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Jasper Point Of Journey LLC

618 Gennett Drive, Jasper, GA 30143 · For profit - Limited Liability company · 60 certified beds · (706) 692-6323 Medicare & Medicaid certified

Call the home — (706) 692-6323 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$4,233 in federal fines
Insights

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

Worth asking about
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $4,233 in federal fines (most recent 2023-10-23)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (72%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS
Urgent care / clinic
North Main Street · (706) 253-2266 · Call to confirm hours
Pharmacy
1100 Old Philadelphia Rd · (706) 301-9076 · Call to confirm hours
Grocery
1100 Old Philadelphia Rd · (706) 299-8040 · Call to confirm hours
Park
599 Lumber Company Rd · (706) 692-9100 · Typically dawn to dusk
Place of worship
213 Pioneer Industrial Blvd · (706) 253-5965

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased29.1%15.3%15.4%worse
Long-stay residents who lose too much weight11.1%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.9%0.9%better
Long-stay residents with a urinary tract infection0.5%2.5%2.0%better
Long-stay residents with depressive symptoms43.4%11.3%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.7%3.2%3.3%worse
Long-stay residents whose ability to walk worsened26.9%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication35.7%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine86.0%95.0%95.3%typical
Long-stay residents with pressure ulcers7.7%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control21.7%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table20.8%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine73.7%78.4%79.4%typical
Short-stay residents rehospitalized after admission26.4%25.0%22.6%worse
Short-stay residents with an outpatient ER visit15.2%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.842.151.67typical
Long-stay outpatient ER visits per 1,000 resident days2.021.901.80worse

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.

42.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 69 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.4%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
37.0%U.S. median 56.6%
Met the expected recovery
0.03U.S. median 0.31
Therapy hours / resident / day
0.03hours / resident / day
Speech therapy

Met the expected recovery: 37.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 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 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.4%CMS range 31.7–53.151.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 9.4–16.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge37.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge33.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge37.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified96.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting96.9%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay3.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.5%CMS range 5.2–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.321.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.66
RN hours/ resident / day
0.70
LPN hours/ resident / day
1.85
Aide hours/ resident / day
3.21
Total nurse hours/ resident / day
0.58
RN hoursweekends
71.7%
Total nursing turnover
75.0%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 55.6 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.21 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.88 hrs/resident/day on weekends vs 3.35 on weekdays — 14% thinner on weekends. RN hours go from 0.69 to 0.58 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 72% is well above 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

10
deficiencies at the latest standard inspection (2025-11-21)
9
at the previous standard inspection (2024-07-21)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

  • Actual harm · Gcited before2022-05-22 · 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 observation, record review, staff and resident interviews, and review of the facility policy titled Comprehensive Care Plan, the facility failed to follow the person-centered care plan to ensure pain interventions were implemented during wound care for one resident (R) (#43), resulting in harm to the resident, of 30 sampled residents. Findings include: A review of the facility policy, Comprehensive Care Plans, implemented 2/1/22, revealed the facility would implement a comprehensive person-centered for each resident, consistent with resident rights, to meet each resident medical and nursing needs. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section M-Skin Conditions revealed R#43 had a surgical wound and received surgical wound care. Section O-Special Treatments and Programs revealed R#43 received Hospice care. Section J-Health Conditions revealed R#43 was on…

    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
  • Actual harm · G2022-05-22 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff and resident interviews, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of severe pain during a wound treatment, resulting in harm for resident #43, of 30 sampled residents. Findings include: A review of the facility policy, Pain Management, implemented 2/2/22, revealed the facility would recognize circumstances and situations when a resident's pain could be anticipated. Per the policy, the facility would manage or prevent pain with the comprehensive plan of care, professional standards of practice, and the resident's preferences. Continued review revealed interventions for pain management would be incorporated into the comprehensive care plan and would address specific pain management needs or goals. Pharmacological interventions included reviewing clinical conditions which might require several analgesics and/or adjuvant medications, and facility staff would notify the practitioner if 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-21 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, facility policy review, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program (IPCP) for recording incidents of infections identified under the facility's IPCP, surveillance, tracking and trending, and the corrective actions taken by the facility and failed to ensure heavy duty gloves were available for the laundry room for 49 of 49 census residents. These failed practices had the potential to affect the 49 residents residing in the facility.Findings include:Review of a facility's policy titled, Laundry Handling & Processing Policy, dated 2/1/2025, indicated .Laundry in a healthcare facility may include bed sheets, blankets, towels' personal clothing' patient apparel, gowns, and other linens. The overall risk of disease transmission during the laundry process is low, infection has not been linked to laundry procedures in residential care facilities, even when consumer versions of detergents and laundry additives are…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident family member and staff interviews, and facility policy review, the facility failed to ensure personal information was kept confidential for one of one resident (Residents (R) 10) reviewed for privacy of 34 sample residents. This failure had the potential to cause emotional distress.Findings include:Review of a facility's undated policy titled, Your Rights and Protections as a Nursing Home Resident indicated .As a nursing home resident, you have certain rights and protection under Federal and state law that help ensure you get the care and services you need. You have the right to be informed, make your own decisions, and have your personal information kept private.Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of R10's quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference…

    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 · D2025-11-21 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident family member and staff interviews, record review, and facility policy review, the facility failed to include proper reasons for a discharge/transfer for one of one resident (Resident (R) 10) reviewed for discharge of 34 sample residents. This had the potential for the resident to have significant stress. Findings include:Review of a facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 3/20/2025 indicated .It is the policy of this facility to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions.The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.The transfer or discharge is…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · 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

    Based on staff interviews, record review, and facility policy review, the facility failed to ensure a resident and Resident Representative (RR) received a written transfer agreement and bed hold notice for one (Resident (R)59) out of two reviewed for transfers from a sample of 34 residents. This failure had the potential to affect the resident and their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and contribute to the possibility of denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital.Findings include:Review of facility's policy titled, Transfer and Discharge (including AMA) dated 3/20/2025 indicated, 3. The facility's transfer/ discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge; b. The effective date of transfer or…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected a facility fall for one (Resident (R) 4) of two residents reviewed for falls in the sample of 34 residents. This failure had the potential for unmet care needs.Findings include:Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of muscle weakness, difficulty walking, and a need for assistance with personal care.Review of R4's hospital After Visit Summary paperwork located under the Misc tab of the EMR dated 7/3/2025 revealed the resident had a fall resulting in a contusion of left shoulder and a closed head injury.Review of R4's Care Plan located under the Care Plan tab of the EMR revealed the resident was at risk for falls or fall related injury related to having impaired mobility. On 7/3/2025, the Care Plan revealed the resident had a fall. Staff were…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · 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 ensure residents' care plans reflected current level of care for two of 34 sample residents (Resident (R) 4 and R54) reviewed for care plans. This failure had the potential to affect resident care outcomes. Findings include:Review of the policy titled, Comprehensive Care Plans, dated 3/20/2025, revealed, It is the policy of the 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.1.Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) the resident was admitted to the facility on [DATE] with a diagnosis of Post Traumatic Stress Disorder (PTSD) and bipolar disorder.Review of Resident 4's Progress Notes located under the Prog Note tab in the EMR revealed on 2/26/2025…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 record review, resident and staff interviews, and facility policy review, the facility failed to ensure one (Resident (R)4) out of four reviewed for accidents out of a total sample of 34 residents was properly secured during a Hoyer lift (mechanical lift) transfer and sustained a fall. This had the potential for the resident to sustain serious injury. Findings include:Review of a facility's policy titled, Accidents and Supervision, dated 2/1/2024, indicated . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents.Identifying hazard(s) and risk(s).Evaluating and analyzing hazard(s) and risk(s).Implementing interventions to reduce hazard(s) and risk(s).Monitoring for effectiveness and modifying interventions when necessary.Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of muscle…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for one of one (Resident (R) 21) residents reviewed for respiratory care out of a total sample of 34 residents. Specifically, respiratory equipment, such as nebulizer masks, were not stored in a sanitary manner and physician orders for oxygen levels were not followed. The deficient practice had the potential for a risk of infection and respiratory distress. Findings include:Review of facility's policy titled, Oxygen Administration with a revision date of 2/14/2024, noted Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines Oxygen is administered under orders of a physician.Staff shall perform hand hygiene and don (put on) gloves when administering oxygen or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure the clinical records were complete for one of three residents (Resident (R) 10) reviewed for pressure ulcers out of a total sample of 34 residents. This failure created the opportunity for inaccurate medical records to be accessible to staff.Findings include:Review of a facility's policy titled, Verbal Orders, dated 2/14/2024, indicated .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered healthcare specialist who are legally authorized to do so.Review of R10's electronic medical record (EMR) titled admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease.Review of R10's EMR quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 8/29/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of nine out of 15, which revealed 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer one of five residents (Resident (R) 26) reviewed for flu/pneumonia vaccinations out of 34 sample residents and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards. In addition, the facility failed to have an acute policy displaying the CDC's recommendation. This practice had the potential to increase the risk for residents to contract pneumonia.Findings include:Review of a facility's policy titled, Infection Prevention and Control Program, dated 3/20/2025, indicated .Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere.Review of R26's electronic medical record (EMR) titled, admission Record located under the Profile tab indicated the resident was admitted to the facility on…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · Ecited before2024-11-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure 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 interviews and record review the facility failed to complete Fall Risk Assessments during the admission process and post falls for two Residents (R) (R3 and R4) of three residents reviewed for falls. Findings include: 1.R3 was admitted to the facility on [DATE]. Her admitting diagnoses include, but not limited to unspecified fracture of shaft of left femur, Alzheimer's disease, fall on same level, and encounter for other orthopedic aftercare. The Brief Interview of Mental Status (BIMS) was conducted on 9/27/2024 and revealed that R3 was rarely/never understood. Review of care plan revealed that resident had falls on 9/29/2024, 10/8/2024, and 10/9/2024. Review of the medical record revealed falls occurring on 9/29/2024, 10/8/2024, and 10/09/2024. Further review revealed that there was no evidence that a Fall Risk Assessment was completed for date of admission, post fall on 9/29/2024, post fall on 10/8/2024, or post fall 10/9/2024. Further records review revealed that fall risk evaluation was completed on…

    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 · F2024-07-21 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interviews, and review of facility documents titled, Facility Assessment Tool and the PBJ (payroll-based journal) Staffing Data Report, the facility failed to ensure that the facility had adequate nursing staff on the weekends. The deficient practice had the potential to affect the care provided to the 51 residents that resided in the facility. Findings include: Review of The Facility Assessment Tool dated 4/17/2024 revealed the average daily census in the facility was 57 residents. The Facility Assessment Tool documented the average hourly staffing needs per day were 36 - 48 hours for licensed nurses providing direct care, and 105 - 120 hours for nurse aides. Review of the PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (1/1/2024 through 3/31/2024) revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing. Review of PBJ Data Hours Log, provided by the facility, for FY Quarter 2, revealed an average of 77 hours per day for nurse's aides for weekends. Interview on 7/21/2024 at 3:00 pm with the Regional…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-21 · tag F0908 — failed to keep essential equipment working — widespread
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to maintain the walk-in freezer in a manner to prevent ice buildup from forming on the freezer unit. This failure had the potential to contaminate food items located under the ice and place the 51 residents receiving an oral diet from the kitchen at risk of contracting a foodborne illness. The facility census was 51. Findings include: Observation of the walk-in freezer on 7/19/2024 at 8:00 am revealed ice formations hanging from the freezer unit located to the left side of the door. The ice formations ranged in size from 6 inches in diameter at the top to less than 1 inch in diameter at the floor and were observed on the shelving below the freezer unit and the freezer floor. The Certified Dietary Manager (CDM) verified the ice formation and the buildup of ice on the freezer floor. In an interview on 7/19/2024 at 8:00 am, the CDM stated the walk-in freezer had malfunctioned a while back, and the Maintenance Director and Interim Administrator were aware. She further stated an outside company had inspected the freezer, but…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-21 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure the Medical Director or an appointee of the Medical Director's attendance and participation in QAPI committee meetings, at least quarterly. Specifically, the Medical Director or their appointee was not present and did not attend three of the six QAPI committee meetings reviewed. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) date implemented 8/1/2023 revealed under the section titled Policy Explanation and Compliance Guidelines number two The Quality Assessment and Assurance (QAA) Committee shall be interdisciplinary and shall consist at minimum of the Director of Nursing (DON), Medical Director or his/her designee, and at least three other members of the facility's staff, at least one of which must be the Administrator, Owner, a Board Member or other individual in a leadership role, and the Infection Preventionist. Review of the QAPI committee meeting…

    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
  • Potential for harm · D2024-07-21 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 staff interviews, record review, and a review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to submit a PASARR Level II for two of four residents (R) (R5 and R19) reviewed after a new mental illness diagnosis was added. This deficient practice had the potential to affect the appropriate level of care and services provided for R5 and R19. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program dated 2/12/2022 revealed the Policy stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance section stated, 6. The Social Services Director shall be responsible 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-21 · 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, resident and staff interviews, record review, and review of the facility policies titled Comprehensive Care Plan and Oxygen Administration, the facility failed to develop a person-centered comprehensive care plan for one of 20 sampled residents (R) (R15). This failure increased the potential for R15 not to receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Comprehensive Care Plans dated 2/12/2022 revealed the Policy Explanation and Compliance Guidelines stated, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. A review of the facility policy titled Oxygen Administration dated 2/12/2022 revealed the Policy stated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Nebulizer Therapy and CPAP/BiPAP (continuous/bilevel positive airway pressure machine) Cleaning, the facility failed to ensure that respiratory supplies were stored properly for two of 21 sampled residents (R) (R14 and R27). This deficient practice increased the risks of spreading microorganisms and placed R14 and R27 at risk for respiratory infections and a diminished quality of life. Findings include: Review of the policy titled Nebulizer Therapy, date implemented 2/12/2022, documented under Care of the Equipment: 1. Clean after each use. 2. Wash hands before handling equipment. 3. Disassemble parts after every treatment. 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a [brand name] (re-sealable) bag. Review of the facility policy titled CPAP/BiPAP Cleaning revised…

    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 · D2024-07-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy titled, Use of Psychotropic Medications, the facility failed to ensure that a psychotropic medication, with appropriate diagnoses, including antianxiety medication, was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of six residents (R) (R19) reviewed for unnecessary medications. Findings include: Review of the facility policy titled Use of Psychotropic Medication dated 8/1/2023 documented the following under Policy Explanation and Guidelines: . 9. PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's record and indicate the duration for the PRN…

    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 · D2024-07-21 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to maintain medications in a locked and secure environment when not under direct supervision of the nurse for one of two medication carts (the 300 Hall cart). This failure placed residents, staff, and visitors at risk of having unauthorized access to residents' medications. Findings include: Review of the facility policy titled Medication Storage date implemented 2/12/2022 revealed under Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the section titled Policy Explanation and Compliance Guidelines and subsection General Guidelines letter C revealed during medication pass, medications must be under the direct supervision of the person administering the medications or locked in the medication…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled, Clean Dressing Change, the facility failed to ensure hand hygiene was performed during wound care for one of five residents (R) (R1) with pressure ulcers. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Clean Dressing Change, date implemented 2/12/2022, revealed the policy of the facility was to provide wound care in a manner to decrease potential for infection and/or cross contamination. The subsection titled Policy Explanation and Compliance Guidelines revealed number 14 stated, Wash hands and put on clean gloves. A review of the electronic medical record (EMR) revealed R1 was admitted to the facility with pertinent diagnoses including but not limited to pressure ulcer of the sacral region, stage IV. Review of R1's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/2/2024 revealed a Brief Interview…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-29 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Environmental Quality, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment on three of three halls (Unit 100 hallway, Unit 200 hallway, and Unit 300 hallway). Specifically, all three hallways were filled with equipment and clutter, a wall behind a resident's bed was scuffed up, a wall across from the nurses' station was broken and covered with tape, and the shower room was cold with broken and stored clutter and a leaking shower head. Findings include: Review of the facility policy titled Resident Environmental Quality dated 2/22/2022 and revised 2/22/2023, item number 12 under General Guidelines revealed that all facility personnel are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately. Observation on 12/18/2023 at 8:45 am during a general tour of the facility revealed three resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-01-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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, resident family and staff interviews, record review, and review of the facility policy titled, Falls Prevention Program, the facility failed to ensure residents received adequate supervision or intervention to prevent accidents for one of eight sampled residents (R) (R3). Findings include: Review of the facility policy titled Falls Prevention Program revealed: Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: . 3. The nurse will indicate on the (specify location) the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. The nurse will refer to the facility's High Risk or Low/Moderate Risk protocols when determining primary interventions. 6. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-29 · tag F0742 — isolated
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
    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 policies titled, Behavioral Health Services, Suicide Prevention, and Suicide Assessment, the facility failed to provide timely treatment and services for one of eight sampled residents (R) (R5). Specifically, R5 was not provided adequate protection for possible self-harm during a suicide attempt with anxiety and depression. Findings include: Review of the facility policy titled Behavioral Health Services dated 2/22/2023, under section Policy Explanation and Compliance Guideline, item 2.d., revealed: The facility utilizes the comprehensive assessment . Ongoing monitoring of mood and behavior. Item 10. revealed that the Social Worker Director will provide behavioral services. Review of the facility policy titled Suicide Prevention dated 2/22/2023, revealed that all staff members will immediately report any suicide ideations to the charge nurse and social worker and immediately notify the physician even if the person doesn't have a specific plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-05-22 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor 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 record review, interviews, and review of the facility policy titled Communication of Code Status, the facility failed to communicate and ensure family preference for the change in code status from full code to do not resuscitate (DNR) was updated in the medical record for one of 30 sampled residents (R) (R#59). Findings include: Review of the facility policy titled Communication of Code Status dated 2021, revealed it is the policy to adhere to residents' rights to formulate advance directives. In accordance to these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. Compliance Guidelines: 7. The resident's code status will be reviewed at least quarterly and documented in the medical record. Review of the clinical record for R#59 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to chronic obstructive pulmonary disease (COPD), hemiplegia, hypertension (HTN), dysphagia,…

    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 · D2022-05-22 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review, staff interviews, and review of the facility policy, Comprehensive Care Plans, the facility failed to revise and update the care plan to include appropriate interventions for restorative care for one of 30 sampled residents (R) (#14). Findings include: A review of the facility policy entitled Comprehensive Care Plans, implemented on 2/1/22, revealed the comprehensive care plan would include measurable objectives and timeframes to meet the resident's needs. The objectives would be utilized to monitor the resident's progress, and alternative interventions would be documented as needed. A further review revealed that staff responsible for carrying out the interventions specified in the care plan would be notified of their roles and responsibilities for implementing the interventions initially and when changes were made. A medical record review revealed that R#14 was admitted to the facility on [DATE]. R#14 had diagnoses including but not limited to hypertensions (HTN), Cerebrovascular…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-05-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interviews, and review of the facility policy titled Catheter Care, the facility failed to ensure one staff implemented infection control standard precautions by not washing/sanitizing hands before and after glove removal and not double gloving during and after catheter care was performed for one resident (R) (R #11) reviewed of three residents with indwelling urinary catheter. Findings include: Review of the policy titled Catheter Care dated 2/1/22, revealed the policy is to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Compliance guidelines: 7. perform hand hygiene. 8. don gloves. Observation on 5/22/22 at 8:30 a.m. revealed Certified Nursing Assistant (CNA) AA, in R#11's room, wearing gloves when surveyor entered room. She was not observed to have washed her hands prior to gathering supplies to perform catheter care for R#11. She explained procedure to resident. Without changing gloves, CNA AA pulled back the covers and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2022-05-22 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days after completion for seven residents (R) (R#1, R#2, R#3, R#5, R#7, R#8, and R#33) triggered for past due MDS assessment, of 30 sampled residents. Findings include: During an interview on 5/21/22 at 3:45 p.m. with the Corporate Nurse she confirmed the MDS assessments for R#1 Entry Record dated 1/25/20, R#2 Entry Record dated 1/25/19, R#3 Entry Record dated 6/1/17, R#5 Entry Record dated 1/18/22 , R#7 Entry Record dated 9/17/22, R#8, Entry Record dated 6/25/20 and R#33 Entry Record dated 5/18/20 had not been transmitted within the 14 days after completion and she revealed she transmitted all 7 assessments at this time. During an interview, and review of the MDS Assessments for R#1, R#2, R#3, R#5, R#7, R#8, and R#33, on 5/21/22 at 3:47 p.m. with the MDS Coordinator revealed she is the MDS Coordinator for a sister facility and is filling in today for MDS Coordinator for the facility. She stated she can go over the MDS assessments for the residents who triggered as…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$4,233 in federal fines across 1 penalty.

  • $4,233 — penalty dated 2023-10-23

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 JOURNEY HEALTHCARE — 32 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 2 of 52.3-0.3 vs chain
Staffing 1 of 51.5-0.5 vs chain
Quality measures 1 of 52.7-1.7 vs chain
The other 31 homes this chain runs (chain average 1.9★, per CMS)
1 of 5Calhoun Crossing Of Journey LLCCalhoun, GA 1 of 5Clifton HeightsLouisville, KY 1 of 5Crossroads of Flowery Branch of Journey LLC, TheFlowery Branch, GA 1 of 5Fairburn Heights Of Journey LLCFairburn, GA 1 of 5Jesup Ridge of Journey LLCJesup, GA 1 of 5Kirtland Woods Of JourneyKirtland, OH 1 of 5Morgantown Heights Of JourneyMorgantown, WV 1 of 5Murray Woods Of Journey LLCChatsworth, GA 1 of 5Reserve at Appling of Journey LLC, TheAppling, GA 1 of 5Stanford CrossingStanford, KY 1 of 5Stone Mountain Run Of Journey LLCStone Mountain, GA 1 of 5Thomasville Vistas of Journey LLCThomasville, GA 1 of 5Tucker Park Crossing of Journey LLCTucker, GA 2 of 5Crossings At East Lake Of Journey Llc, TheDecatur, GA 2 of 5Fort Valley Crossing of Journey LLCFort Valley, GA 2 of 5Frankfort TrailsFrankfort, KY 2 of 5Glasgow Hills Of JourneyGlasgow, WV 2 of 5Reserve at Fort Gaines of Journey LLC, TheFort Gaines, GA 2 of 5Warrenton Woods of Journey LLCWarrenton, GA 2 of 5Woods at Lumber City of Journey LLC, TheLumber City, GA 3 of 5Bainbridge Landing of Journey LLCBainbridge, GA 3 of 5Cartersville Crossing Of Journey LLCCartersville, GA 3 of 5Chardon WoodsChardon, OH 3 of 5Dublin Trails Of Journey LLCDublin, GA 3 of 5LaGrange Trails of Journey LLCLagrange, GA 3 of 5Riverside Valley Of JourneySaint Albans, WV 3 of 5Twin City Trails of Journey LLCTwin City, GA 3 of 5Vanceburg HillsVanceburg, KY 4 of 5Green River TrailsGreensburg, KY 4 of 5Roberta Trails of Journey LLCRoberta, GANot rated (Special Focus)Lyndon Crossing, LLCLouisville, KY

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
JOURNEY OX OF GA LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2024
3 BEES HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
AJOJ HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
BEES FAMILY IRREVOCABLE TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
BLUE OCEAN TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
JOURNEY OX GA HEALTHCARE HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
SHASAM FAMILY TRUSTOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
SHASAM HOLDINGS LLCOrganizationINDIRECT OWNERSHIP INTERESTsince 11/01/2024
MCGUINNESS, BERNARDIndividualINDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/01/2025
JOURNEY OX GA MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
BILBO, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/20/2024
CLARKE, BOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
CONRAD, CAMERONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
DYKES, MICHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
FRINKS, TERENCEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
JOHNSON, JENNIFERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
JONES, ANTONIOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/18/2024
OMARA, JODYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
SILLINGS, NIKKIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/13/2025
SPRINGS, ERICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
TRAMMELL, MATTHEWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2024
SUMMIT JASPER LLCOrganizationADP OF THE SNFsince 11/01/2024

CMS files one row per role, so the 37 rows in the source record cover these 22 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.

10 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.

$5.8M
Net patient revenuemost recent cost report
-32.4%
Operating marginrevenue minus expenses
$295K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 11%Other / private 29%

This home reported $295K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$394per resident / day
operating cost
$11,985per month
≈ monthly operating cost
$298per day
avg. revenue, all payers

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

What families pay in GA

Paying with Medicaid

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.

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115502. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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