Altamaha Healthcare Center
1311 West Cherry Street, Jesup, GA 31545 · For profit - Corporation · 62 certified beds · (912) 427-7792 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,017 in federal fines (most recent 2024-07-31)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.0% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.6% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.8% | 0.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.2% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 26.1% | 11.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.7% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 22.0% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 27.1% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.1% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.7% | 15.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 31.3% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.4% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 28.1% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.5% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.15 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.26 | 1.90 | 1.80 | worse |
§ 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.
57.6% 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 51 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 69.2% 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 52 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.6%CMS range 41.0–69.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.6–13.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 69.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 61.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 51.9% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.3% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.0–12.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 62 beds and averages 51.5 residents a day — about 83% occupied, or roughly 10 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 2.78 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.26 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.60 hrs/resident/day on weekends vs 2.86 on weekdays — 9% thinner on weekends. RN hours go from 0.30 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2025-08-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policies titled Safe Smoking Standard and Fall Management, the facility failed to ensure an environment free from accident hazards for two of 42 sampled residents (R) (R51 and R6). Harm was identified to have occurred on 7/30/2025, when Certified Nursing Assistant (CNA)12 was independently providing a bed bath for R51, and the resident fell from the bed. It was determined that R51 required two-person assistance for bed mobility (turning from left to right in the bed). Findings included:A review of the facility's policy titled Fall Management, dated January 2025, indicated, The facility strives to reduce the risk of falls and injuries by promoting the implementation of the Risk Reduction: Falls and Injuries Program. Residents are assessed for the fall risk factors. The interdisciplinary team works with the residents and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. A review of the facility's policy titled Safe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2026-06-04 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews, record review, review of the facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the facility policy titled, Staffing Policy, the facility failed to ensure Registered Nurse (RN) coverage was available in the facility for eight consecutive hours daily. This failure had the potential to negatively impact all residents at the facility.Findings included:Review of the facility's policy titled, Staffing Policy, dated January 2025 documented Procedure. 4. Staffing will include a Registered Nurse (RN) 8 hours a day. 5. The nursing services department will be under the authority and responsibility of the director of Nursing service who is a licensed registered nurse and who works as least eight hours a day. Review of the facility's PBJ Staffing Data Report for fiscal year 2026, Quarter 1 (October 1, 2025- December 31, 2025) identified by the submitted data, including but not limited to: no RN hours on four or more days during the quarter. The report documented no RN hours on the following dates: 10/04/2025,…
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.
- Potential for harm · F2025-08-09 · tag F0585 — failed to handle grievances — widespreadHonor 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 staff interviews and review of the facility's policy titled Grievance Policy, the facility failed to develop a grievance policy that met all regulatory requirements. This failure had the potential to affect all 56 residents who resided in the facility.Findings included:A review of the facility's policy titled, Grievance Policy, dated January 2025, revealed the policy did not include procedures to notify the resident of their right to file a grievance in writing or orally, the right to file a grievance anonymously, the reasonable timeframe the resident could expect a completed review of the grievance, the right to obtain the review in writing, the required contact information of the grievance official, and the contact information of outside entities with whom grievances could also be filed. The policy did not identify the grievance official and did not include steps to prevent any further potential violation of any resident's rights during the grievance review. Furthermore, the policy did not describe how the facility supported the resident's right to voice any 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.
- Potential for harm · F2025-08-09 · tag F0761 — failed to label and store drugs safely — widespreadEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that two of two medication carts were locked when out of the sight of a licensed nurse.Findings included:A review of the facility's policy titled Medication Administration, dated 1/2025, indicated, Medication carts are to be kept locked at all times and under the visual supervision of the licensed nurse.During an observation on 8/4/2025 at 11:22 am, the medication cart in the 300 Hall was unlocked, and the nurse was in a room down the hall.During a concurrent observation and interview on 8/6/2025 at 8:45 pm, a medication cart located by room [ROOM NUMBER] was unlocked, and there were three bottles of medications on top of the cart: iron, melatonin, and docusate sodium. Licensed Practical Nurse (LPN)1 walked down the hall after coming out of room [ROOM NUMBER] and stated the medication cart should have been locked when she walked away, but a resident needed something…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-09 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews and review of the facility's policy titled Resident Rights & Dignity Management, the facility failed to ensure mail was delivered to residents on Saturdays. Specifically, mail was delivered to a locked box outside the facility on Saturdays; however, no staff retrieved and delivered the mail to the residents until Monday morning. This had the potential to affect all residents who might have received mail on Saturdays.Findings included:A review of the facility's policy titled Resident Rights & Dignity Management, dated January 2025, indicated, 3. The facility will make every effort to assist each resident in exercising their right to ensure that the resident is always treated with respect, kindness, and dignity.During a Resident Council meeting on 8/5/2025 at 3:00 pm, six residents stated they did not receive mail on Saturdays. Per the residents, the Activities Director (AD) delivered the residents' weekend mail on Monday mornings.During an interview on 8/9/2025 at 10:08 am, the AD stated that mail delivery came around 11:30 am, Monday through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-09 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observation, interview, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was five percent (%) or less. There were six medication errors out of 27 opportunities, which yielded a medication error rate of 22.2% for three of five residents (R) (R5, R10, and R45) observed for medication administration.Findings included:A review of the facility's policy titled Medication Administration, dated 1/2025, indicated, Policy: To promote the health and safety of the residents we serve by ensuring safe assistance and administration of medications and treatments. The policy specified, b. The residents' MAR [medication administration record] is reviewed to determine what medications are to be administered, and then the staff removes those medications from the medication cart. c. Staff will compare the MAR with the label of each medication for the following: i. Right Person ii. Right Medication iii. Right Date iv. Right Time v. Right Route vi. Right Dose vii. Expiration Date.1. A review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-09 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, review of the Healthcare Professional Operator's Manual and review of the facility's policies titled, Glucometer Cleaning, and Respiratory Management, the facility failed to ensure that infection control practices were followed for five of five of 42 sampled residents (R) (R30, R45, R49, R24 and R47). Specifically, the nurse failed to ensure that the glucometer was cleaned and disinfected between use for R30, R45, and R49; the facility also failed to ensure that staff did not touch medication with their bare hands for R45 during medication administration; and the facility failed to ensure that respiratory equipment was cleaned and stored appropriately for R24 and R47.Findings included: A review of the facility's policy titled Glucometer Cleaning, dated January 2025, indicated, All glucometers must be cleaned/disinfected after each resident use. Per the policy, Wipe Down with Sani-cloths. The policy specified, Supplies and medications for finger stick monitoring or insulin administration should not be placed on potentially contaminated environmental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interviews, record review, and review of the facility's policy titled Behavior Management Standard, the facility failed to discuss the risks and benefits and obtain informed consent before the administration of a psychotropic medication for one of five residents (R) (R4) reviewed for unnecessary medications.Findings included:A review of the facility's policy titled Behavior Management Standard, dated January 2025, indicated, The resident or their responsible party has the right to be informed about the resident's condition; treatment options; risks/benefits and expected outcomes of treatment for the purpose of making informed choices about the use of medications including the right to refuse care and treatment.A review of R4's admission Record revealed that the resident had a medical history that included diagnoses of vascular dementia, seizures, and nontraumatic subdural hemorrhage.A review of R4's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/20/2025, revealed R4 had a Brief Interview for Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
Based on staff and resident interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to report an allegation of abuse and neglect for two of two residents (R) (R66 and R14) reviewed for abuse out of a total sample size of 42 residents. Specifically, the facility failed to report an allegation of abuse/neglect made on 10/16/2024 by R66 that Certified Nursing Assistant (CNA)15 was rough during the provision of care and did not check on the resident or provide incontinence care from 6:00 pm to 6:00 am on 10/16/2024. Also, the facility failed to report an allegation of verbal abuse made on 10/22/2024 by R14 that CNA15 yelled at them.Findings included:A review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, dated January 2025, indicated, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, the facility failed to investigate an allegation of abuse and neglect for two of two residents (R) (R14 and R66) reviewed for abuse out of a total sample size of 42 residents.Findings included:A review of the facility's policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts, dated 1/2025, indicated, All alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state and federal law.1. A review of R66's admission Record revealed the resident had a medical history that included a diagnosis of chronic pain. The admission Record indicated the resident was discharged from the facility on 11/5/2024.A review of R66's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/8/2024, revealed R66 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0644 — isolatedCoordinate 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
Based on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I was updated and resubmitted following the onset of a new mental illness diagnosis for one of 42 sampled residents (R) (R46) reviewed for PASARR.Findings included:A review of R46's admission Record revealed that the resident had a medical history that included diagnoses of vascular dementia with anxiety (onset date 7/1/2025), generalized anxiety disorder (onset date 11/1/2023), and other bipolar disorder (onset date 4/1/2025).A review of R46's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/25/2025, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident had active diagnoses to include anxiety disorder and bipolar disorder.A review of R46's Care Plan Report, included a focus area revised 4/25/2023, that indicated the resident used anti-anxiety medications related to a diagnosis of anxiety…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · D2025-08-09 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility's policy titled Resident Hygiene, the facility failed to ensure nail care was provided for one of two residents (R) (R39) reviewed for activities of daily living (ADL) care. Findings included:A review of the facility's policy titled Resident Hygiene, dated January 2025, revealed that Nail care includes daily cleaning and regular trimming. Nail trimming for diabetic residents is per the MD [medical doctor] order. Podiatry care is scheduled as needed for those residents with identified podiatry needs. A review of R39's admission Record revealed that the resident had a medical history that included diagnoses of type 2 diabetes mellitus and the need for assistance with personal care. A review of R39's Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/31/2025, revealed R39 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills for daily decision-making. The MDS indicated the resident was dependent on staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and record review, the facility failed to follow up on outside physician recommendations, which caused a delay in treatment for one of two residents (R) (R47) reviewed for skin conditions. Findings included: A review of R47's medical records revealed the resident had a medical history that included a diagnosis of seborrheic dermatitis.A review of R47's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/12/2025, revealed R47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A review of R47's Care Plan Report included a focus area revised 4/15/2025, which indicated the resident had a potential for impairment to skin integrity related to eczema, edema, fragile skin, limited mobility, diabetes mellitus, and peripheral vascular disease. A review of R47's dermatology Office Visit Note dated 7/31/2025, revealed recommendations for treatment for the resident's diagnosis of seborrheic dermatitis on their face and ears included triamcinolone twice a day…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Respiratory System Management, the facility failed to ensure respiratory equipment was available and functioning properly for one of four residents (R) (R24) reviewed for respiratory services.Findings included:A review of the facility's policy titled Respiratory System Management, dated January 2025, indicated Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BIPAP) Policy. CPAP/BIPAP is provided to residents who have a physician's order. The procedure specified, 10. The nurse or respiratory therapist should observe the resident with the mask on for proper fit.A review of R24's admission Record revealed that the resident had a medical history that included diagnoses of obstructive sleep apnea and dependence on other enabling machines and devices.A review of R24's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/30/2025, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure the medical records were complete and accurate for two of 14 sampled residents (R) (R10 and R47). Findings included:A review of R10's admission Record revealed the resident had a medical history that included a diagnosis of cerebral infarction due to thrombosis of an unspecified precerebral artery.A review of R10's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 7/1/2025, revealed R10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated that the resident currently used tobacco.A review of R10's Care Plan Report included a focus area initiated on 9/27/2022, which indicated the resident smoked.A review of R10's smoking assessment dated [DATE] indicated that the resident did not smoke, vape, or dip.During an interview on 8/4/2025 at 3:28 pm, R10 stated they smoked cigarettes.During an interview on 8/6/2025 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-07-31 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and policy review, the facility failed to ensure food was not stored on the floor, expired foods were disposed of in a timely manner, ready-to-eat food was not touched with bare hands, and moldy food was not stored for use in accordance with professional standards for food service safety as required for 52 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among facility residents. Findings include: Review of a facility policy titled, Nutrition Services Manual, dated 06/2015, revealed, The facility strives to promote good sanitation practices in order to protect its residents/patients and employees from foodborne illness. The facility sanitation system will ensure a clean, safe environment for its residents/patients and staff .The Nutrition Services staff follows infection control procedures including maintaining personal hygiene and handling foods to prevent contamination .Verify expiration dates are appropriate on individual cartons .Store delivered items immediately upon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-07-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, personnel file review, and policy review, the facility failed to 1. follow manufacturer's instructions regarding the cleaning and disinfecting of one of one glucometer between residents' use. 2. follow pre-employment and annual purified protein derivative (PPD) (skin test that determines if you have tuberculosis) guidelines of obtaining PPD 1st and 2nd step at the time of employment for six of nine personnel files (Administrator, Director of Nursing (DON), Certified Nurse Aide (CNA) 2, Licensed Practical Nurse (LPN) 2, Dietary Aide (DA) 1, and LPN3) reviewed, 3. obtain annual PPD test for two of nine personnel files (LPN1 and CNA1) reviewed, and 4. maintain a current infection surveillance program for 2024. Failure to follow infection control guidelines could result in the residents acquiring a blood-borne pathogen or infectious disease. Findings include: 1. Review of the facility's policy titled, Diabetic Management. dated August 2021. indicated Guidelines .14.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-07-31 · tag F0578 — failed to honor advance directives / code status — patternHonor 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, interview, and policy review, the facility failed to provide written information to five residents (Resident (R) 48, R18, R12, R24, and R4) and/or their resident representative concerning the right to formulate an advance directive of 28 sample residents. The failure to discuss advance directive information with the resident and resident representative could potentially affect their ability to make informed decisions about their care. Findings include: Review of the facility's policy titled, Advance Directive, dated 08/09/22, indicated The facility must inform and provide written information to all adult residents concerning the right .to formulate an advance directive .Upon admission/readmission, the facility Social Service Director will inform and educate the resident, or POA [Power of Attorney] in writing about the right .to an advance directive . and upload to the resident's chart . 1. Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was admitted on [DATE].…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on personnel file review, interview, and policy review, the facility failed to follow their policy to obtain background and criminal checks at time of employment for four of nine employee files (Certified Nurse Aide (CNA) 1, CNA2, Licensed Practical Nurse (LPN) 2, and Dietary Aide (DA) 1) reviewed for background checks. The failure to obtain background and criminal checks had the potential to allow facility staff with criminal backgrounds to work with the residents. Findings include: Review of the facility's policy titled, Background and Criminal Checks, dated 12/21/23, indicated The facility .may investigate all statements contained in any documents, applications and/or resumes you have provided. A background check will be conducted . to include .criminal history .fingerprints .references .upon submitting an application of employment, you release the facility . from obtaining such information . Review of four of nine personnel files revealed the Administrator was unable to provide background and criminal checks information for the following staff: -CNA1's file revealed hire…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure seven of seven residents and their representatives (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent hospital transfer, from a total sample of 28 residents, were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, other information regarding the transfer, and information on the right to appeal the transfer. This failure had the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled, Discharge Plan/Transfers, revised 10/20/23, showed it did not address a written notice of transfer, the required contents, or the provision of the notice to the Resident and RR. 1. Review of R27's admission Record from the electronic medical record (EMR) Profile…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-07-31 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of facility policy, the facility failed to ensure seven of seven residents (Resident (R) 27, R29, R38, R48, R116, R112, and R44) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information of 28 sample residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's room following a hospitalization for residents transferred to the hospital. Findings include: Review of the facility policy titled Discharge Plan/Transfers, revised 10/20/23, showed: Policy: All Residents are given the option of reserving their bed when leaving the facility with the intent to return. This temporary absence may be for hospitalization or therapeutic leave. All Residents or their Responsible party are informed in writing about the facility's bed-hold policy at the time of admission. A copy of the bed hold agreement is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI) review, and policy review, the facility failed to revise the care plan to include fall interventions and ensure care conferences were held for one resident (Resident (R) 48) of 28 sample residents reviewed for care planning. The failure to revise the care plan could affect staff implementing interventions to prevent a future fall. Failure to conduct care plan conferences with the resident and/or their resident representatives could cause the resident to not be informed of care interventions as well as for the resident and/or the resident representative to ask questions about the resident's care. Findings include: Review of the facility's policy titled, RAI/Care Plan Management, dated August 2021, indicated Care Conferences are held after the MDS [Minimum Data Set] is completed but before the care plan is due for all new admissions.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0700 — isolatedTry 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 observation, record review, and interview, the facility failed to ensure that three of three residents (Resident (R) 5, R38, and R3) reviewed for bed rail use out of a total of 28 sampled residents had bed rail assessments and attempted alternatives with documented reasons for the failure of the alternative prior to the use of the bed rails. This failure increased the potential risks associated bed rail use and could put the residents at risk for injury, entrapment, and/or death. Findings include: 1. During an observation on 07/29/24 at 10:42 AM, R5 was asleep in bed with bilateral assist bars in the up position; on 07/29/24 at 12:27 PM, and 07/30/24 at 9:45 AM, R5 was asleep in bed with bilateral assist bars. On 07/29/24 at 12:30 PM, R5 was observed in bed eating lunch and the bilateral assist bars were in the up position on the bed. Review of R5's admission Record from the electronic medical record (EMR) showed a facility admission date of 12/12/23 with medical diagnoses that included dementia, periprosthetic fracture around internal prosthetic left hip, peripheral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure pharmacy provided medications timely and residents received medications as ordered by the physician for one of six residents (Residents (R) 113) reviewed for medication administration out of 28 sample residents. The failure of the facility to ensure medications were provided from the pharmacy had the potential to affect all residents requiring administration of medications. Findings include: Review of the facility's policy titled, Medication Administration Guide, dated July 2023, revealed If a medication is not administered because the medication is not available, make every effort to locate the medication. If the medication cannot be located, check the interim or emergency kit for the medication so that the medication pass can be completed .Document unavailable medications appropriately per facility policy. Contact the pharmacy and arrange for delivery of the medication. Review of R113's admission Record located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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, interview, and policy review, the facility nurses failed to document the behaviors that were occurring and what nonpharmacological interventions were attempted prior to the administration of antipsychotic medication, Seroquel Intramuscularly (IM) for one of five residents (Resident (R) 48) reviewed for unnecessary medications of 28 sample residents. The failure could result in the resident receiving unnecessary medication. Findings include: Review of the facility's policy titled, Behavior Management Standard, dated September 2021, indicated . Goals for use of psychoactive .The Interdisciplinary Team (IDT) will ensure the following have been completed before a psychoactive medication is administered .targeted behavior is identified; behavior monitoring sheets are initiated .Appropriate nonpharmacological interventions have been identified prior and implemented based on an individual resident assessment . Review of R48's electronic medical record (EMR) Profile tab, indicated R48 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-31 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility nurse failed to follow the physician order and provide the resident his insulin per the sliding scale order for one of seven residents (Resident (R) 3) reviewed during medication administration of 28 sample residents. Specifically, the resident did not have the insulin available for medication administration. This failure caused a significant medication error which could affect the management of R3's diabetes and glucose levels. Findings include: Review of the facility's policy titled, Medication Administration Guidelines dated August 2021, indicated, General and Specific Guidelines on Administration of Medications by Routes .c. Staff will compare the MAR [Medication Administration Record] with the label of each medication for the following: Right person, Right medication .e. Staff will compare the label with the MAR for a second time. G. Staff will compare the label on the medication to the MAR for a third time before administering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-24 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASRR) accurately reflected diagnosed mental illnesses for three (Resident [R] #3, R#44, and R#50) of six sampled residents who were reviewed for PASRR. Findings include: During an interview on 6/24/2022 at 8:20 AM, the Administrator revealed the facility did not have a policy for PASRR. 1. A review of the admission Record for R#3 revealed the facility admitted the resident on 4/8/2019 with diagnoses of paranoid schizophrenia and bipolar disorder. A review of the PASRR Level I Assessment Form, dated 04/08/2019 revealed the screening did not reflect the resident's diagnosed mental illnesses. Review of a Minimum Data Set (MDS) Care Area Assessment (CAA) Summary, dated 11/16/2021, revealed R#3 received psychoactive medications for diagnoses of schizophrenia, manic depression, depression, and anxiety disorders. Review of a Care Plan, revised 4/16/2022, revealed R#3 had a cognitive deficit related to paranoid schizophrenia and bipolar disorder, was at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-24 · tag F0759 — failed to keep medication error rate low — patternEnsure 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 observation, staff interviews, record review, and review of policy titled Medication Administration Guidelines, the facility failed ensure the medication error rate was less than 5%. There were six medication errors with 25 opportunities, which resulted in a 24% medication error rate. This failure affected two residents, Resident (R) #41 and R#15. Findings include: A review of the facility document titled, Medication Administration Guidelines, dated September 2019, revealed, Medication Administration: Upon administering medication, the licensed nurse will compare the label on the medication to the MAR [Medication Administration Record] to ensure accuracy. All variances are to be reported to the pharmacy immediately. General and Specific Guidelines on Administration of Medication by Routes: A. General procedures completed before administering medication by any route: c. Staff will compare the MAR with the label of each medication for the following: i. Right Person ii. Right Medication iii. Right Date iv. Right Time v. Right Route. vi. Right Dose vii. Expiration date. D. 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.
- Potential for harm · Dcited before2022-06-24 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of policy titled Advance Directives/DNRO [Do Not Resuscitate Order] Log, the facility failed to ensure the resident's code/advanced directive status was promptly determined and documented in an easily accessible location in the medical record to facility staff's ability to honor the resident/responsible party's wishes for one (Resident [R] #154 of three sampled residents reviewed for advance directives. Findings include: Review of a facility policy titled, Advance Directives/DNRO [Do Not Resuscitate Order] Log, dated 02/2015, revealed, To assist in recording and managing Advance Directives information in the medical record. Responsible Person: Director of Social Services. When: Upon admission. Review and update quarterly. Review and update with change of condition. The policy also indicated, 3. Indicate presence of Advance Directives by referring to Advance Directives documents. Initial next to each one applicable. 4. Indicate if the resident/patient has a DNRO. 5.…
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.
- No harm found · C2024-07-31 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that the daily nurse staffing was posted to accurately reflect the actual staff hours to care for the 52 current residents for three of four survey days. This failure had the potential to inaccurately inform any resident, family member, or visitor of the available nursing staff caring for residents. Findings include: An observation throughout the facility on 07/28/24 at 6:43 PM revealed the daily nurse staffing was not posted. Observations throughout the facility on 07/29/24 at 9:30 AM and at 10:40 AM revealed the daily nurse staffing was not posted. An observation throughout the facility on 07/30/24 at 6:05 PM revealed the daily nurse staffing was not posted. During an interview on 07/31/24 at 8:15 AM, the Administrator stated that the daily nurse staff posting should have been posted in the glass display window near the front of the facility each day. She confirmed the staffing had not been posted for three of the four survey days.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,017 in federal fines across 1 penalty.
- $4,017 — penalty dated 2024-07-31
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 BEACON HEALTH MANAGEMENT — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.5 | -0.5 vs chain |
| Health inspection | 1 of 5 | 1.8 | -0.8 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 2.1 | -0.1 vs chain |
The other 10 homes this chain runs (chain average 1.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RWC HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| PWW HEALTHCARE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| MUKWINDIDZA, CHIDO | Individual | W-2 MANAGING EMPLOYEE | — | since 06/01/2021 |
| BEACON HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2016 |
| WERTHEIM, BRUCE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2016 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $519K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115577. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-09, 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.