 2014, instructs the staff the urinary drainage bag must be always held or positioned lower than the bladder to prevent the in the tubing and drainage bag from flowing back into the urinary bladder. It also directs the staff when emptying the drainage bag to use a separate, clean collection container and void splashing and prevent contact of the drainage spigot with the nonsterile container. When cleaning the catheter staff should use a clean washcloth with warm water and soap to cleanse and rinse 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 · Dcited before2023-03-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and a review of facility's policy titled, Nebulizer Therapy, the facility failed to provide a nebulizer treatment in accordance with professional standards for one of 35 sampled residents (R) (#117). The nurse failed to assess the resident's lung sounds pre- and post- administration of nebulizing treatment. The facility failed to assess the effectiveness of the nebulizer treatment for the resident. Findings include: Review of a facility's policy titled Nebulizer Therapy with a review date March 2023 instructs the staff to perform hand hygiene before touching the equipment. Obtain resident's vital signs and perform respiratory assessment to establish a baseline. Observation on 03/23/2023 at 9:25 a.m., during the medication pass, Licensed Practical Nurse (LPN)1 was observed administering a nebulizer treatment to R#117. LPN1 performed hand hygiene and prepared albuterol (medication used to treat difficulty breathing). LPN1 removed the treatment mask from the plastic bag and poured one albuterol ampule into the medicine chamber of the mask. LPN1…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and a review of the facility's policy titled, Dialysis: Hemodialysis (HD)-Communication and Documentation, the facility failed to provide dialysis care and services to meet the needs of two of two sampled residents (R) (#45 and #105) reviewed for dialysis. The facility failed to provide ongoing assessment and monitoring of the dialysis access fistula/catheters. This failure had the potential to place the residents at risk for complications before and after dialysis treatments. Findings include: Review of an undated facility policy titled, Dialysis: Hemodialysis (HD)-Communication and Documentation, revealed, .Patients who require HD services receive care consistent with professional standard of practice, the comprehensive person-centered care plan, and the patients goals, and preferences .Professional standards of practice included .Ongoing assessment and oversight of the patient before and after HD treatments, including monitoring for complications, implementing…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-24 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 a review of the facility's policy titled, COVID-19 Vaccination, the facility failed to ensure one of five sampled residents (R) (#49) who were reviewed for immunizations, had his COVID-19 vaccination status identified upon admission. This failure had the potential to place the resident at risk of acquiring and/or transmitting a contagious disease. Findings include: Review of a facility policy titled, COVID-19 Vaccination, dated 09/12/2022, revealed, .It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-I9 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine .The resident's medical record will include documentation of the following .Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-I9 vaccine .If the resident did not receive the COVID- 19 vaccine due to medical contraindication or refusal . Record…

    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

“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 EMPIRE CARE CENTERS — 20 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 51.9+1.1 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 2 of 51.5+0.5 vs chain
Quality measures 5 of 53.0+2.0 vs chain
The other 19 homes this chain runs (chain average 1.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
PMGA2 HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF100%since 01/04/2023
DONATH, BARRYIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
SWERDLOFF, ARYEHIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
HELLER, SHLOMOIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
NUSSBAUM, EPHRAIMIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
EMPIRE CARE CENTERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
BHATIA, VAANIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
BURNEY, LINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/29/2025
COLEMAN, SHMEKAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/09/2024
ELLIS, RENEEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
ENDSLEY, LKESHIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/13/2023
HARDY, LEANTHONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2022
LEWIS, JACKIEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
MCMICHAEL, ROBERTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/06/2023
PRESCOTT, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/21/2026
SMITH, BECKEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
SONE-EBELOUE, GLADYSIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/04/2023
TOLBERT, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/23/2023
ENSH CONSULTING LLCOrganizationADP OF THE SNFsince 03/31/2026

CMS files one row per role, so the 42 rows in the source record cover these 19 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

$17.0M
Net patient revenuemost recent cost report
+0.9%
Operating marginrevenue minus expenses
$1.2M
Related-party expense7% of expenses
Who pays — share of resident-days
Medicaid 54%Medicare 13%Other / private 33%

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$392per resident / day
operating cost
$11,908per month
≈ monthly operating cost
$395per 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 115246. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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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