Harmony Health and Rehabilitation
176 Lincoln Ave, Fitzgerald, GA 31750 · For profit - Limited Liability company · 167 certified beds · (229) 423-5621 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has 2 actual-harm citations
- a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,017 in federal fines (most recent 2024-12-19)
- 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 2 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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 improved from 1 to 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 | 27.2% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 11.7% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.3% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 27.5% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 29.8% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 88.2% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.0% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 63.0% | 19.9% | 17.1% | check this† — see note marked dagger below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.6% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 39.7% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.8% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.47 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.32 | 1.90 | 1.80 | worse |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Met the expected recovery: 46.1% 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 26 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 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 17% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.1%CMS range 6.8–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.1% | 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 | 38.5% | 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 | 26.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 3.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 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 167 beds and averages 88.2 residents a day — about 53% occupied, or roughly 79 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.00 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 3.15 hrs/resident/day on weekends vs 3.62 on weekdays — 13% thinner on weekends. RN hours go from 0.53 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
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.
22 citations, most serious first. The 12 most serious are shown; the remaining 10 are one tap away and print in full.
- Actual harm · Gcited before2025-10-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review and review of the facility's policy titled Comprehensive Care Plans, the facility failed to follow the care plan interventions related to falls for one of four Residents (R) (R1) Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia Findings include:A review of the facility's policy titled Comprehensive Care Plan dated 6/2/2025 under Policy revealed, 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 include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2025-10-30 · 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 observations, interviews, record review and review of the facility's policy titled Incident and Accidents, the facility failed to provide adequate supervision to prevent accidents for one of four residents (R) (R1) reviewed for falls. Actual harm occurred on 10/2/2025 when R1 who required two person assist with Activities of Daily Living (ADL) care rolled out of bed onto the floor during incontinent care that was being provided by one Certified Nursing Assistant (CNA). As a result of the fall, R1 sustained a distal fracture of left femur and a fracture of the lower end of the right tibia.Findings include:A review of the facility's policy titled Incidents and Accidents dated 4/1/2025 under Policy revealed, It is the policy of this facility for staff to utilize the Risk Management porta [sic] to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involved a resident. Under the Compliance Guidelines section revealed,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to provide Form CMS 10055, Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), in a timely manner to two of three sampled residents(R) (R13 and R73) reviewed for liability notices. This failure prevented the residents or their responsible parties from having the ability to make an informed decision regarding the cost of continued therapy services.Findings include:1. Review of R13's electronic medical record (EMR) admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE].Review of R13's document provided by the facility titled, Notice of Medicare Non-Coverage indicated R13's skilled therapy services would end on 12/10/2025.Review of R13's SNF/ABN, provided by the facility indicated that R13 signed the SNF ABN on 12/22/2025. The form indicated that the resident's signature acknowledged receipt of and understanding of the notice eleven days after therapy services ended.Review of R13's EMR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0628 — isolatedProvide 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, staff interviews, and review of the facility policy titled Bed Hold Notice Upon Transfer the facility failed to notify the ombudsman and to provide a resident and their representative with the required written transfer and bed-hold notices following an emergency hospital transfer for one of two sampled residents (R) (R87). This failure limited the residents' and representative's ability to understand appeal rights and access ombudsman information, placing them at risk for potential denial of readmission.Findings include:Review of the admission Record located in the electronic medical record (EMR) under the Profile tab revealed that R87 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. R87 had diagnoses including osteomyelitis (bone infection) and acquired absence of the left foot (amputation).Review of R87's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/26, located in the EMR under the MDS tab revealed a Brief Interview for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, the facility failed to complete a baseline care plan for two of 27 sampled residents (R) (R85 and R29). This failure had the potential to result in the residents' medical, nursing, mental, and psychosocial needs not being met, increasing the risk for adverse outcomes.1.Review of R85's Electronic Medical Record (EMR) located under the Minimum Data Set (MDS) tab revealed a revealed an admission date of 10/31/2025. Review of the EMR located under the Evaluation tab revealed no documentation that R85's base line care plan had been completed. Interview on 03/03/2026 at 4:05 PM the MDS Coordinator (MDSC) stated that it is the nurse's responsibility to complete the base line care plan at the time of admission. The MDSC also stated that it does not look like the baseline care plan for R85 was completed. Interview on 03/03/2026 at 4:15 PM with the Administrator stated that R85's base line care plan was not done. The Administrator confirmed that the baseline care plan would be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-05 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interviews, and review of the facility's policy titled Hemodialysis, the facility failed to ensure safe and coordinated dialysis care for one of one sampled resident(R)(R87). Specifically, the facility did not complete required pre and post dialysis assessments, did not maintain effective communication with the contracted dialysis provider, and did not have a formal written contract or agreement with the dialysis agency responsible for providing services to the resident. These failures placed the R87 at risk for compromised health, safety, and continuity of care.Findings include:Review of the admission Record, located in the electronic medical record (EMR) under the Profile tab revealed that R87 was originally admitted to the facility on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis.Review of R87's Care Plan located in the EMR under the Care Plan tab revealed a Focus area revised 07/03/2025, [R87] needs dialysis type hemo r/t…
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 · D2025-07-02 · 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
Based on record review, staff interview, and review of the facility's policy titled Documentation of Wound Treatments, the facility failed to ensure the medical record documentation was completed and/or accurate for three of three residents (R) (R1, R3 and R4) reviewed for pressure ulcers from a total sample of nine residents. Findings include: Review of the facility's policy titled Documentation of Wound Treatments dated 9/1/2024 under Policy revealed, The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry, intact). 1. Review of clinical records revealed R1 was admitted to the facility with the following diagnoses but not limited to: congestive heart failure, chronic obstructive pulmonary disease, hypertension, atherosclerosis, morbid obesity, and peripheral vascular disease. Review of R1's…
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 · F2025-01-08 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled, Cleaning Instructions: Ice Machine and Equipment, the facility failed to ensure the ice machine was maintained in a clean and sanitary condition and failed to ensure staff wore appropriate head covering in the food service area. This deficient practice had the potential to affect 82 of the 85 residents receiving an oral diet. Findings include: Review of the facility's undated policy titled, Cleaning Instructions: Ice Machine and Equipment revealed the purpose was, to ensure that ice machine and equipment (scoops and receptacles that are used to hold or transport ice) will be cleaned and sanitized on a regular basis. Procedures explained: 2. Wash the interior thoroughly using a detergent solution. Rinse and drain the interior with clean hot tap water. 6. Clean the exterior of the machine with detergent solution daily. Rinse and allow to air dry. Clean the area underneath and around the machine. Observation on 1/7/2025 at 11:45 am with the Dietary Manager upon inspection of ice machine in the main…
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 · F2025-01-08 · tag F0945 — failed to train staff on abuse prevention — widespreadInclude as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility's policy titled, Annual Inservice Education for Long Term Care 2024, the facility failed to establish, implement, and sustain a comprehensive training program for all staff that would include education on standards, policies, and procedures for infection prevention. This deficient practice had a potential to increase the risk of healthcare-associated infections and compromise the quality of care provided to the residents of the facility. Findings include: Review of the facility's undated policy titled, Annual Inservice Education for Long Term Care 2024, revealed that the annual education calendar is to be implemented each year as scheduled, along with any additional educational needs that are identified. The calendar provides a monthly education schedule for 2024, covering a variety of topics, including infection control and prevention, among others. The facility was unable to provide the survey team with documentation of in-service training provided to staff. Interview on 1/6/ 2025, at 4:50 pm with the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the facility's policy titled, Resident Rights and Dignity Management, the facility failed to ensure one of 13 residents (R) (R17) was able to exercise their right to smoke. Findings include: Review of facility's policy titled, Resident Rights and Dignity Management, dated October 2023, in section self-determination and participation standard revealed, our facility respects and promotes the right of each resident to exercise his/her autonomy regarding what the resident considers to be important facets of his/her life . 3. The resident shall be encouraged to make choices about aspects of his/her life in the facility including: roommates, smoking. Review of the clinical record revealed that R17 was admitted to the facility with the diagnoses of but not limited to, intracranial injury without loss of consciousness, schizoaffective disorder bipolar, chronic obstructive pulmonary disease, and emphysema. Further record review revealed completed smoking and safety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Resident Assessment Instrument (RAI)/Care Planning Management, and Process for Completing the MDS, CAAs and Care plans, the facility failed to ensure that the care plan was followed for three of 15 residents (R) (R24, R7, and R54). Specifically, the facility failed to ensure the care plan was followed for R24 for receiving oxygen therapy, for R7 related to positioning of an indwelling catheter, and for R54 for behaviors related to oxygen use. This deficient practice had the potential for R24, R7, and R54 to not have the care provided to them according to their individual care needs. Findings included: Review of the undated facility's policy titled, Resident Assessment Instrument (RAI)/ Care Planning Management, revealed that the Comprehensive Care Plan is completed within seven (7) days after the care area assessments (CAAs) are completed and reviewed quarterly thereafter. If modifications, deletions, additions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and record review, the facility failed to properly administer respiratory inhalant medications for one of 15 residents (R) (R24) receiving inhaled respiratory medication. Specifically, the facility failed to ensure that the Licensed Practical Nurse (LPN) properly administered inhaled medications by having the resident rinse their mouth after receiving inhaled respiratory medication. Findings include: A facility policy for administrating inhaled medications was requested. There was no policy provided by the facility. Observation on 1/7/2025 at 9:32am to 9:40 am revealed Registered Nurse (RN) EE preparing medications for R24 that included but not limited to Trelegy inhaler. RN EE performed hand hygiene, entered room of R24, and handed the inhaler to the resident. RN EE instructed R24 to take in one puff, hold her breath for as long as she could before removing the inhaler and exhaling. LPN EE then had the resident take her pills. She performed hand hygiene before leaving 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.
Show the remaining 10 citations
- Potential for harm · D2025-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory System Management, the facility failed to ensure that one of 15 residents (R) (R24) receiving oxygen (O2) therapy was administered the therapy in accordance with the physician's orders. This deficient practice had the potential to put R24 at risk for medical complications. Findings include: Review of the facility's policy titled, Respiratory System Management, revised in August 2021, under the section Oxygen Therapy Protocol, outlines the following procedures: 1) Verify the physician's order in the resident's clinical record . Review of the electronic record revealed R24 admitted to the facility with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD) and pneumonia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. Section I, Active Diagnoses,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Hand Hygiene, Indwelling Catheters, Two-Tier Transmission Based Precautions, and Infection Control Manual, the facility failed to ensure infection control practices were followed for two of seven Residents (R) (R435 and R7). Specifically, the facility failed to ensure hand hygiene was performed during medication administration, failed to ensure residents with an indwelling catheter drainage bag was secured properly, and failed to ensure that the infection control policy and procedures were reviewed annually. Findings include: Review of the facility's policy titled, Hand Hygiene, with a revision date of 9/2023, revealed that the facility will follow the Center for Disease Control guidelines for hand hygiene. Hand Hygiene is the single most important procedure for preventing nosocomial infections. The facility requires personnel to wash hands thoroughly to remove dirt, organic material, and transient…
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 · D2024-12-19 · 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 staff interviews, record review, and review of the facility's Standard and Task List titled, Elopement Management, the facility failed to ensure that the physician and responsible party were notified of an elopement of one resident (R) (R1) from a total sample of 24 residents. This deficient practice had the potential to place R1 at risk of unmet needs and a diminished quality of life. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, a progress note (in the clinical record) was to be completed at the time of the elopement with an accurate timeline of events, and MD/RP (Medical…
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 · D2024-12-19 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure the care plan was revised for one of 24 sampled residents (R) (R1). Specifically, the facility failed to revise and update R1's care plan following an elopement on 10/17/2024. This deficient practice had the potential to place R1 at risk of not receiving treatment and/or care according to their needs. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, the care plan was to be updated. Review of the clinical record revealed R1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-19 · 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 staff interviews, record review, and review of the facility's Elopement Standard and Task List titled, Elopement Management, the facility failed to ensure one of 24 sampled residents (R) (R1) was adequately supervised to prevent elopement. In addition, the facility failed to ensure a door leading to the outside was secured to prevent elopement by residents. This deficient practice had the potential to place R1 at risk of avoidable injury and a diminished quality of life. Findings included: Review of the facility's Elopement Standard and Task List titled, Elopement Management, dated 2023, defined elopement, Elopement occurs when a resident leaves the facility or a safe area without authorization. If a resident is off facility property, then an elopement has occurred. If a resident is on facility property but not under supervision as need identifies; then an elopement has occurred. The standard and task list also included that post elopement, a progress note (in the clinical record) was to be completed 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.
- Potential for harm · D2023-11-29 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, review of the facility's resident admission agreement in the admission packet, and review of the facility's policy titled, Advance Directives, the facility failed to ensure one of three residents (R) (R49) wishes were correctly entered into orders to reflect the residents preferred code status and failed to ensure a copy of the resident's advance directives were obtained and filed in the medical record. Findings include: Review of the facility's Resident admission Agreement included in the Residents admission Packed revealed under the Refusal of Treatment and Issuance of Advance Directive section that the resident may also issue an Advance Directive in accordance with state law that describes the residents' wishes with respect to treatments that may be administered or withheld in the event the resident becomes unable to make health care decisions for him or herself. Review of the facility's policy titled, Advance Directives with an effective date of [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 · Dcited before2023-11-29 · 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 observation, staff interview, record review, and review of the facility policy titled, Care Plan Development, the facility failed to implement a care plan for one resident (R) R70 who had a diagnosis of post-traumatic stress syndrome and failed to follow the care plan for one resident R49. The sample size was 33 residents. Findings include: Review of the facility undated policy titled, Care Plan Development revealed: an individualized comprehensive care plan using the results of the RAI /MDS assessment, resident/family and interdisciplinary input will be developed for each resident in the facility within 21 days of admission or 7 days after the completion date of the comprehensive MDS assessment and describe the services that are to be furnished to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident. The care plan will include measurable objectives, interventions, goals, and timetables. The care plan will be reviewed and revised on an as needed basis…
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 · D2023-11-29 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Care of Fingernail/Toenails, the facility failed to ensure that residents received toenail care timely for two of 33 sampled residents (R) (R65) and (R1). This failure had the potential to affect one resident's bilateral foot health. Findings include: Review of an undated policy provided by the facility titled Care of Fingernails/Toenails, revealed, Under Purpose: The Purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Podiatry care is scheduled as needed for those residents with identified podiatry needs. Proper nail care can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his/her skin (unless medically contraindicated). R65 was admitted with a diagnosis to include but not limited to Type 2 diabetes…
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 · D2023-11-29 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review, and review of the facility's policy titled Restorative Programs the facility failed to follow an Occupational Therapy (OT) restorative referral recommendation for passive range of motion (PROM) and orthotic application for one of one resident (R) (#49) reviewed for PROM and splint application to resident's left hand. The facility also failed to obtain a physician's order defining the specific restorative program and frequency. The deficient practice had the potential to reduce residents ability to improve independence and/or result in the progression of contractures. The sample size was 33 residents. Findings include: Review of the facility's policy titled, Restorative Program dated August 2021 revealed Under Introduction Restorative Programs: Restorative care is a dynamic process which aids a resident in achieving optimum physical, emotional, psychological, and social well-being. The purpose of these restorative programs is to allow the facilities to be 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 · D2023-11-29 · 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
Based on resident interviews, staff interviews, record review, and review of the facility policy titled, Medication Administration Guidelines, the facility failed to ensure one of five residents (R) 29, reviewed for unnecessary medications received medications as ordered by the physician. Specifically, the facility failed to transcribe a medication as ordered by the provider. Findings include: Review of the facility's undated policy titled, Medication Administration guidelines, revealed under Guidelines: To enforce and adhere to the Nurse Practice Act and DEA requirement of safe practice of administering medication. Definitions: Transcribing: Ensuring accurate transcription and documentation of medications from physician telephone orders, faxed orders, etc., Medication Administration: Prior to administering medications, the resident must have a physician order prescribing the medication. This order remains in effect until discontinued by the physician. Review of R29's record revealed resident had diagnoses of unspecified dementia with other behavioral disturbances, schizophrenia,…
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
$4,017 in federal fines across 1 penalty.
- $4,017 — penalty dated 2024-12-19
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 BRIGHTON HEALTHCARE — 8 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 | 1.5 | +0.5 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 1.9 | +1.1 vs chain |
| Quality measures | 2 of 5 | 1.6 | +0.4 vs chain |
The other 7 homes this chain runs (chain average 1.5★, 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 |
|---|---|---|---|
| STATESBORO HOLDCO LLC | Organization | DIRECT OWNERSHIP INTEREST | since 05/01/2025 |
| FISCHER, DAVID | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 05/01/2025 |
| INZELBUCH, AZRIEL | Individual | INDIRECT OWNERSHIP INTEREST | since 05/01/2025 |
| LEFKOWITZ, ZEV | Individual | INDIRECT OWNERSHIP INTEREST | since 05/01/2025 |
| FEAGLE, BREIANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| PEACOCK, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2025 |
| BRIGHTON MANAGEMENT THREE LLC | Organization | ADP OF THE SNF | since 05/01/2025 |
CMS files one row per role, so the 11 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
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.
About 95% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $879K paid to related parties — landlords or management companies under common ownership — equal to about 10% 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. 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
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
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 115654. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.