Pruitthealth - Decatur
3200 Panthersville Road, Decatur, GA 30034 · For profit - Limited Liability company · 146 certified beds · (404) 212-3400 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (24) — 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)
- about 24% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.6% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.8% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 11.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.3% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.3% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.7% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.7% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 3.0% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 15.4% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.3% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.3% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.11 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.32 | 1.90 | 1.80 | better |
* 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.
55.0% 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 77 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 34 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 0.21 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 55.0%CMS range 42.0–67.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.3%CMS range 9.8–18.3 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 50.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 67.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 8.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.9%CMS range 3.8–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 146 beds and averages 133.4 residents a day — about 91% occupied, or roughly 13 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.35 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 2.65 hrs/resident/day on weekends vs 3.63 on weekdays — 27% thinner on weekends — a notable drop. RN hours go from 0.69 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% 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
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.
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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Fcited before2026-03-04 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 and staff interviews, the facility failed to protect clean linen from cross-contamination. This deficient practice had the potential to affect two of two floors. The census was 135 residents.Findings include: Observation and interview on 03/02/2026 at 1:32 PM with Laundry Aide WW revealed Laundry Aid WW delivering clothes on a partially covered laundry cart. She confirmed that she was delivering to the first floor and acknowledged that she should be utilizing the transportation cart that was enclosed. However, she opted to use the laundry sorting cart due to concerns regarding her back, as it was difficult for her to push. Laundry Aid WW also noted that she should have had the cart covered. Interview on 03/04/202, at 6:11 PM with the Environment Manager revealed that the expectations for laundry were that it should be delivered in a timely manner, properly covered, and without any additional items on the cart. The Environment Manager explained that there were four laundry transportation units, with two assigned to each floor, and each unit has designated…
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.
- Potential for harm · Ecited before2026-03-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 and staff interviews, the facility failed to store potentially hazardous chemicals so that they were not accessible to cognitively impaired residents. Specifically, a can of cleanser powder was left on a handrail accessible to residents on the first floor.Findings include: Observation on 03/04/2026 at 5:28 AM of the second-floor hallway revealed a 21 ounce can of 'name brand' cleanser deodorizing powder placed on the handrail by a resident's room with no staff or housekeeping cart in sight. Interview on 03/04/2026 at 5:31 AM with Licensed Practical Nurse (LPN) SS confirmed the can of powder was in the hallway and that it should not be there. She stated she was not sure why it was left there. When asked about the consequences of leaving chemicals in the hallway, she stated that a resident could swallow it. Interview on 03/04/2026 at 5:45 PM with the Director of Health Services and the Administrator revealed that chemicals should not be left in the hallway and should be in a locked area for the health and safety of staff and residents. When asked about 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.
- Potential for harm · D2026-03-04 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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, staff and resident interviews, and record review, the facility failed to provide dignity to one of two residents (R) (R88) with an indwelling catheter urinary bag. This deficient practice had the potential to cause emotional distress to R88.Findings include:The facility does not mention covering the indwelling urinary bag in either their resident rights policy or the indwelling catheter policy.Review of the electronic medical record (EMR) revealed R88 was admitted to the facility with pertinent diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus without complications, epilepsy, without status epilepticus, hyperlipidemia, contracture of the left hand, receptive-expressive language disorder, dysphagia (swallowing problems).A review of R88's Minimum Data Set (MDS) assessment revealed that one had not been completed for this current admission. Review of the Care Area Assessment (CAA) 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.
- Potential for harm · D2026-03-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident, resident family and staff interviews, record review, and review of the facility policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of verbal abuse by a staff member to the State Survey Agency (SSA) for one of 50 sampled residents (R) (R144). The deficient practice had the potential for the alleged abuse to continue and to affect other residents.Findings include: Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/20/2025 revealed under Policy Statement: It is the policy of 'name of corporation' and its affiliated entities (collectively, the Organization) to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Under Policy: 2. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-04 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 and staff interviews, the facility failed to ensure the need of a Level II Preadmission Screening and Resident Review (PASARR) for evaluation and determination for specialized services were offered to meet resident needs for one of 50 sampled residents (R)(R14). The deficient practice had the potential for R14's needs and services to go unmet.Findings include:PASARR/Level II policy requested but was not received as it was reported that the facility does not have a policy related to PASARR/Level II.Review of electronic medical record (EMR) for R14 revealed diagnoses of but not limited to bipolar disorder, current episode manic without psychotic features, unspecified, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, post-traumatic stress disorder (PTSD), unspecified, accidental discharge from unspecified firearms or gun, sequela (a condition which is the consequence of a previous disease or injury). Review of the 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.
- Potential for harm · D2026-03-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to add indwelling urinary catheter irrigation to the care plan for one of 50 sampled residents (R) (R51). This deficient practice had the potential to cause errors in care and omission of service ordered by the physician.Findings include:Review of the facility's policy titled Care Plan, revised 10/21/2025, Section 3 under the comprehensive care plan should describe the following: The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of R51 care plan dated 12/10/2025 indicated a problem of an indwelling catheter related to neurogenic bladder, BPH, and urinary retention. Interventions included, but not limited to, R51's spouse prefers urinary catheter to be changed at the urologist's office monthly and not the facility. Administer cranberry supplement for UTI (urinary tract infection) prophylaxis as ordered. Keep the catheter tubing free of kinks. Keep 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.
- Potential for harm · D2026-03-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide 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, resident and staff interviews, and record review, the facility failed to ensure two of 50 sampled residents (R) (R13 and R38) received timely incontinence care and failed to provide sterile catheter irrigation and follow the irrigation procedure for one of 50 sampled residents (R) (R51). The deficient practices had the potential to affect resident's skin integrity and increase the potential for urinary tract infections (UTI).Findings include: A policy regarding incontinence care was requested but the facility did not submit one. Review of the facility's policy titled Clinical Procedure: Indwelling Catheter-Irrigation, revised 2025, printed from Relias education, Section Pre-Procedure: gather and set up supplies, clean and sterile gloves, Sterile irrigation set and syringe (60ml [milliliter]), Sterile normal saline, sterile protective cap for drainage tubing. 1. Review of the electronic medical record (EMR) revealed R13 was admitted to the with pertinent diagnoses including but not limited…
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.
- Potential for harm · D2026-03-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policy titled, Medication Storage in Healthcare Center, the facility failed to ensure one of two medication carts on the first floor was locked. The deficient practice had to potential for items in the unlocked medication cart to be accessible to residents, staff and visitors.Findings include:Review of the facility policy titled Medication Storage in Healthcare Centers revised 11/11/2025 revealed in the Policy Statement medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. Procedures revealed: .2. Only licensed nurses, certified medication aides, and the pharmacy personnel are allowed access to medications. Respiratory Therapists may access medications used in the provision of respiratory services. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 7. Potentially harmful substances (e.g., urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly…
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.
- Potential for harm · E2025-01-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, record review, staff interviews, and review of the facility's policies titled, Labeling, Dating, and Storage and Foodborne Illness, the facility failed to dispose of expired food items in the kitchen. The deficient practice had the potential to affect the 124 residents (R) receiving food from the kitchen. The facility's census was 130. Findings include: Review of the facility's policy titled Labeling, Dating, and Storage revised 11/11/2022 documented under Policy Statement: It is the policy of [name of facility] for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety. Review of the facility's policy titled Foodborne Illness reviewed 1/8/2021 documented under Procedure: 2. Foods will be used before the expiration date, use by date, best by date, and sell by date, indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. Observation on 1/28/2025 at 9:20…
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.
- Potential for harm · Ecited before2025-01-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility's policies titled, Infection Prevention-Hand Hygiene, Handwashing and Enhanced Barrier Precautions (EBP), the facility failed to place one of 19 residents (R) (R88) with wounds on EBP and failed to perform hand hygiene while serving meals in the dining room. The deficient practices had the potential to cause infection for R88 and other facility residents. The facility census was 130. Findings include: Review of the facility's policy titled Infection Prevention-Hand Hygiene revised 10/15/2024 documented under Policy Statement: [name of facility] partners will improve hand hygiene practices and reduce Healthcare Associated Infections (HAIs) . D. Indications Requiring Hand Wash or Hand Rub 1. Before and after contact with the resident. 8. After contact with inanimate objects (i.e., including medical equipment) in the immediate vicinity of the resident. 9. Passing meal trays to residents. Review of the facility's policy titled…
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.
Show the remaining 14 citations
- Potential for harm · D2025-01-30 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 record review and staff interviews, the facility failed to assure the correct order was on file and medical records reflect the resident's choice per the Physician Orders for Life Sustaining Treatment (POLST) for two of four Resident (R) (R13 and R90) reviewed. The sample size was 55 residents. Findings include: 1. Review of the Electronic Medical Records (EMR) revealed, R13 was admitted to the facility with diagnoses that included but not limited to hypertensive heart, chronic kidney disease, heart failure, type 2 diabetes mellitus and dilated cardiomyopathy. Review of R13's POLST [a medical order form that helps persons who have serious illnesses make decisions about their care] dated 8/23/2024 revealed, POLST: Full Code. Review of R13's Physician's orders dated 2/28/2024 revealed, Code Status: Do Not Resuscitate (DNR). Review of R13's Face Sheet revealed, Advance directive: Full Code, Do Not Intubate (DNI). Interview on 1/30/2025 at 12:40 pm with the Social Services Director (SSD) CC confirmed R13's face sheet had both full code and DNI, her orders stated DNR, and 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.
- Potential for harm · D2025-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, review of the facility policy titled, Clean Air Filters, review of manufacturer recommendations titled Amana- Packaged Terminal Air Conditioner (PTAC) Manual, and the facility policy titled, Infection Control-Housekeeping Services, the facility failed to maintain two of 67 resident rooms in a clean, sanitary manner. Specifically, the facility failed to ensure that the PTAC was maintained in a clean and sanitary manner for room [ROOM NUMBER] and failed to keep the bathroom in room [ROOM NUMBER] free of bodily fluids. These failures had the potential to compromise the health and safety of the residents sharing those rooms by increasing the risk of infection and negatively impacting their quality of life. The facility census was 130 residents. Findings include: Review of the facility policy titled, Clean Air Filters, documented under section titled, Building: Main Building revealed, 1. Remove or open access cover. 2. Remove air filter and inspect for…
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.
- Potential for harm · D2025-01-30 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to submit for a Preadmission Screening and Resident Review (PASARR) Level II after a new mental illness diagnosis was added for one of one resident (R) (R10) reviewed for PASARR. This deficient practice had the potential to affect the appropriate level of care and services provided for R10. Findings include: Review of R10's Electronic Medical Records (EMR) revealed, he admitted on [DATE] and received diagnoses that include but are not limited to bipolar disorder, current episode manic without psychotic features with diagnosed date of 6/30/2021; major depressive disorder, anxiety disorder, and post-traumatic stress disorder (PTSD) with diagnosed date of 4/22/2020. Review of R10's most recent Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: no PASRR Level II; Section C-Cognitive Patterns: Brief Interview of Mental Status (BIMS) score of 99, indicating resident was unable to complete.…
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.
- Potential for harm · Fcited before2023-08-03 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled, Transmission-Based Isolation Precautions Policy, the facility failed to ensure infection control measures were appropriately implemented and maintained related to Transmission Based Precautions (TBP) for two out of two residents, Resident (R)44 and R84 who were reviewed for TBP. The facility also failed to ensure that the laundry facility kept clean laundry separated from dirty laundry. These failures had the potential to affect all 131 residents in the facility. Findings include: The facility's Transmission-Based Isolation Precautions Policy most recently dated 3/6/2019 read, Transmission-based precautions are used in combination with Standard Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens for which additional precautions are needed to prevent or to interrupt transmission of the suspected or confirm infectious agents. The appropriate isolation precaution signs should be placed in a readily visible…
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.
- Potential for harm · E2023-08-03 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, family interview, and review of the facility policy titled, Involuntary Transfer and Discharges, the facility failed to ensure four of four residents and or their representatives (Resident (R) 24, R78, R115, and R119) reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and/or their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the Involuntary Transfers and Discharges policy with a reviewed date of 3/30/2023 revealed, It is the policy of this healthcare center to permit each patient to remain in the healthcare center and not transfer or discharge them involuntarily unless it is necessary and for appropriate reasons. This policy applies to transfers or discharges initiated by the facility, not 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.
- Potential for harm · E2023-08-03 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, review of the Resident Assessment Instrument (RAI manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure five of 16 residents (Resident (R) 19, R45, R66, R78, and R120) reviewed for a Minimum Data Set (MDS) assessment had a comprehensive admission/annual assessment completed within the allotted time frame. Findings include: Review of the October 2019 RAI Manual, page 2-16 (a timeline chart for assessments) showed: Annual (Comprehensive) Assessment Reference Date No later than: ARD of previous comprehensive assessment +366 calendar days AND ARD of previous Quarterly assessment + 92 calendar days MDS completion date No later than: ARD plus 14 calendar days CAA's [Care Area Assessment] completion date No later than: ARD + 14 calendar days Care Plan completion date No later than: CAA(s) Completion date +7 calendar days Transmission date No later than: Care Plan Completion Date + 14 calendar days Review of the facility policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-08-03 · tag F0640 — patternEncode 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, review of the Resident Assessment Instrument (RAI)' manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure nine of 16 residents (Resident (R) 2, R8, R35, R37, R72, R76, R77, R80, and R91) reviewed for Minimum Data Set (MDS) had assessments transmitted within the allotted time frame. Findings include: Review of the facility policy titled MDS Assessment Accuracy, revised 12/6/2022, showed: 6. All MDS Assessments must be completed following the guidance set forth in the RAI manual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the October 2019 RAI Manual, page 2-16 (a timeline chart for assessments) showed: Significant Change in Status Assessment (SCSA) (Comprehensive). Assessment Reference Date No Later than: 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). MDS completion date No later than: 14th calendar day…
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.
- Potential for harm · E2023-08-03 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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 observation, staff interview, record review, and review of the facility policies titled, Oxygen Administration and Respiratory Equipment Changeouts, the facility failed to clean the filter and/or the outside casing of the oxygen (O2) concentrator and failed to provide evidence the oxygen tubing was changed weekly for five of six residents (Residents (R)8, R34, R43, R118, and R120) sampled for respiratory services. Findings include: Review of the facility policy titled, Oxygen Administration with a revision date of 11/1/2019 revealed, Policy Statement: to provide oxygen safely and accurately to appropriate patients. Infection Control Policy of O2, 7. The large external, black filter should be washed with soap and water once each week and PRN. Dry with towel and reinsert. Do not discard unless it is damaged. 10. Clean exterior of concentrators weekly and between each patient use with bactericidal surface cleaner. Review of the facility policy titled, Respiratory Equipment Changeouts with a revision date…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, staff interviews, record review, and review of the facility policy titled, Medication Administration: General Guidelines, the facility failed to ensure one of one (Resident (R)109) reviewed for self-administration of medications did not self-administer medications without first being assessed by the facility to determine if the practice was clinically appropriate. This deficient practice had the potential to allow the resident to administer the medication to not receive the correct dose of medication or receive it in an unsafe manner. Findings include: Review of the facility policy titled Medication Administration: General Guidelines, with a revision date of 4/10/2019, revealed: Policy Statement: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure:…
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.
- Potential for harm · D2023-08-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and document review, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), CMS-10055, were signed and dated for two of three residents (Resident (R)132 and 133) reviewed for SNFABN. This deficient practice could potentially lead to uninformed decisions made by the resident or representative about their care. Findings include: Review of the undated facility form instruction titled Advance Beneficiary Notice of Noncoverage revealed, Overview: The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. They must complete the ABN as described below and deliver the notice to affected beneficiaries or their representative before providing the items or services that are subject of the notice. The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-03 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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, review of the Resident Assessment Instrument (RAI) manual, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure one of 16 residents (Resident (R) 59) reviewed for Minimum Data Set (MDS) assessment had a significant change of status assessment transmitted within the allotted time frame as stated in the Resident Assessment Instrument [RAI] manual. Findings include: Review of the facility policy titled MDS Assessment Accuracy, revised 12/6/2022, showed: 6. All MDS Assessments must be completed following the guidance set forth in the RAI manual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the October 2019 RAI Manual, page 2-16 (a timeline chart for assessments) showed: Significant Change in Status Assessment (SCSA) (Comprehensive). Assessment Reference Date No Later than: 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar…
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.
- Potential for harm · Dcited before2023-08-03 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to ensure a Level I Pre-admission Screening Resident Review (PASSAR) was completed correctly for two out of five residents (Resident (R) 6 and R8) that were diagnosed with a mental disorder. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: The facility did not have a Pre-admission Screening Resident Review (PASSAR) policy. They only had a PASSAR User Manual. 1. Review of R8's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, revealed an admission date of 5/16/2013 with diagnoses including schizophrenia, and a dementia diagnosis on 7/8/2019. Review of R8's PASSAR provided by the facility revealed that the PASSAR Level I was requested on 5/16/2013. R8 was in an acute hospital setting before being admitted to the facility. The PASSAR Level I had no diagnosis on the form. 2. Review of R6's Face Sheet located in the EMR under the Face Sheet tab, revealed an admission date of 9/10/2018 with diagnoses including…
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.
- Potential for harm · D2023-08-03 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 record review, staff interviews, and review of the facility policies titled, Care Plans and Occurrences, the facility failed to ensure a Care Plan was updated related to the required number of staff necessary to provide care safely for one of one (Resident (R)111) reviewed for Care Plans of 30 sampled residents reviewed. Findings include: Review of the Care Plans Policy with a review date of 7/27/2023 revealed, It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Review of Occurrences Policy with a reviewed date of 11/29/2022 revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences,…
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.
- Potential for harm · Dcited before2023-08-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 record review, staff interview, and review of the facility policy titled, Occurrences, the facility failed to ensure one of one (Resident (R) 111) reviewed out of a sample of 30 for accidents had the appropriate number staff members assisting with care, resulting in the resident sustaining a fall. Findings include: Review of Occurrences Policy with a reviewed date of 11/29/2022 revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risks. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Review of the Face Sheet from the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] and had diagnoses of Alzheimer's Disease, chronic kidney disease, iron deficiency anemia, 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PRUITTHEALTH — 95 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 2 of 5 | 2.5 | -0.5 vs chain |
| Quality measures | 4 of 5 | 3.6 | +0.4 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
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 / manager | Type | Role | Since |
|---|---|---|---|
| NWP 2020 CHILD TR FBO NEIL L PRUITT JR | Organization | INDIRECT OWNERSHIP INTEREST | since 01/14/2025 |
| PRUITT, NEIL | Individual | INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR | since 11/05/2009 |
| SMALL, PHILIP | Individual | CORPORATE DIRECTOR | since 11/27/2013 |
| PRUITT, NANCY | Individual | CORPORATE OFFICER | since 11/27/2013 |
| PRUITTHEALTH INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 11/05/2009 |
| WESLEY, PATRICK | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/21/2025 |
| PRUITTHEALTH CONSULTING SERVICES INC | Organization | ADP OF THE SNF | since 11/26/2013 |
CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 24% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
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.
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 115647. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-04, 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.