Fayetteville Center For Nursing & Healing LLC
110 Brandywine Boulevard, Fayetteville, GA 30214 · For profit - Limited Liability company · 162 certified beds · (770) 461-2928 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,171 in federal fines (most recent 2023-11-09)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.4% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.3% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.8% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.4% | 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 | 0.8% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.6% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.5% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 83.0% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 5.1% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 2.8% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.0% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 59.1% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.6% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 3.48 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.79 | 1.90 | 1.80 | typical |
§ 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.
50.2% 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 179 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 50.5% 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 97 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 0.37 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 10% 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 | 50.2%CMS range 42.6–57.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.8%CMS range 9.6–16.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 50.5% | 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 | 54.6% | 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 | 51.5% | 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 | 99.6% | 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 | 100.0% | 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 | 100.0% | 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 | 0.8% | 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 | 3.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 9.8%CMS range 7.1–14.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 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 162 beds and averages 139.2 residents a day — about 86% occupied, or roughly 23 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 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.96 hrs/resident/day on weekends vs 3.60 on weekdays — 18% thinner on weekends. RN hours go from 0.34 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.
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.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · G2023-11-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY AMENDED 11/30/2023 Based on staff interviews, record review, and review of the facility policy titled, Pressure Injury Prevention and Management the facility failed to identify and treat a pressure wound for one of five sampled residents (R) (R1) reviewed for pressure ulcer prevention and treatment. Harm was identified to occur on 7/29/2023 when the facility failed to identify and treat the wound resulting in the resident being sent out to the hospital for diagnosis of septic shock due to an infected sacral decubitus wound with bacteremia and requiring surgical debridement of the wound. Findings included: A review of the facility's policy titled, Pressure Injury Prevention and Management with a revision dated of February 2023, indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-11-19 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, family and staff interviews, and review of the facility policy titled Notification of Changes, the facility failed to notify the physician and Responsible Party (RP)/family of a fall of one of seven Residents (R) (R7) reviewed for notification of change.Findings include:Review of the facility policy titled Notification of Changes, reviewed/revised date of January 2024, revealed: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative (consistent with their authority) when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents. Review of the admission Record for R7 revealed 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 · D2025-11-19 · tag F0585 — failed to handle grievances — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record reviews, and review of the facility policies titled Resident and Family Grievances, and Resident Personal Belongings, the facility failed to make a prompt effort to file a grievance for one of nineteen sampled residents (R) (R8) who's family/responsible party (RP) reported both a written and verbal grievance. This deficient practice had the potential to place residents at risk of not having their grievances resolved in a timely manner. Findings include: Review of the policy titled Resident and Family Grievances, with a reviewed/revised date of 12/2024, revealed: Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. 10. Procedure:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 family and staff interviews, record reviews, observations, and the facility policies titled Abuse, Neglect and Exploitation, and Safe Resident Handling/Transfer, the facility failed to protect two out of five Residents (R) (R7 and R16) by neglecting to use the designated mechanical lift to transfer the residents. Specifically, Licensed Practical Nurse (LPN) III and Certified Nursing Assistant (CNA) DDDD attempted to transfer R7 from the floor to the bed by his legs and his neck. During this improper transfer from the floor to the bed CNA DDDD lost control and dropped R7, causing his head to hit the floor. The facility allowed the LPN III and CNA DDDD to continue working with the vulnerable residents for an additional 15 days. CNA EEEE transferred R16 from the bed to the chair without using the required mechanical lift, causing a laceration to R16's right great toe. The neglect had the potential to affect fifty residents who require a mechanical lift for transfer. Findings include:A review of the policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-19 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 reviews, family and staff interviews, text messages, and the facility policies titled Bed Hold Prior To Transfer, EXHIBIT B Bed Hold Policy, and the Immediate Discharge Notice the facility failed to permit one of three Residents (R) (R7) to return to the facility after being sent to the hospital emergency room. The facility also denied R7's family from entering the building to obtain the resident's personal belongings. This deficient practice had the potential to place the residents who are sent to the hospital in an unsafe and unsuitable situation and cause stress and harm to the residents.Findings include:Review of the policy titled Bed Hold Prior To Transfer, with a reviewed/revised date of March 2025, revealed: Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices at the time of a transfer for hospitalization. Policy Explanation and Compliance Guidelines: 2. In the event of an emergency transfer…
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 before2025-11-19 · 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 staff interviews, record reviews, the facility policy titled Comprehensive Care Plans, and the Charge Nurse Job Description, the facility failed to implement the care plan interventions for mechanical lift with two staff assistants for transfers for two Residents (R) (R7 and R16). In addition, the facility failed to implement fall mats and update R7's care plan after an incident and an accident.Findings include: A review of the policy titled Comprehensive Care Plans, reviewed/revised date of March 2025. Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Policy Explanation and Compliance Guidelines: 5. The comprehensive care plan will be reviewed 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 · D2025-11-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on family and staff interviews, record reviews, observations, and the facility policy titled Safe Resident Handling/Transfer, the facility failed to provide appropriate interventions while transferring two of five residents (R) (R7 and R16), reviewed for mechanical lift transfers. Findings include:A review of the policy titled Safe Resident Handling/Transfer, reviewed/revised date of March 2025. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual Lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical Lifts are a safer alternative and should be used. Compliance Guidelines: 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. 1. Review of the admission Record for R7 revealed a diagnosis of, but not limited to bilateral rotator cuff injuries, cerebral infarction, 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 · D2025-11-19 · 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 record review, staff interviews, and review of the facility policy titled Oxygen Administration, the facility failed to obtain a physician's order for oxygen use, including the frequency of use and flow rate, and an order for a continuous positive airway pressure (CPAP) for one of four sampled resident (R) (R8) of four sampled residents. This deficient practice had the potential to place R8 at increased risk for respiratory complications.Findings include:Review of the policy titled Oxygen Administration reviewed/revised date 12/2025. Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician. Types of delivery systems include: a. Nasal Cannula. d. CPAP Mask - This mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of the facility policy titled Medication Administration, the facility failed to assess three of 73 sampled residents (R) (R51, R482, and R456) for self-administration of medication. This deficient practice had the potential to place R51, R482, and R456 at risk of unsafe medication use and unauthorized medication access by other residents. Findings include: Review of facility's policy titled Medication Administration indicated under Practice Standards: . 8. Medication Administration. 8.1 Assist patient as needed. 8.2 Remain with patient until administration is complete. Do not leave medication at the patient's bedside. 1. Review of the electronic health record (EHR) for R51 revealed the resident was admitted to the facility with diagnoses including but not limited to cerebral infarction, type 2 diabetes mellitus without complications, chronic diastolic congestive heart failure, bronchiectasis (uncomplicated), generalized muscle…
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 before2025-06-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive, person-centered care plan for one of 73 sampled residents (R) (R101). The deficient practice had the potential to place R101 at risk of unmet needs, medical complications, and a diminished quality of life. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated October 2022, revealed under Policy Statement: The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered be considered in developing the care plan. Review of R101's admission record from 9/17/2024 revealed the resident had diagnoses including, but not limited to, bipolar disorder, post-traumatic stress disorder (PTSD), and hyperlipidemia. Review of R101's Minimum Data Set (MDS) assessment, dated 3/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 01…
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 · D2025-06-13 · 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 observation, staff interviews, record review, and review of the facility's policies titled Medication Administration and Unavailable Medications, the facility failed to ensure that two of five residents (R) (R452 and R580) reviewed for medication administration received medications as ordered by the physician. Specifically, the facility failed to ensure R452 received ordered intravenous (I.V.) antibiotics, oral antibiotics, insulin injections, and oral diabetic medications after admission to the facility, and failed to ensure that R580's anti-hypertensive medications were administered as ordered by the physician. Findings include: Review of the facility's undated policy titled Medication Administration revealed under the Purpose of the Policy To provide a safe, effective medication administration process 4. Medications will be administered as soon as possible, but no more than two hours after doses are prepared. 5. Doses will be administered within one hour of the prescribed time unless otherwise…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2025-06-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure medications were not available for use past their expiration date and were stored in the original container on two of seven medication carts (Hall 900 and Hall 800). These deficient practices created the potential for residents to receive medications with altered effectiveness. Findings include: Review of the facility's policy titled Medication Storage, revised December 2022, revealed under Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments) i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .6. Refrigerated Products: a. All medications…
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 · D2025-06-13 · 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
Based on observations, staff interviews, record review, and review of the facility's policies titled Handwashing/Hand Hygiene and Cleaning and Disinfection of Resident-Care Equipment, the facility failed to consistently perform hand hygiene during two of four medication pass observations and failed to sanitize shared medical equipment between residents during one of four medication pass observations. This failure had the potential to increase the risk of infection transmission among staff and residents. Findings include: Review of the undated facility policy titled, Handwashing/Hand Hygiene revealed the Policy Interpretation and Implementation section included . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap(antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . l. After contact with objects (eg., medical equipment) in the immediate vicinity of the resident . Review of the undated facility policy titled Cleaning 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 before2024-02-01 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Medication Administration, the facility failed to assess for the ability to self-administer medications prior to leaving medications at the bedside for one of 42 sampled residents (R) (R118). 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's policy titled Medication Administration revised January 2023 indicated the following: Policy Explanation and Compliance Guidelines: 15. Observe resident consumption of medication if resident requests meds to be left at bedside, confirm cognition prior to. Review of the medical record for R118 revealed diagnoses including but not limited to secondary malignant neoplasm of bone cancer, spinal stenosis thoracic region, other hydronephrosis, hypercalcemia, personal history of other disease of the digestive system, long-term use of opiate…
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 · D2024-02-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the Medication Administration Record (MAR) documentation was completed for one of 42 sampled residents (R) (R31). Findings include: Review of the policy titled Medication Administration dated January 2023 revealed the policy was: Medication is administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section revealed: 17. Sign MAR after administered. For those meds requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign the narcotic book. Review of diagnoses for R31 included, but not limited to, chronic pain syndrome. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to complete a thorough investigation for one of three sampled residents (R) (R25) reviewed for misappropriation of personal property. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, revision date 9/8/2022, revealed An immediate investigation is warranted when suspicion of abuse, neglect or exploitation or reports of abuse neglect or exploitation occur . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation. A review of R25's admission Record revealed a diagnosis that included chronic pain syndrome. A review of R25's Order Summary Report, dated 5/11/2023, revealed an order for Fentanyl Transdermal Patch 72 hour 25 micrograms (MCG)/ hour (HR) (Fentanyl) apply one packet transdermal every 72 hours for chronic pain. A review…
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 before2023-11-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled, Notification of Changes the facility failed to provide care and treatment according to professional standards for two of 33 sampled residents related to (1) failing to notify the physician when a resident's blood pressure was out of range for R10; and (2) failing to follow physician's orders to obtain a urinalysis for R32. Findings included: A review of the facility's policy titled, Notification of Changes, revision date of January 2023, indicated, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident' s physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. 1. A review of Resident (R) 10's admission Record revealed admission diagnoses that included chronic kidney disease and type two diabetes without complications. A review of R10's care plan, revision date 4/11/2023, revealed R1 has a history…
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 · D2023-11-09 · 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 Based on staff interviews, record review and review of the facility pharmacy manual titled, Medication Ordering and Receiving from Pharmacy the facility failed to follow the procedure for medications received from the pharmacy for one of three residents (R) (R25) reviewed for misappropriation of personal property. Findings included: A review of the facility pharmacy manual titled, Medication Ordering and Receiving from Pharmacy, revision date January 2018, revealed Upon arrival at the facility, the [courier/driver] delivers the medication directly to a licensed nurse, facility representative or to an Automated Dispensing System (ADS). The pharmacy provides a method such as a manifest, for both parties to confirm delivery and receipt of all items. The nurse receiving the delivery provides a written or electronic signature to the [courier/driver] as proof of delivery, or in the case of delivery to and ADS, an electronic receipt is generated. A review of R25's admission Record revealed a diagnosis that included…
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 · D2023-11-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Medication Errors the facility failed to maintain a medication error rate of less than five percent (%). There were three errors made in 25 opportunities, resulting in a medication error rate of 12.0 %. These errors affected three out of four residents (Resident 31, Resident 32, and Resident 33) observed during medications pass. Findings included: A review of the facility's policy titled, Medication Errors, with a revision date of February 2023, indicated, The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. 1. A review of the admission Record for R31 revealed admission diagnoses that included acute respiratory failure, and chronic obstructive pulmonary disease. A review of the quarterly Minimum Data Set (MDS) assessment, dated 9/19/2023, indicated R31 had a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive…
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 before2022-04-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy Change in a Resident's Condition or Status, the facility failed to notify the physician of an accident sustained by one resident (R) (R#78) of three residents investigated for accidents. Findings include: A review of facility policy titled, Change in a Resident's Condition or Status, revised June 2013, revealed, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: 1. An accident or incident involving the resident. A review of R#78's admission Record revealed the facility admitted the resident with diagnoses of rheumatoid arthritis, osteoarthritis, diabetes mellitus II, venous insufficiency, obesity, and edema. The admission Record revealed R#78 was their own responsible party (RP). A review of R#78's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.…
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 · D2022-04-01 · tag F0655 — isolatedCreate 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
Based on interview, record review, and review of facility policy Policy: Baseline Care Plan, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one resident (R) (R#135) of three residents reviewed for a closed record review. Findings include: A review of the undated facility policy titled, Policy: Baseline Care Plan, revealed, The baseline care plan will: a. Be developed within 48 hours of a resident's admission. A review of an admission Record revealed the facility admitted R#135 on 1/4/22 with diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, chronic kidney disease stage III, atrial fibrillation, atherosclerotic heart disease, acute bronchospasm, and cardiogenic shock. A review of R#135's electronic medical record (EMR) revealed there was no baseline care plan for the resident. During an interview on 3/30/22 at 11:38 a.m., Minimum Data Set (MDS) Licensed Practical Nurse (LPN) MM confirmed the baseline care plan was not done for R#135. MDS LPN MM stated the baseline care plan should be created…
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 before2022-04-01 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 Medication Orders policy, the facility failed to follow physician's orders for over the counter (OTC) moisturizer for one resident (R) (R#29) of 44 residents reviewed for physician's orders. Findings include: A review of the Medication Orders policy, undated, revealed, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. When recording treatment orders, specify the treatment, frequency and duration of the treatment. A review of R#29's admission Record, revealed the facility admitted the resident with diagnoses of cerebrovascular disease (CVD), diabetes II, hemiplegia/paresis following cerebrovascular disease, major depressive disorder (MDD), and epilepsy. A review of R#29's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS revealed the resident required…
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 · D2022-04-01 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide 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 record review, interviews, and facility policy review, the facility failed to weigh a resident upon admission or weekly for one resident (R) (R#140) from a total of five residents reviewed for nutrition. Findings include: A review of a facility undated, Weight Policy indicated, Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter unless otherwise directed by physician. A review of R#140's Face Sheet revealed the facility admitted the resident on 12/24/21 with diagnoses including type II diabetes mellitus, generalized muscle weakness, difficulty in walking, abnormal posture, and oropharyngeal phase dysphagia. A review of a hospital Case Management SNF [skilled nursing facility] Initial Placement Report, reflecting a hospital admission date of 12/13/21 and a last edited date of 12/20/21, revealed R#140 weighed 193 pounds and nine ounces with a principal problem listed as acute stroke due to embolism of the left middle cerebral artery. A review of an…
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
$11,171 in federal fines across 2 penalties.
- $3,728 — penalty dated 2023-11-09
- $7,443 — penalty dated 2023-11-09
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EMPIRE CARE CENTERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 3 of 5 | 2.2 | +0.8 vs chain |
| Staffing | 1 of 5 | 1.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 19 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| SWERDLOFF, ARYEH | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| DONATH, BARRY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/07/2021 |
| HELLER, SHLOMO | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| NUSSBAUM, EPHRAIM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| EMPIRE CARE CENTERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/05/2026 |
| BROWN, JEQUEITA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/14/2023 |
| BROWN, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/2022 |
| ELLIS, RENEE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| FERRALL, SHANNON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/20/2024 |
| HARDY, LEANTHONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2022 |
| MCCAIN, THOMAS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/04/2025 |
| REED, JOEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2023 |
| SIMMONS JOHNSON, KORTNEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/06/2025 |
| SONE-EBELOUE, GLADYS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2021 |
| STEPHENS, CARRIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/09/2025 |
| STINSON, CHRYSTAL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/29/2024 |
| WILLIAMS, DAEQWONA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/05/2025 |
| WILLIAMS, RASHUNDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/18/2024 |
| ENSH CONSULTING LLC | Organization | ADP OF THE SNF | since 05/01/2021 |
CMS files one row per role, so the 41 rows in the source record cover these 19 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.
2 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.
This home reported $3.4M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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 115360. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-13, 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.