Chatuge Regional Nursing Home

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

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.

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.

32.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 68 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 39.1% 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 23 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 0.14 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% 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.

Staffing

How full it usually is: this home is certified for 112 beds and averages 80.7 residents a day — about 72% occupied, or roughly 31 beds typically open. It usually has some room. 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 3.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.78 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.29 hrs/resident/day on weekends vs 3.98 on weekdays — 17% thinner on weekends. RN hours go from 0.99 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are 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.

33 citations, most serious first. The 15 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · L2024-06-08 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident abuse, exploitation, and injury of unknown origin, which were reported to him. The failure of the Administrator to take appropriate action which was reported to him has the likelihood to lead to future allegations of abuse, exploitation, and injury of unknown origin that are not identified, reported, or investigated. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-06-08 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect 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 record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect the resident's right to be free from abuse from by facility staff. Specifically, the facility failed to protect two residents (R) (R78 and R107) of 27 total sampled residents from physical, mental, and verbal abuse from Certified Nursing Assistant (CNA) staff. Due to the vulnerable nature of the nursing home population and the likelihood of resident abuse in the facility, immediate action was required to prevent further events of abuse. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the first Immediate Jeopardy was identified to have…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-06-08 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 review of policy titled Abuse Reporting and Investigation, the facility failed to protect one resident (R) (R71) out of a total sample of 27 from exploitation perpetrated by Certified Nurse Aide (CNA)1. Due to the vulnerable nature of the nursing home population, a potential for serious exploitation existed, and the likelihood of CNA 1 exploiting other residents in the facility required immediate action to prevent further events of exploitation. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. The noncompliance related to the second Immediate Jeopardy was identified to have existed on 7/12/2023 when the facility failed to protect R71 from exploitation by…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-06-08 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to ensure allegations of abuse, an injury of unknown origin that resulted in a hip fracture, and an allegation of employee to resident exploitation were reported to the State Survey Agency (SSA). Specifically, residents (R) (R71 and R107) were verbally abused by staff; R71 sustained an injury of unknown origin and potential exploitation by facility staff. The failure of the facility to report these incidents has the likelihood to lead to future unreported injuries of unknown origin, exploitation, and mental and verbal abuse against residents. The sample size was 27. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-06-08 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond 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 record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to ensure that allegations of abuse, allegations of exploitation, and an injury of unknown origin, were thoroughly investigated for three residents (R) (R78, R71, and R107) reviewed out of a total sample of 27 residents. Specifically, the facility failed to investigate allegations of employee to resident abuse for R78 and R107, perpetrated by Certified Nurse Aide (CNA) 2. In addition, the facility failed to investigate an injury of unknown origin that resulted in a hip fracture and failed to investigate allegations of exploitation for R71 perpetrated by CNA 1. The failure of the Administrator to investigate these incidents have the likelihood to lead to future unreported allegations of abuse and exploitation as well as injuries of unknown origin. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and facility policy review, the facility failed to evaluate a resident's physical and cognitive ability to safely self- administer medication for one (Resident (R) 27) of six residents during medication administration observations out of a total sample size of 21 residents. This failure resulted in the resident administering the incorrect amount of medication.Findings include:Review of the facility's policy titled, Self-Administration of Medications, dated May 2020, revealed, . 1. The facility and Interdisciplinary Care Team should assess and determine resident eligibility to self-administer medications by: a. Evaluating resident's functionality and health condition, b. Educate the resident to ensure the resident is able to state the name, dose, strength, frequency and purpose for use of his/her medications, c. Educate the resident to ensure he or she understands the possible side effects of medications and that he or she should notify the facility staff if…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of each 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 observations, family member and staff interviews, record review, and facility policy review, the facility failed to ensure the call button to activate the emergency call light was accessible for two (Resident (R) 3 and 87) of 21 residents in the sample. This failure placed the residents at risk for accident, injury, or unmet needs related to an inability to call for staff assistance.Findings include:Review of the policy titled, Call Light System Policy and Procedure dated June 2024, revealed, Staff should verify the call light is within reach prior to leaving the resident alone in their room.1. Review of R3's Record of Admission, located in the Resident tab in the Snapshot of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including paraplegia, weakness, and vascular dementia. Review of R54's Care Plan, dated 7/1/2023 and found in the Resident tab under Care Plans in the EMR revealed, [R3] was at risk for fall [sic] or injury from fall related to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure written notices for bed holds and transfers were provided to residents and/or resident representatives and that the Ombudsman was notified when residents transferred to the hospital for four of 21 sampled residents (Resident (R)1, R7, R83, and R94) reviewed for hospitalization. These failures had the potential to cause confusion for residents and their representatives regarding the reason for their hospitalization, their ability to return to the facility, and their ability to appeal the discharge.Findings include:Review of the policy titled, Bed Hold and Returns, dated October 2024, revealed, Prior to transfers and therapeutic leaves, the residents or resident representative will be informed in writing of the bed-hold and return policy . Prior to a transfer, written information will be given to the resident and the resident representatives that explain in detail: a. The rights and limitations 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.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-04 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan directing interventions for positioning and feeding for two (Resident (R) 3 and R57) of a total sample of 21 residents. This failure placed the residents at risk for unmet care needs.Findings include:Review of the policy titled, Care Plan Meetings, dated September 2024, revealed Each resident will have an individualized plan of care in place . The Comprehensive Care Plan will be resident centered having the individual resident as the locus of control. The Comprehensive Care Plan will be resident centered having individual resident as a unitary being.1. Review of R3's Record of Admission, located in the Resident tab in the Snapshot of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with paraplegia, weakness, and vascular dementia. Review of R54's Care Plan, dated 8/23/2023 and found in the Resident tab under Care Plans in…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  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 facility policy review, the facility failed to ensure clinical criteria were met prior to prescribing and administering an antibiotic for a urinary tract infection (UTI) for two (Resident (R) 5 and R34) of six residents reviewed for unnecessary medications. This failure had the potential to cause antibiotic resistance, increased risk of Clostridioides difficile (C. diff) infection, and adverse drug reactions.Findings include:Review of the facility policy titled, Surveillance for Infections, dated September 2017, revealed, . 2. The criteria for such infections are based on the current standard definitions of infections, . 5. Nursing staff will monitor residents for signs and symptoms that may suggest infection, according to current criteria and definitions of infections, and will document and report suspected infections to the charge nurse as soon as possible, e. Bacteriuria WITH corresponding signs and symptoms of UTI; and f. Other positive…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-04 · tag F0759 — failed to keep medication error rate low — isolated
  Ensure medication error rates are not 5 percent or greater.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, staff interviews, record review, facility policy review, and document review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had three errors in 47 opportunities, which resulted in a six percent error rate. This affected three (Resident (R) 27, R42, and R87) out of six residents observed. Medication errors have the potential to result in adverse health outcomes.Findings include:Review of the facility's policy titled, Storage of Medication, dated May 2020, revealed, . III. Expiration Dating . 3. Certain medications or package types, such as . multiple dose injectable vials . require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency . 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date 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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-06-08 · tag F0585 — failed to handle grievances — widespread
  Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, and review of the policy titled Grievance Policy, the facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident (R) (R107) out of 27 sampled residents. Additionally, the facility failed to have a process in place for residents to file a grievance anonymously. This had the potential to affect all of the residents of the facility. Findings include: Review of the facility's policy titled, Grievance Policy, dated May 2022 revealed the policy of the facility is to assist residents and their family members or advocates in filing grievances when such requests are made. Procedure: Number 1. Any resident, his/her representative, family member, or advocate may file a grievance concerning his/her treatment, medical care, behavior of other residents, staff members, theft of property, etc. without fear of threat or reprisal in any form. Number 3. The Administrator has delegated the responsibility of the grievance investigation to the Social Services department. Number 4. Upon receipt of the grievance…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-06-08 · tag F0700 — pattern
  Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure that informed consents were signed prior to the use of bedrails for four of 27 sampled residents (R) (R1, R45, R72, and R78) reviewed for bed rail use. The failure had the potential for risks of injury, entrapment, and/or death. Findings include: Review of the policy titled Proper Use of Side Rails, revised December 2016, revealed the policy is to ensure the safe use of side rails as resident mobility aids. General Guidelines: Number 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 1. Review of R1's Face Sheet from the electronic medical record (EMR) Face Sheet report tab showed a facility admission date of 11/5/2008. The residents quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 4/12/2024 revealed a Brief Interview for Mental Status score of 15 out of 15, indicative of being cognitively intact. Review of the care plan for R1 dated…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-06-08 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medications were removed from one of two medication carts, failed to remove expired phlebotomy supplies for one of two phlebotomy carts, and one of two medication rooms. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The census was 104. Findings include: Review of the undated policy titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles revealed Procedure: C.9. Nursing staff will monitor for expired drugs and cleanliness of medication room/medication carts once weekly. Procedure: D. Facility should ensure that medications and biologicals: (1) have an expiration date on the label; (2) have been retained longer than recommended by the manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-06-08 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green and pink halls. Findings include: Interview on 6/4/2024 at 9:30 am, the Registered Dietician (RD) and the Dietary Manager (DM) stated the designated meal times were: Breakfast was to be served at 8:00 am, Lunch to be served at 12:00 pm, and Dinner was to be served at 5:00 pm. Interview on 6/4/2024 at 1:39 pm, R48 stated she had not received her lunch yet. At that moment, a staff member entered the room with her tray. R48 stated the trays should be there at noon or 12:30 pm. Her roommate also did not have a tray and revealed it was supposed to be noon. Interview on 6/4/2024 at 2:08 pm, R45 stated he had not received his lunch tray. The interview ended at 2:25 PM and the lunch tray had still not arrived. During a group interview on 6/6/2024 at 10:00 am with members of the Resident Council (R88, R15, R17, R2, R44, R94 and R8), residents confirmed meal delivery was consistently late. R88…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“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.

Fines & penalties

$64,214 in federal fines across 1 penalty.

• $64,214 — penalty dated 2024-06-08

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.

Who owns this facility

CMS files one row per role, so the 18 rows in the source record cover these 10 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in GA