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Pavilion At Brandon Wilde

4275 Owens Road, Evans, GA 30809 · For profit - Limited Liability company · 65 certified beds · (706) 868-9800 Medicare only — no Medicaid

Call the home — (706) 868-9800 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0607) — cited Apr 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — 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 (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
465 N Belair Rd · (706) 854-2222 · Call to confirm hours
Pharmacy
4223 Washington Rd · (706) 869-0937 · Call to confirm hours
Grocery
4272 Washington Rd · (855) 922-0429 · Call to confirm hours
Park
1202 Town Park Ln · (706) 854-6703 · Typically dawn to dusk
Place of worship
1 Islamic Center Dr · (706) 210-5030

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 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 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 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.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased17.0%15.3%15.4%worse
Long-stay residents who lose too much weight2.8%5.6%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.9%0.9%better
Long-stay residents with a urinary tract infection3.2%2.5%2.0%worse
Long-stay residents with depressive symptoms0.5%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury6.2%3.2%3.3%worse
Long-stay residents whose ability to walk worsened20.4%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication18.3%20.5%18.9%typical
Long-stay residents given the seasonal flu vaccine98.4%95.0%95.3%typical
Long-stay residents with pressure ulcers1.9%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control16.7%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.4%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication2.9%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine97.5%78.4%79.4%better
Short-stay residents rehospitalized after admission24.0%25.0%22.6%typical
Short-stay residents with an outpatient ER visit13.7%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.802.151.67worse
Long-stay outpatient ER visits per 1,000 resident days1.961.901.80typical

§ 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.

55.8% 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 98 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.8%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
48.0%U.S. median 56.6%
Met the expected recovery
0.38U.S. median 0.31
Therapy hours / resident / day
0.11hours / resident / day
Physical therapy
0.21hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 48.0% 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 50 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 0.38 therapist hours per resident per day in 2026Q1 — more than 64% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF55.8%CMS range 46.8–64.351.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.0–15.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge48.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge54.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge36.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.4%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.2%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.6%CMS range 4.5–14.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.111.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.13
RN hours/ resident / day
0.94
LPN hours/ resident / day
2.38
Aide hours/ resident / day
4.45
Total nurse hours/ resident / day
0.63
RN hoursweekends
43.6%
Total nursing turnover
55.0%
RN turnover

How full it usually is: this home is certified for 65 beds and averages 62.2 residents a day — about 96% occupied, or roughly 3 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.45 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.13 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.38 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 3.63 hrs/resident/day on weekends vs 4.78 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.34 to 0.63 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 44% 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

8
deficiencies at the latest standard inspection (2026-04-17)
5
at the previous standard inspection (2025-02-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · E2026-04-17 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and policy review, the facility failed to ensure grievances were promptly resolved for five residents (Resident (R) 9) R23, R35, R50, and R61 of 22 sample residents. Specifically, the facility failed to date, summarize findings, and document corrective action taken as a result of the grievance. This failure had the potential to cause further grievances to be unresolved for residents throughout the facility. 1.Review of R23's ) revealed a quarterly Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/13/26 revealed R23's admission date was 08/26/25. R23 had a diagnosis that included kidney insufficiency. R23 had a Brief Interview for Mental Status (BIMS)score of 14 out of 15 which indicated no cognitive impairment. 2.Review of R61's EMR revealed a quarterly ''MDS'' assessment, located under the ''MDS'' tab, with an ARD of 03/23/26 revealed R61's admission date was 12/17/25. R61 had a BIMS score of 9 which indicated moderate cognitive impairment. Active…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-17 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed prior to date of hire for one of seven new hire employees and reference checks were completed for seven of seven new hire employees. The deficient practice could result in a staff with an unknown criminal background having access to residents. 1.Review of employee records for the Administrator revealed he was hired on 12/01/25. The required GCHEXS fingerprint background check was completed on 12/02/25.During an interview on 04/17/26 at 3:42 PM, the Human Resources Director (HRD) stated GCHEXS background checks are completed for all employees except nurses and are required to be completed prior to the start date. The HRD stated the Administrator is not a facility employee but is a corporate employee based out of Iowa. 2.Review of employee records for the Administrator, Assistant Director of Nursing (ADON), Licensed Practical Nurse (LPN) 1, LPN 3, Registered Nurse (RN) 1, Certified Nurse Aide (CNA) 1, and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy, the facility failed to ensure residents were informed of the benefits, risks, and alternatives of treatment prior to initiating psychotropic medication for one (Resident (R) 42) of five residents reviewed for unnecessary medications out of a total sample of 22 residents. This failure increased the risk of residents not knowing the potential side effects of the medications. 1. Review of R42's admission Record located under the Profile tab of the electronic medical record (EMR), revealed R42 was admitted to the facility on [DATE] with diagnoses that included depression, dementia, and anxiety disorder. Review of R42's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/26, located under the MDS tab of the EMR, revealed R42 was unable to complete a Brief Interview for Mental Status (BIMS) and was assessed by staff as severely cognitively impaired. The MDS revealed R42 took antianxiety medications.Review of R42's Medication…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility's policy, the facility failed to convey information to hospital at the time of transfer, failed to notify resident and resident representative in writing of the reason for the transfer/discharge to the hospital, and failed to notify the resident/resident representative of the facility policy for bed hold including reserve bed payment. one of three residents (Resident (R) 7) reviewed for hospitalization out of 22 sampled residents. This failure creates the potential for residents and responsible parties to be misinformed of the transfer out of the facility and to not have the information needed to safeguard their return to the facility. Review of R7's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses that included diastolic (congestive) heart failure (CHF), atrial fibrillation, presence of cardiac pacemaker, and anxiety disorder. Review of R7's annual…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0636 — isolated
    Assess 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

    Based on record review, interview, and facility policy review, the facility failed to ensure the Discharge Return Anticipated Minimum Data Set (MDS) was completed for one of three residents (Resident (R) 7) reviewed for hospitalization out of a total sample of 22 residents. This had the potential to lead to inaccurate goals of care, including functional and health status and strengths and needs of the resident. Findings include:Review of medical record 02/9/26 no evidence of documented transfer notification; einteract transfer or bed hold. 02/9/26 Discharge MDS marked out in error - not completed; 02/10/26 Entry MDS marked out in error - not completeAn interview on 04/17/2026 at 7:16 PM with the Director of Nursing (DON) revealed she was unable to locate transfer notice to hospital, transfer notification to resident/resident representative or bed hold notice. The DON stated a notice of transfer is required to be sent with the resident to the hospital, written notice to the resident representative, and bed hold notice is required to be sent. DON confirmed 2/9/26 Discharge Return…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to ensure the comprehensive assessment accurately reflected a discontinued antipsychotic medication for one (Resident (R) 22) of five residents reviewed for unnecessary medications in the sample of 22 residents. This failure had the potential to lead to a lack of alternative interventions. Review of R22's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R22 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia with behavioral disturbance.Review of R22's monthly Pharmacy Review provided by the facility revealed a pharmacy recommendation to discontinue quetiapine 25 milligrams (mg) one tablet by mouth daily starting on 03/05/26.Review of R22's Medication Administration Record located under the Orders tab of the EMR revealed Seroquel oral tablet 25 milligrams (mg) (quetiapine fumarate) give one tablet by mouth in the evening related to dementia with behavioral…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure a physician's order for oxygen was obtained prior to administering oxygen; ensure appropriate oxygen signage was posted on the resident's door; and ensure respiratory supplies were dated and stored in a sanitary manner in accordance with professional standards for one of one residents (Resident (R) 68) reviewed for respiratory care out of a sample of 22 residents. This failure had the potential to compromise infection control and increase the risk of infection transmission within the facility. Cross Reference F658Findings include:Review of R68's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R68 was admitted on [DATE] with a diagnosis of pneumonitis due to inhalation of food and vomit.Review of R68's Care Plan located under the Care Plan tab of the EMR dated 04/07/26 revealed the resident was not care planned for oxygen.Review of Progress Notes located under…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record reviews, the facility failed to ensure personal resident refrigerators were maintained to prevent potential food borne illness for two residents of two sampled residents (Resident (R)33) and R50) who owned a refrigerator. This failure had the potential to cause the residents to eat spoiled food which could cause a decline in the residents' overall health. Findings include:1.Review of R33's quarterly ''Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab of the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 03/03/26 revealed R33 admission date was 12/29/21. R33 had a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severe cognitive impairment. R33 had a diagnosis that included high blood pressure.During an observation and interview on 04/14/26 at 2:56 PM, R33 had a personal refrigerator near the door in her room. On the outside of the refrigerator door, a Refrigerator Temperature Log was attached to the door. There were no temperatures recorded on 04/11/26 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-02-20 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Dignity, the facility failed to treat residents with dignity for one out of three Residents (R) (R8) observed during dining and for one out of three Residents (R) (262) observed during medication administration. Specifically, the facility failed to ensure R8 received a meal tray at mealtime due to a lack of sufficient dining table space causing R8 to observe other residents eating their meals while waiting for a space to become available and assistance. In addition, the facility failed to ensure R262's blood glucose testing procedure was completed in a private area to protect the resident's dignity. Findings include: Review of the facility's policy titled, Dignity, revised 2/2021, under the Policy Statement revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-bring, level of satisfaction with life, and feelings of self-worth and self-esteem. Under the section…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, record review, and review of the facility's policy titled Administering Oral Medications, the facility failed to ensure care and services were provided in accordance with accepted professional standards for one out of three Residents (R) (R55) observed during medication administration. Specifically, Registered Nurse (RN) (RN#7) withheld R55's physician-ordered medications without consulting with the physician for an order to do so. Findings include: Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, under the section titled Purpose revealed, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy did not address withholding ordered medications. Review of the facility's policy titled, Medication Holds revised 4/2007, under the Policy Statement revealed, Temporary medication holds may be ordered by the resident's attending physician. Review of the admission Record revealed, R55 admitted to the facility with diagnoses that included 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2025-02-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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, staff interviews, record review, and review of the facility's policies titled, Medication Holds and Administering Oral Medications, the facility failed to ensure the medication error rate was less than 5% for two out of Residents (R) (R55 and R29) of three residents observed during medication administration. Observation of medication administration revealed 4 medication errors out of 31 opportunities, which resulted in a medication error rate of 12.9 %. Findings include: Review of the facility's policy titled, Medication Holds, revised 4/2007, revealed under Policy Statement, Temporary medication holds may be ordered by the resident's attending physician. Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, revealed under Purpose, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. The policy revealed under Steps in the Procedure, . 9. Prepare the correct dose of medication: Remove the cap from the bottle and place cap upside down on the work surface. Hold 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility's policy titled, Administering Oral Medications, the facility failed to ensure medications were accurately labeled for one out of three Residents (R) (R55) observed during medication administration. Findings include: Review of the facility's policy titled, Administering Oral Medications, copyrighted in 2001, revealed under Purpose, The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Under Steps in the Procedure, . 6. Check the label on the medication and confirm the medication name and dose with the MAR [Medication Administration Record]. Review of the admission Record revealed R55 had a medical history that included diagnoses of essential hypertension, atrial fibrillation, and heart disease. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/6/2025, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Review of R55's Care…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control Program, the facility failed to ensure infection control practices to prevent the potential spread of infection were maintained during medication administration for residents receiving medications from one of four medication carts observed. The failed practice affected one out of three Residents (R) (R55) observed during medication pass and one out of one (R262) observed receiving a blood glucose check. Specifically, the nurse attempted to remove medications from a medication cup with an ungloved fingernail for R55, placed a glucometer on a bedside table without disinfecting the table or placing a barrier for R262, failed to promptly replace an overflowing sharps container on the medication cart, and had an open personal beverage sitting on top of the cart uncovered throughout the medication pass. These failures had the potential of exposing residents to infections. Findings include: A facility policy titled, Infection Prevention and Control Program,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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 Based on staff interviews, record reviews, and review of the facility's policy titled, Accepting Delivery of Medications, the facility failed to administer medications per physician's orders for one resident (R) (R4). Specifically, the facility failed to ensure that R4 received baclofen (muscle relaxant) and vitamin B12 (water-soluble vitamin) as ordered by the physician. Findings include: Review of the facility's policy titled Accepting Delivery of Medications, dated February 2021, under subtitle, Policy heading revealed 1. All staff should follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the pharmacist and Director of Nursing. Review of R4's admission Record located in the Electronic Medical Record (EMR) under the Profile tab revealed R4 was admitted with a primary diagnosis of cerebral infraction due to unspecified occlusion or stenosis of unspecified vertebral artery. Review of R4's quarterly Minimum Data Set (MDS) with…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-09-17 · tag F0554 — pattern
    Allow 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 observations, resident and staff interviews, record review, and review of the facility's policy titled, Self-Administration of Drugs, the facility failed to assess six of 28 residents (R) R#33, R#53, R#55, R#54, R#20, and R#2 reviewed for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility policy titled Self-Administration of Drugs effective date 12/22/2014 revealed: Intent statement: It is the intent of this facility to permit residents to self-administer their drugs and medications unless such practice for the resident is deemed unsafe. 1. The care planning team should assess each resident's mental, physical, and visual ability to determine if the resident is capable of self-administration of drugs and medications. 2. Should the care planning team determine that the resident is unable to carry…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Urinary Drainage Bag; the facility failed to maintain dignity by ensuring a dignity bag was provided for three residents (R) (R33, R55, and R2) of 28 residents reviewed for an indwelling urinary catheter. Findings include: Review of the policy titled Urinary Drainage Bag dated December 24, 2014, revealed the intent was to provide appropriate care for urinary drainage bags (bedside bag and leg bag) per current standard of care and/or physician order. 1.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section G-Functional Status: documented R33 required extensive to total dependence for activities of daily living (ADL)s; Section H-Bladder and Bowel: documented R33 had an indwelling catheter. Review of R33's care plan revealed resident had an indwelling urinary catheter with interventions that included to provide care of urinary catheter per policy. Review of the physicians' orders revealed an order…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-17 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Care Planning - Comprehensive Preliminary, the facility failed to implement a care plan intervention for one of four residents (R) (R2) reviewed with an urinary catheter. Specifically, the facility failed to ensure the resident's urinary catheter drainage bag was placed in a privacy bag as instructed on the care plan. The sample size was 28 residents. Findings include: Review of the facility policy titled Care Planning - Comprehensive Preliminary with an effective date of 12/18/2014 revealed the intent was for the facility to develop and maintain an individualized plan of care for each resident. The Procedural Guidelines section revealed: 3. The care plan is available for use by all personnel providing care/services to/for the resident. It includes but is not limited to: A. Incorporate identified problem areas; B. Incorporate risk factors(s) associated with the identified problem (s). Observations on 9/15/2023 at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and a review of the facility's policies titled, Administering Medications through a Small Volume (Handheld) Nebulizer, and Oxygen Therapy - Mask And Nasal Cannula the facility failed to ensure oxygen equipment was properly stored while not in use and failed to properly administer and assess resident after nebulizer treatment for four (4) residents (R) (R33, R52,R20, and R26) receiving treatment for respiratory care. The deficient practice had the potential to increase the risk of respiratory complications and infection. The sample size was 28. Findings include: Review of policy titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, Steps in the Procedure: 6. Obtain baseline pulse, respiratory rate and lung sounds. 17. Remain with the resident for the treatment. 18. Approximately five minutes after treatment begins (or sooner if clinical judgement indicates) obtain the resident's pulse. 19. Monitor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-17 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review and review of the facility policy titled Hemodialysis Access Care, the facility failed to ensure communication between the facility and the dialysis center was documented after each dialysis treatment for one of one resident (R) (R 20) reviewed for dialysis care. The sample size was 28 residents. Findings include: Review of the policy titled Hemodialysis Access Care with a revision date of September 2010 revealed in section subtitled Documentation stated: The general medical nurse should document in the residents' medical record every shift as follows: 3. If dialysis was done during shift; 4. Any part of report from dialysis nurse post-dialysis being given. Interview on 9/15/2023 at 10:08 am with R20 revealed she went to off-site dialysis treatment three times per week. Interview on 9/15/2023 at 2:30 pm with R20 revealed she had an off-site dialysis treatment on this date. Review of electronic medical record (EMR) revealed R20 diagnoses included but not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) R45 reviewed for medication management. This failure had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. The sample size was 28 residents. Findings include: Review of clinical records revealed R45 had diagnoses of but not limited to Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder. Review of R45 Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of the physician orders for R45 dated September 2023 revealed an order for lorazepam 0.5 milligram (mg) by mouth every four (4) hours as…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-17 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    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, and review of the facility's policy titled, Lab and Diagnostic Test Result- Clinical Protocol the facility failed to follow a Nurse Practitioner's (NP) order to collect a urine specimen to send to the laboratory for a urinalysis in a timely manner for one resident (R) (R11) of 24 sampled residents. This failure placed the resident at risk for medical complications and delay of treatment. Findings include: Review of the facility's policy titled Lab and Diagnostic Test Result- Clinical Protocol dated 11/2018, under subtitle, Assessment and Recognition revealed: 2. The staff will process test requisitions and arrange for tests. Review of R11's Electronic Medical Record (EMR) revealed R11 diagnoses included but not limited to dehydration, elevated white blood cell count, dysphagia, and oropharyngeal. Review of R11's Quarterly Minimum Data Set (MDS) dated [DATE] assessment revealed Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) of 99 which indicated…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIFE CARE SERVICES — 43 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 54.1-2.1 vs chain
Health inspection 2 of 53.7-1.7 vs chain
Staffing 4 of 54.4-0.4 vs chain
Quality measures 2 of 54.0-2.0 vs chain
The other 42 homes this chain runs (chain average 4.1★, per CMS)
1 of 5Burcham Hills Retirement CenterEast Lansing, MI 1 of 5Cottage Grove PlaceCedar Rapids, IA 2 of 5Casa De Las CampanasSan Diego, CA 2 of 5Linn Manor Care CenterMarion, IA 2 of 5Oakton Place Health And Rehabilitation At The ArliNaples, FL 2 of 5Signature PointeDallas, TX 2 of 5The Stewart Health CenterCharlotte, NC 3 of 5Carillon INCLubbock, TX 3 of 5Friendship Village Of TempeTempe, AZ 3 of 5Westminster Village - West LafayetteWest Lafayette, IN 4 of 5Croasdaile VillageDurham, NC 4 of 5Dallas Retirement Village Health CenterDallas, OR 4 of 5Health Care Ctr At The Forum At Rancho San AntonioCupertino, CA 4 of 5Oaks Health Ctr At The Marshes Of Skidaway IslandSavannah, GA 4 of 5Parkwood VillageBedford, TX 4 of 5The Cedars of Chapel HillChapel Hill, NC 4 of 5Wesley Pines Retirement CommunityLumberton, NC 4 of 5Whitestone a Masonic and Eastern Star CommunityGreensboro, NC 5 of 5Acacia Health CenterPhoenix, AZ 5 of 5Avalon Health Care Center At StoneridgeMystic, CT 5 of 5Briarwood At Timber RidgeIssaquah, WA 5 of 5Chestnut Grn Hlth Ctr BlakehurTowson, MD 5 of 5Cypress Glen Retirement CommunityGreenville, NC 5 of 5Eastcastle Pl Bradford Ter Conv CtrMilwaukee, WI 5 of 5Essex Meadows Health CenterEssex, CT 5 of 5Friendship VillageKalamazoo, MI 5 of 5Green Hills Health Care CenterAmes, IA 5 of 5Greenwood Village SouthGreenwood, IN 5 of 5Hearthwood SNF Senior LivingBartlett, IL 5 of 5MarquetteIndianapolis, IN 5 of 5Premier Place At The GlenviewNaples, FL 5 of 5Radford GreenLincolnshire, IL 5 of 5Residences At Vantage PointColumbia, MD 5 of 5Rolling Green VillageGreenville, SC 5 of 5Somerfield At The HeritageBrentwood, TN 5 of 5Springs At Monarch Landing, TheNaperville, IL 5 of 5Terraces At The ClareChicago, IL 5 of 5The Arbour At Westminster ManorAustin, TX 5 of 5The Birches At Trillium WoodsPlymouth, MN 5 of 5The Preston Health CenterHilton Head Island, SC

Showing 40 of 42; 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 / managerTypeRoleSince
LCS BRANDON WILDE JV LLCOrganizationDIRECT OWNERSHIP INTERESTsince 12/20/2023
LCS BRANDON WILDE HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
LCS CC HOLDINGS INCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2026
LCS HOLDING COMPANY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
LCS LIVING HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2026
LCS LIVING INTERMEDIATE I LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2026
LCS LIVING INTERMEDIATE II LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2026
LCS LIVING LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 05/01/2026
LCS MANAGEMENT HOLDING COMPANY LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2025
LIFE CARE COMPANIES LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
LIFE CARE SERVICES COMMUNITIES LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
MCCARTHY GROUP LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
MPM SENIOR LIVING INVESTORS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
OAK INVESTMENT TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
OAK INVESTMENT TRUST IIOrganizationINDIRECT OWNERSHIP INTERESTsince 01/01/2025
RCI LEGACY HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
REDWOOD HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 12/20/2023
BANK OF AMERICA CORPOrganization5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTERESTsince 01/01/2025
BIRD, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/20/2023
LAHEY, DANIELIndividualCORPORATE OFFICERsince 01/01/2025
SHAW, GELYNNAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025
VICTOR, JASONIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/20/2023
LIFE CARE SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/18/2025
LEGENDARY, ZECHARIAHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/28/2026
PULLIAM, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/19/2025
PURSLEY, GEORGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2026
UHLEMANN, BRIDGETTEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2025

CMS files one row per role, so the 34 rows in the source record cover these 27 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.

19 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.

$11.1M
Net patient revenuemost recent cost report
-126.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 6%Other / private 94%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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

$591per resident / day
operating cost
$17,955per month
≈ monthly operating cost
$260per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Georgia Medicaid page for homes that do.

Typical monthly cost in Georgia
$8,821/mo
Nursing home (semi-private)
$9,429/mo
Nursing home (private)
$5,300/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115524. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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