Parkside Center For Nursing And Rehab At Ellijay
1362 South Main Street, Ellijay, GA 30540 · For profit - Limited Liability company · 110 certified beds · (706) 635-7881 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has 3 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 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 improved from 1 to 4 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 | 19.2% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.3% | 5.6% | 5.4% | worse |
| 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 | 2.1% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.3% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 29.9% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 9.8% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.5% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 4.3% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 80.4% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 21.1% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.19 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.48 | 1.90 | 1.80 | better |
§ 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.
5.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse 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.
Met the expected recovery: 69.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 197 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 0.55 therapist hours per resident per day in 2026Q1 — more than 85% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 35% 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
| 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 | 5.6%CMS range 3.5–9.4 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 8.3–13.5 | 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 | 69.5% | 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 | 60.4% | 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 | 65.0% | 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 | 98.3% | 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 | 90.2% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | 90.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.7% | 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 | 0.0% | 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 | 7.3%CMS range 5.1–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.30 | 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 110 beds and averages 104.4 residents a day — about 95% occupied, or roughly 6 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 3.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.91 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.26 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.33 hrs/resident/day on weekends vs 4.16 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.98 to 0.74 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% 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.
25 citations, most serious first. The 13 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2023-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the policy titled Comprehensive Care Plans, the facility failed to implement appropriate interventions on the care plan for two of 45 sampled residents (R) (R#39 and R#20) related to (1) pain management during wound care for R#39 resulting in harm; and (2) assessment of the arteriovenous fistula (AVF) access site after dialysis treatment for R#20. Findings included: A review of the policy titled Comprehensive Care Plans, dated March 2023 revealed the policy was to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy explanation and Compliance Guidelines revealed line numbered: The comprehensive care plan will describe, at a minimum, the following: a. The services that are…
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.
- Actual harm · G2023-04-30 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to develop, and implement a plan related to effective communication goals for one of 45 sampled residents (R) (R#55) as it relates to provide care and services for activities of daily living as it related to communication and offering a functional communication system. This failure resulted in psychosocial harm related to R#55 experiencing emotional distress, crying often, and frustrated when she was not able to communicate daily needs with facility staff. Findings included: A review of the clinical record revealed that R#55 was admitted to the facility on [DATE] with a diagnosis of Cerebral Vascular Accident (CVA). A review of the quarterly Minimum Data Set, dated [DATE] revealed R#55 had a Brief Interview for Mental Status score of 15, indicating intact cognition; requires extensive 2+ person assistance with all Activities of Daily Living; and that R#55 receives an antidepressant seven out of seven days per week. A review of the care plan…
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.
- Actual harm · G2023-04-30 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, interview, and review of facility policy Pain Management the facility failed to stop and address verbal expression of pain during wound care for one of three residents (R) (R#39) observed for wound care. The facility staff failed to recognize the need for modified approaches/interventions when R#39 experienced severe pain during wound care treatment resulting in harm for R#39. Findings included: Policy titled Pain Management revised on 1/24/23 revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Pain Assessment: 2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: g. Identifying activities,…
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 · D2026-03-05 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 Administration of Insulin, the facility failed to ensure professional standards were followed when preparing and administering insulin for one of 17 residents (R) (R142) receiving insulin from a pen device. The deficient practice had the potential to result in the resident receiving an incomplete insulin dose, which could lead to ineffective blood glucose control, and adverse clinical outcomes.Findings include:Review of the facility's policy titled Administration of Insulin, updated 03/04/2026, revealed the Policy section documented: 6. Insulin pens will be primed prior to each use to avoid collection of air in the insulin reservoir. h. Prime the insulin pen: i. Dial 2 units by turning the dose selector clockwise. ii. With the needle pointing up, push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. j. Injecting 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 · D2026-03-05 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that oxygen (O2) therapy was administered according to physician's orders for one of 17 residents (R) (R69) receiving oxygen. The deficient practice had the potential to place R69 at risk for respiratory complications, adverse clinical outcomes, and diminished quality of life.Findings include:Review of the facility's undated policy titled Oxygen Administration, last reviewed 1/2025, under Policy section documented: 1. Oxygen is administered under orders of a physician. 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LPNs, and respiratory therapists.Review of the electronic medical record (EMR) revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to pneumonia, pleural effusion, acute respiratory failure, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF).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.
- Potential for harm · D2026-03-05 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review, staff interviews, and review of the facility's policy titled Medication Administration, the facility failed to ensure a medication error rate of less than five percent. Two medication errors were identified out of 31 opportunities observed, resulting in a medication error rate of 6.45 percent. This deficient practice had the potential to place resident (R) (R123) at risk for medical complications and a diminished quality of life.Findings include:Review of the facility's policy titled Medication Administration, updated 5/2022, revealed the Policy section documented: Ensure that the six rights of medication administration are followed: .c. Right dosage. e. Right time. 12. Compare the medication source (bubble pack, vial, etc.) with the EMAR to verify resident name, medication name, form, dose, route, and time.Licensed Practical Nurse (LPN) DD was observed administering 9:00 AM medications to Resident (R)123 on 03/04/2025 at 9:50 AM. She removed the medications from the source and placed them into a medication cup (aspirin, Orgovyx, tamsulosin HCl…
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 · D2026-03-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 Medication Administration, the facility failed to ensure that one of six residents (R) (R140) reviewed for medication administration was free from significant medication errors. Specifically, the facility failed to ensure medications were administered to the correct resident, resulting in R140 receiving medications intended for another resident. This deficient practice had the potential to place the resident at risk for adverse drug reactions, medication side effects, and adverse clinical outcomes.Findings include:Review of the facility's policy titled Medication Administration, updated 5/2022, documented Policy Explanation and Compliance Guidelines: .3. Identify resident by photo in the MAR (Medication Administration Record).10. Ensure that the six rights of medication administration are followed: a. Right resident; b. Right drug; c. Right dose; d. Right route; e. Right time; f. Right documentation.12. Compare 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 · Dcited before2026-03-05 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, staff interviews, and review of the facility's policies titled Enhanced Barrier Precautions and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently implement enhanced barrier precautions (EBP) and sanitize shared medical equipment (blood pressure machine and glucometer) between resident uses in four of 13 medication administration observations. This deficient practice had the potential to expose residents to harmful pathogens, increasing the risk of cross contamination, and spread of infections.Findings include:Review of the facility policy titled Cleaning and Disinfection of Resident-Care Equipment, reviewed 01/06/2026, documented in the Policy section: 3. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include:.b. Each user is responsible for routine cleaning and disinfection of multi-resident items [NAME] each use, particularly before use for another…
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 · D2025-01-31 · tag F0623 — isolatedProvide 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, resident and staff interview, and facility policy review, the facility failed to ensure three of five residents (Resident (R) 8, R18, and R91) and/or their resident representatives (RR) out of a sample of 23 residents 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 residents and their RRs 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 facility's undated policy titled, Transfer and Discharge (including [against medical advice] AMA) revealed the following (12) e. provide orientation for transfer or discharge to minimize anxiety and to ensure safe and orderly transfer or discharge, in a form or manner that the resident can understand .(h) the Social Services Director, or designee, will provide copies of notices for emergency transfers to 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 · Dcited before2025-01-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to complete the comprehensive care plan to include the use of oxygen for one of 23 sample residents (Resident (R) 20) reviewed for care planning. The failure had the potential for R20's medical, nursing, mental, and psychosocial needs not being met. Findings include: Review of the facility's policy titled, Comprehensive Care Plans, indicated .develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/24 and located in the electronic medical record (EMR) under the MDS tab, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident…
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 · D2025-01-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure medications were received in a manner that allowed administration for one of one resident (Resident (R) 91) reviewed for medication administration of 23 sample residents. This failure has the potential to cause R91 not to receive the therapeutic benefits of their prescribed medications. Findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 10/01/19, revealed (1) medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. Review of the facility's policy titled, Pharmacy Services, dated 2024, under the Compliance Guidelines section revealed the following (1). the facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state 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.
- Potential for harm · Dcited before2025-01-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to identify target behaviors for monitoring effectiveness of antipsychotic medication for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 23 sample residents. This failure had the potential to contribute to unnecessary antipsychotic medication use in R48 who used the medication to treat behavioral symptoms of anxiety. Findings include: Review of the facility's undated policy titled, Use of Psychotropic Medication, revealed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documented of the resident response to the medication. 4. The indication for use of any psychotropic drug will be documented in the medical record. Review of R48's undated admission Record located in 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 · F2024-03-07 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, staff interviews, and record review, the facility failed to hire qualified dietary staff certified to serve food in a clean, safe and sanitary manner. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: Interview on 3/06/2024 at 10:36 am with the Food Service Director revealed he did not know about two essential areas needed to keep residents safe from foodborne illnesses, the appropriate dish machine temperatures to ensure clean, sanitized dishes and utensils, or the safe holding temperature for meals served to residents on their trays. Review of the Food Service Director's employee file revealed no certification for Certified Dietary Manager (CDM) or safe food handling card. His title was Food Service Director and did not claim to be a CDM. He corrected the surveyor twice when called CDM. Interview on 3/7/2024 at 10:54 am with the Human Resource Director revealed the Food Service Director does not have a CDM certificate or safe food handling card.
Show the remaining 12 citations
- Potential for harm · F2024-03-07 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, and record review, the facility failed to serve the appropriate quantities of food according to the prescribed dietary recipe. The deficient practice had the potential for malnutrition and could affect 84 of 85 residents receiving an oral diet from the kitchen. Findings Include: Observation on 3/5/2024 from 11:46 pm to 12:02 pm, the Dietary [NAME] placed chicken and dumplings, and peas on two resident's plates using a 3-ounce (oz) sized ladle for the chicken and dumplings. When asked about the size of the serving ladle, the Dietary [NAME] immediately grabbed a 4 oz ladle. She stated that the 4 oz ladle will be used to serve the meal/meat, then the 3 oz ladle will be used to fill the bowl with just the liquid. The Dietary [NAME] added This is how the chicken and dumplings are served. Review of the chicken and dumplings recipe dated 10/24/2023 revealed the serving utensil sizes as Spoon & 6 oz ladle. Interview on 3/6/2024 at 12:24 pm with the facility's Registered Dietician (RD) revealed that food service staff are required 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.
- Potential for harm · Fcited before2024-03-07 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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, resident and staff and complainant interviews, and record reviews, and review of the facility policy titled, Temperature for Food Safety, the facility failed to serve food that is palatable, attractive and at required temperatures. The deficient practice had the potential to affect 84 of 85 residents utilizing dining services. Findings Include: Review of the facility policy titled Temperature for Food Safety dated 3/6/2024 indicated 135 [degrees] F [Fahrenheit] minimum temperature for holding hot food. Danger Zone 41 [degrees] -135 [degrees] F Rapid Bacteria Growth Zone. On 3/4/2024 at 5:15 pm, a test tray of Monday's menu Week 4 Dinner was served to this Surveyor, which included stuffed cabbage soup, roast beef sandwich, carrot raisin salad, and mixed melon salad. The stuffed cabbage was flavorless and not edible. The roast beef sandwich was served with just meat and cheese, no lettuce, tomato, onions, etc. The mixed melon salad only contained cantaloupe that appeared to have been frozen and thawed or was fresh and was going bad. The cantaloupe was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-03-07 · tag F0806 — failed to honor food preferences — widespreadEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, and record review, the facility failed to serve residents their preferences and alternative meals. The deficient practice had the potential to affect 84 of 85 residents receiving meals from the kitchen. Findings include: During the initial tour on 3/4/2024, multiple residents complained that their food choices were not honored. Interview on 3/4/2024 at 9:14 am with anonymous resident (A) (A5) revealed that the food is okay, but she prefers raw fruit and vegetables like avocados. Interview on 3/4/2024 at 9:28 am with A6 revealed they do not serve fresh fruit or veggies. Interview on 3/4/2024 with A7 revealed that the meat is too tough like the pork shops, steak, and hamburgers, and would like more veggies. Sliced apples in a packet are the only fresh fruit we receive. Interview on 3/4/2024 with A2 revealed that the only fruit usually served is canned fruit, but they do serve fresh sliced oranges or apples. Interview on 3/5/2024 at 8:33 am with A4 revealed he requested that Dietary not to serve him boiled eggs (on at least fifteen…
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 · F2024-03-07 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and record reviews, the facility failed to recognize the dish machine was malfunctioning and producing temperatures too low to kill bacteria and germs for the last 10 months. The potential for foodborne illnesses could affect 84 of 85 residents. Findings include: The facility had no policy for the required temperatures for the dishwashing machine. Review of the Resident Council Minute/Grievance dated 6/21/2023 showed various complaints as follows Residents continue to voice that coffee cups are dirty and Numerous residents report hair being found in their food. Observation and interview on 3/6/2024 at 10:24 am with the Food Services Director, the Food Service Director found dirty utensils in a pile of clean, ready to use silverware. The silverware contained caked on debris that the Food Service Manager was able to flick off or remove with his fingernails. This led to the discovery that the dish machine was not working properly. The Food Service Director revealed that he looked at the temperature logs once a week or maybe once every two weeks.…
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 before2023-04-30 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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 observation, staff interviews, and recipe review, the facility failed to ensure puree recipes were followed to conserve nutrient value of puree vegetable and puree chicken strips for six of six resident receiving puree consistency. Findings included: A review of the recipe for Puree Vegetable Medley revealed that the recipe yielded 20 servings. Ingredients included vegetable medley, water, butter, salt, vegetable seasoning. A review of the recipe for Puree Chicken Fingers revealed that the recipe yielded 5 servings. Chicken fingers 10 pieces, hot water 3/4 cup, and chicken base 1 tablespoon. Observation on 4/29/23 at 11:10 a.m. of Dietary [NAME] AA complete puree food items for lunch meal revealed no recipes were used, reviewed, or available for reference. Dietary [NAME] AA placed an unmeasured amount of cooked vegetable medley in the food processor and pureed. Dietary [NAME] AA then added an unmeasured amount of vegetable broth two different times to achieve proper puree consistency. An interview on 4/29/23 at 11:10 a.m. with Dietary [NAME] AA during observation, he…
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 · F2023-04-30 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 policy review the facility failed to ensure the pipes to the fire suppression system under exhaust hood were clean and free from grease build-up; failed to ensure pans were stored dry to prevent wet nesting; failed to proper store foods in dry storage area; failed to ensure label, date, and securely wrap opened food items in the kitchen and resident nourishment room; failed to ensure kitchen equipment was properly cleaned to prevent cross contamination; failed to ensure food spills were cleaned from walls; and failed to ensure dietary staff wore hair restraint while in the kitchen. This had the potential to affect 90 residents receiving an oral diet. Findings included: 1. An observation on 4/28/23 at 8:50 a.m. of the pipes to the fire suppression system under the exhaust hood revealed they were coated with a heavy layer of grease. Suspended collection of grease was noted attached to the pipe directly under the fryer. An observation on 4/30/23 at 11:10 a.m. of the pipes under the exhaust hood continued to be coated with a heavy layer 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.
- Potential for harm · F2023-04-30 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews the facility failed to ensure that the dumpsters doors/lids were closed at all times and failed to ensure the area surrounding the dumpsters was free from trash debris. This had the potential to affect all 91 residents in the facility. Findings included: An observation on 4/29/23 at 8:40 a.m. of the dumpster area revealed that the facility had three large dumpsters located at the back of the building. The dumpsters were sitting on concrete and a concrete retaining wall was to one side. Continued observation revealed the dumpster closest to the retaining wall, both side doors were wide open exposing trash contents inside. Further observation revealed a white 50-gallon round trash can next to a dumpster with no lid, exposing the inside which consisted of several trash bags as well as an empty eight-ounce carton of milk and an empty individual cereal bowl of mini-wheats. The ground around the dumpsters had several pieces of trash such as plastic spoons, paper masks, blue latex gloves, and pieces of paper. During an interview on 4/29/23 at 8:40…
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 before2023-04-30 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility (1) failed to ensure proper infection control practices during wound care for two of three residents (R) (R#39 and R#86); (2) failed to ensure staff wore Personal Protective Equipment (PPE) into Transmission Based Precaution (TBP) rooms and that appropriate signage was on the door for two of three residents (R#5 and R#9) on TBP; and (3) failed to develop an updated water management program plan for the prevention of Legionella for 91 of 91 residents in the building. Findings included: 1. A review of the facility policy titled Clean Dressing Change, undated, revealed it is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. if the table is soiled,…
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 · E2023-04-30 · tag F0655 — patternCreate 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 interviews, record review, and a review of facility's policy titled, Baseline Care Plan, the facility failed to develop a 48-hour base line care plan for 16 of 45 sampled residents (R) (R#48, R#241, R#242, R#192, R#49, R#246, R#87, R#240, R#68, R#195, R#340, R#342, R#245, R#341, R#244, and R#247). Finding included: A review of the facility's document titled Basic Care Plan revised 12/2/22 and implemented 9/19/22 states the facility's policy interpretation and implementation include the following: The baseline care plan will be developed within 48 hours of the resident's admission. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed 1. A review of the admission Record for R#48, located in the electronic medical record (EMR), revealed the resident was admitted on [DATE] with diagnoses that included metabolic encephalopathy, acute vulvitis, atherosclerosis of native arteries, venous thrombosis and embolism, peripheral vascular disease and muscle wasting, dementia,…
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 · E2023-04-30 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility policy titled, Nutritional Management, the facility failed to complete a Comprehensive Nutritional Assessment for nine of 45 sampled residents (R) (R#86, R#20, R#10, R#70, R#77, R#25, R#192, R#38, and R#16). Findings included: A review of the facility policy, Nutritional Management, revised 4/1/23, revealed a comprehensive nutritional assessment would be completed by a dietician within 72 hours of admission, annually, quarterly, and upon a significant change in condition. Follow-up assessments would be completed as needed. 1. A review of the clinical record revealed that R#86 was an [AGE] year-old male admitted on [DATE] with diagnoses including acute kidney failure, pressure ulcer of left heel, muscle weakness and age-related physical debility. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#86 presented with Brief Interview for Mental Status (BIMS) score of 15; indicating that the resident was cognitively…
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 · D2023-04-30 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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 observations, resident and staff interviews, record review, and review of the policy titled Hemodialysis, the facility failed to ensure that one of two residents (R) (R#20) receiving dialysis treatment received care and services consistent with professional standards of practice related to assessing the arteriovenous fistula (AVF) access site and documenting findings daily and after dialysis treatments and providing documented communication between the facility and the dialysis center before and after dialysis appointments. Findings included: A review of the policy titled Hemodialysis dated 1/1/21 and revised 3/24/23 revealed the purpose was to assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing communication and collaboration…
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 before2023-04-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, record review, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for as-needed (PRN) psychotropic medications for one of five residents (R) (R#41) reviewed for unnecessary medications. Findings included: A review of the facility policy, Use of Psychotropic Medication, revealed if an attending physician or prescribing practitioner believed it was appropriate for an as-needed (PRN) psychotropic medication order to be extended beyond 14 days, they would document their rationale in the resident's medical record and indicate the duration for the PRN order. A review of the physician orders for R#41, dated 2/17/23, revealed the physician ordered Klonopin 0.5 mg, one tablet by mouth twice a day, as needed for agitation. The order had no stop date. A review of the Monthly Administration Record (MAR) revealed R#41 received Klonopin, 0.5 mg by mouth, on the following dates and times: A review of the MAR revealed R#41 was administered klonopin 0.5 mg by mouth on 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.
“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 MICHAEL FEIST — 7 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 | 3 of 5 | 3.6 | -0.6 vs chain |
| Health inspection | 3 of 5 | 3.1 | -0.1 vs chain |
| Staffing | 3 of 5 | 3.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 4.3 | -0.3 vs chain |
The other 6 homes this chain runs (chain average 3.6★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PARKSIDE HOLDING COMPANY LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 01/16/2019 |
| FEIST, MICHAEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/16/2019 |
| JACOBOWITZ, KALMAN | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 01/16/2019 |
| MERMELSTEIN, HOWARD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/16/2019 |
| FROMM, STEFAN | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/01/2023 |
CMS files one row per role, so the 8 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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 115683. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.