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Jonesboro Center for Nursing and Healing LLC

2650 Highway 138 SE, Jonesboro, GA 30236 · For profit - Limited Liability company · 129 certified beds · (770) 473-4436 Medicare & Medicaid certified

Call the home — (770) 473-4436 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
$16,801 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,801 in federal fines (most recent 2023-10-26)
  • 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 (2/5)
  • nursing-staff turnover (57%) 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 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
7823 Spivey Boulevard · (770) 996-1122 · Call to confirm hours
Pharmacy
899 Highway 138 W · (770) 703-8661 · Call to confirm hours
Grocery
Food Mart1.6 mi
3441 Mount Zion Pkwy · (678) 289-4786 · Call to confirm hours
Park
2300 Hwy 138 SE · (770) 473-5425 · Typically dawn to dusk
Place of worship
2613 Highway 138 E · (770) 478-7887

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 3 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 fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
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 increased12.8%15.3%15.4%better
Long-stay residents who lose too much weight6.6%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 infection1.7%2.5%2.0%better
Long-stay residents with depressive symptoms0.3%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened21.7%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication13.0%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%95.0%95.3%typical
Long-stay residents with pressure ulcers7.3%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control15.2%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table8.8%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine70.5%78.4%79.4%worse
Short-stay residents rehospitalized after admission28.6%25.0%22.6%worse
Short-stay residents with an outpatient ER visit9.0%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days2.472.151.67worse
Long-stay outpatient ER visits per 1,000 resident days1.731.901.80typical

§ 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.

48.9% 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 123 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

48.9%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
31.3%U.S. median 56.6%
Met the expected recovery
0.43U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 31.3% 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 67 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 29% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

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 SNF48.9%CMS range 40.5–58.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.1–14.010.7%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 discharge31.3%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 discharge41.8%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 discharge22.4%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 identified97.2%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 setting100.0%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 discharge96.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.9%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 worsened1.9%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 hospitalization8.9%CMS range 5.5–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 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

0.24
RN hours/ resident / day
1.25
LPN hours/ resident / day
1.83
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.18
RN hoursweekends
56.8%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 129 beds and averages 118.6 residents a day — about 92% occupied, or roughly 10 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 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.24 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.83 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.72 hrs/resident/day on weekends vs 3.57 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.27 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

13
deficiencies at the latest standard inspection (2026-02-12)
3
at the previous standard inspection (2025-03-27)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · F2026-02-12 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility policy titled, Advance Beneficiary Notices, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) as required for three of three sampled residents (Resident (R) 160, R76, and R103) reviewed for beneficiary notices out of a sample of 50 residents. This failure had the potential to lead to financial burdens for residents, as they may have to pay out-of-pocket for care that is typically covered by Medicare.Findings include:Review of the facility provided policy titled, Advance Beneficiary Notices with a revision date of 11/23 indicated Policy:. It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. Policy Explanation and Compliance Guidelines:. 1. The Business Office Manager is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits. A notice alerting residents/ representatives of this contact person…

    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 · F2026-02-12 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 observation, interview, document review, and policy review, the facility failed to ensure tuna salad sandwiches were served at the proper temperature. This deficient practice had the potential to cause food born illnesses affect 115 out of 119 residents. Findings included: During the second kitchen observation and interview on 02/11/26 from 11:58 AM to 12:42 PM, the following observations were made with the Dietary Manager (DM):A small steam table pan was observed on the counter at the left end of the steam table. The steam table pan contained eight tuna salad sandwiches, stacked one on top of one another, in stacks of two. At 12:09 PM the [NAME] stated the tuna salad sandwiches were the alternate menu item and were ready to be served to residents in the dining room. The DM took the temperature of the tuna salad sandwiches; the temperature was 55 degrees Fahrenheit (F). The DM and the Registered Dietician (RD) stated the tuna salad sandwiches should be 41 degrees F to be served. The [NAME] stated she put the tuna sandwiches in the freezer to cool. At 12:20 PM the DM 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility policy titled, Promoting/ Maintaining Resident Dignity, the facility failed to ensure staff dressed residents in daily clothing for one of one (Resident (R) 30) reviewed for dignity. This failure had the potential to cause embarrassment for the resident and failed to respect the resident's autonomy to maintain their personal identity.Findings include:Review of the facility provided a policy titled, Promoting/ Maintaining Resident Dignity, with a revision date of 03/25 indicated Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines:1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.Review of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    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 interview, and review of the facility policy titled, MDS3.0 Completion, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) within the required timeframe when a resident experienced multiple areas of functional decline for one of five residents (Resident (R) 57) reviewed for resident assessments. This failure placed R57 at risk for further decline if care plan revisions and interventions addressing the resident's change in condition were delayed.Findings include:Review of the facility's policy titled, MDS3.0 Completion, dated October 2025, revealed, an SCSA within 14 days of identifying a qualifying status change that affects more than one area and requires Interdisciplinary Team review and revision of the care plan. Review of R57's admission Record, dated 02/12/26 located in the resident's electronic medical record (EMR) under the Profile tab, revealed R144 admitted to the facility on [DATE] with multiple diagnoses including…

    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 · D2026-02-12 · tag F0640 — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and review of the facility policy titled, MDS3.0 Completion, the facility failed to transmit Minimum Data Set (MDS) assessments within the federally required timeframe for two of five residents (Resident (R) 4 and R144) reviewed for Resident Assessments. This failure had the potential to affect the accuracy and timeliness of federally required resident assessments. Findings include:Review of the facility's policy titled, MDS3.0 Completion, dated October 2025, documented the MDS transmission requirements of All assessments shall be transmitted to the designated [Centers for Medicare and Medicaid Services] CMS System (iQlES) within 14 days of completion. 1. Review of R144's admission Record, dated 02/10/26 located in the electronic medical record (EMR) under the Profile tab revealed R144 was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes, end stage renal disease, and dementia. Review of R144's admission MDS, with an Assessment…

    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 · D2026-02-12 · 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 interview, record review, and review of the facility policy titled, the facility failed to ensure accurate assessments were completed for four of 50 sample residents (Resident (R) 33, R117, R67 and R96) by failing to capture services the residents were receiving. This failure has the potential to prevent residents from receiving a needed service.Findings include: Review of the facility's policy titled, MDS 3.0 Completion, dated October 2025, indicated the discharge MDS assessment requirements as follows: Discharge Assessment – completed using the discharge date as the ARD and must be completed within 14 days of the discharge date /ARD. 1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia. Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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 record review, interview, and facility policy titled, Resident Assessment-Coordination with PASARR Program, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II assessment was completed for one resident (Resident (R) 94) reviewed for PASARR, who has a diagnosis of bipolar disorder and requires specialized services. This failure had the potential of placing R94 at risk for inappropriate care and lack of specialized services. Findings include:Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, with a revision date of 12/24 indicated Policy:.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 receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. A11 applicants to this facility will…

    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 before2026-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the policy titled, Activities of Daily Living, the facility failed to ensure good hygiene was maintained for three residents (Residents (R) 1, R7, and R156) out of nine reviewed for activities of daily living (ADL) in the sample of 50 residents. This failure has the potential for the residents to develop skin infections, have poor hygiene and a general decline in health.Findings include:Review of the facility's policy titled, Activities of Daily Living, implemented October 2025, revealed, .based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs (activities of daily living) do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living: Bathing.1.Review of R1's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 04/22/25 with diagnoses of chronic…

    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 · D2026-02-12 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and interviews, the facility failed to ensure two residents (Resident (R) 33 and R12) of two residents reviewed for activities out of a sample of 50 residents received an ongoing activities program to support their choice of activities. This failure had the potential for the residents' physical, mental, and psychosocial well-being to worsen and potentially develop a general decline in health. Findings include:1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia.Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. R33 had bilateral impairment of the upper extremities and on one side of her lower extremities. She was dependent on staff for all activities of daily…

    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 before2026-02-12 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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 observations, interviews, record review, and policy review, the facility failed to ensure one resident (Resident (R) 33) reviewed for skin concerns out of a total sample of 50 residents received the proper care and monitoring to prevent an axilla rash under the left arm from worsening. This failure had the potential for R33's skin to worsen, cause pain, and potentially develop a general decline in health. Findings include:Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date 01/06/22, with diagnoses of chronic systolic (congestive) heart failure and dementia.Review of R33's annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) which indicated the resident was severely cognitively impaired. R33 was dependent on staff for all activities of daily living (ADL). R33 did not have Applications of ointments/medications listed under the skin conditions 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2026-02-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure two of two resident (Resident (R) 33 and R83) reviewed for range of motion (ROM) out of a sample of 50 residents received restorative services to ensure ROM did not worsen in the upper and lower extremities, splint devices were in place, and failed to ensure staff were educated on placement of splint devices. This failure had the potential for the resident's ROM to worsen, cause pain, skin break down and potentially develop a general decline in health. Findings include: 1.Review of R33's Face Sheet, located in the electronic medical records (EMR) under the Profile tab indicated an admission date of 01/06/22 with diagnoses of chronic systolic (congestive) heart failure and dementia. Review of R33's modified annual Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/07/25 indicated R33 was unable to complete the Brief Interview for Mental Status (BIMS) 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-12 · 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 observation, interview, record review, and facility policy review, the facility failed to ensure respiratory supplies were dated and stored in a sanitary manner in accordance with professional standards for one of two residents (Residents (R)117) reviewed for respiratory care. This failure had the potential to affect infection control and had the potential to spread infection in the facility. Findings include:Review of R117's admission Record, located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, asthma, and obstructive sleep apnea. Review of R117's Orders, located under the Orders tab of the EMR revealed an order for Oxygen at three liters through nasal cannula (NC) for shortness of breath (SOB), monitor for SOB when resident is lying flat, if SOB when lying flat lift head of bed, document and notify medical director (MD) of any changes, every shift starting…

    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 · D2026-02-12 · 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, interview, and a review of the facility policy titled Hospice Services Facility Agreement, the facility failed to ensure comprehensive fall assessments were completed after a fall, and implement appropriate, individualized fall interventions, placing residents at risk for falls and fall-related injuries for one of five (Resident (R) 68) residents reviewed for falls and also failed to ensure the medical record was complete and accurate for two of three hospice residents (R14 and R36) out of the total sample of 50 residents. This failure placed residents at risk for unmet care needs. Findings include: Review of the facility's policy titled, Hospice Services Facility Agreement, reviewed 09/23, revealed d. Obtaining the following information from the hospice. i. The most recent hospice plan of care specific to each resident.e. Ensuring that the facility provides orientation to hospice staff of the following.iv. Record keeping requirements. 1. Review of R68's Progress Notes, located under 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 · D2025-03-27 · tag F0625 — isolated
    Notify 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 staff interviews, record review, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for one of 40 sampled residents (R) (R16). This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the electronic medical record (EMR) for R16 revealed they were admitted to the facility with diagnoses of but not limited to end stage renal disease, type 2 diabetes mellitus without complications acute on chronic diastolic (congestive) heart failure spinal stenosis, cervical region, generalized anxiety disorder, chronic kidney disease, stage 5, anemia in chronic kidney disease, Alzheimer's disease, unspecified, acute embolism and thrombosis of deep veins of left upper extremity, pruritus, unspecified, depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R16 documented a Brief…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-27 · 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

    Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Person-Centered Care Plans, the facility failed to implement a care plan for oxygen (O2) therapy for one of 10 residents (R) (R53) receiving O2 therapy. The deficient practice had the potential for R53's needs to go unmet. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans dated January 2025 revealed under Policy: Each resident will have a person-centered plan of Care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Review of the Physician's Orders for R53 revealed an order dated 3/27/2025 for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) as needed for O2 sats (saturations) oxygen in place for R53. Review of R53 care plan revealed a care plan intervention for the use of oxygen set at 2 L (liters). Observation and interview during the initial screening on 3/25/2025 at 10:00 am revealed R53's O2 level was set at 3 LPM. R53…

    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 before2025-03-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident and staff interviews, and review of the facility's policies titled, Admission/readmission Orders and Oxygen (O2) Therapy, the facility failed to transcribe and to have physician orders for catheter care for one of one resident (R) (R93) reviewed with an indwelling catheter; and failed to follow physician orders to administer O2 to one of 10 R's (R53) receiving O2 therapy. The deficient practice had the potential to cause risk of complications, urinary tract infections (UTI) and other catheter-related harm to R93, and low O2 levels to R53. Findings include: Review of the facility policy titled Oxygen Therapy dated January 2025 documented under Procedure: 1: Oxygen Therapy is to be provide under the direction of a written physician's order. A physician order for O2 therapy is to contain liter flow per minute via mask or canula/time frame. On an emergency basis, O2 may be used at 2L/minute (liters per minute-LPM) until the oxygen is ordered. Review of the facility…

    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 · D2023-10-26 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, record review, and review of the policies titled Self-Administration Protocol and Medication Administration: General Guidelines, the facility failed to assess one of four residents (R) (R80) for the ability to self-administer medications prior to leaving medications at the bedside. Findings included: A review of the policy titled Medication Administration: General Guidelines revealed the policy was: Procedure: 2. Medications are administered, in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and the Interdisciplinary Team and in accordance with procedures for self-administration of medications. A review of the policy titled Self-Administration Protocol revealed the policy was: Procedure: 1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order…

    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 · D2023-10-26 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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, interviews, and review of facility documentation, the facility failed to maintain a clean, homelike environment as evidenced by dirty packaged terminal air conditioner (PTAC) filters and grills, detached PTAC cover, missing PTAC ventilation slats, a non-functioning bathroom emergency call light, a missing dresser drawer handle, a broken closet door handle, and detached baseboards which were observed on three of three units. Findings included: During an observation of resident rooms on 10/24/2023 revealed the following: * At 1:26 pm, room [ROOM NUMBER] was observed with dirty PTAC filters. * At 3:02 pm, room [ROOM NUMBER] was observed with dirty PTAC filters, and the bathroom emergency call light did not light up outside the room. * At 3:20 pm, room [ROOM NUMBER] was observed with dirty PTAC filters and a missing dresser drawer handle. During an observation of resident rooms on 10/25/2023 beginning at 11:35 am revealed the following: * room [ROOM NUMBER] was observed with dirty PTAC filters…

    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 before2023-10-26 · 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 review of policy and procedures titled Comprehensive Person-Centered Care Plans the facility failed to implement a care plan for one of three residents (R) (R30) observed during wound care. Findings included: A review of the policy titled Comprehensive Person-Centered Care Plans dated March 2018, revealed each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Under the heading Procedure, number six revealed staff approaches are to be developed for each problem/strength/need and assigned disciplines will be identified to carry out the intervention. An observation of wound care for R30 with Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB assisting RN AA was conducted on 10/25/2023 at 1:31 pm. Prior to beginning wound care, R30 voiced complaints of pain in her leg. RN AA acknowledged the resident stated she…

    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 before2023-10-26 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed provide daily oral care for two of three sampled residents (R) (R51 and R175). Findings included: A review of the undated facility policy titled, A.M. Care, revealed the following: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants Procedure: A. Oral Care: 1. Toothetts for people with no teeth 2. Brush teeth of residents with teeth A review of the undated facility policy titled, P.M. Care, revealed the following: Policy: P.M. Care is provided to the residents daily. Responsibility: All Nursing Assistants 1. An observation and interview with R51 on 10/24/2023 at 2:59 pm in her room, she was alert and oriented, dressed and groomed, and seated in her wheelchair. There was a foul odor coming from her mouth. She stated she was unsure about the frequency of her oral care stating she had very few teeth. She stated she rinses with mouthwash sometimes. A review of the Quarterly Minimum Data Set (MDS)…

    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 · D2023-10-26 · 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 observations, staff interviews, record review, and review of policy and procedures titled Pain Evaluation/Management the facility failed to provide pain management for one of three residents (R) (R30) observed receiving wound care. Findings included: A review of policy titled Pain Evaluation / Management dated April 2014, revealed the policy of the facility for all residents be evaluated for pain at time of admission, re-admission, and as needed. If a new episode of pain is noted complete a Pain Management Evaluation, implement non-pharmacological interventions as appropriate, notify (physician) of unrelieved pain. The (Physician) is called after completion of the Pain Management Evaluation Tool to review evaluation and develop further interventions for relief of pain. An observation of wound care for R30 with Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB assisting the nurse was conducted on 10/25/2023 at 1:31 pm. CNA BB and RN AA performed hand hygiene prior to entering room 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-26 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of policy and procedures titled Handwashing, Pressure Ulcer/Injury and Skin Conditions Guide for Wound Evaluation Documentation and Treatment Technique Competency Audit, the facility failed to ensure hand hygiene was completed between glove changes and between removing old dressings and application of clean dressing during wound care for two of three resident (R) (R50 and R15) reviewed for wound care. Findings included: A review of the policy titled Handwashing dated September 2019, revealed the policy was staff will use proper hand washing technique to prevent the spread of infection. A review of the policy titled Pressure Ulcer/Injury & Skin Conditions Guide for Wound Evaluation Documentation dated November 2017, revealed the practice of the facility was to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection, and prevent new ulcers from developing. A review of Treatment…

    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 · D2023-10-26 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to maintain an emergency bathroom resident call light as evidenced by a malfunctioning emergency call light in one of 24 sampled bathrooms rooms (room [ROOM NUMBER]). Findings included: During an observation of resident room [ROOM NUMBER] on 10/24/2023 at 3:02 pm and 10/25/2023 at 11:35 am revealed the bathroom emergency call light did not light up outside the room when engaged. During an interview and walking rounds on 10/26/2023 at 10:40 am with the Administrator and Maintenance Director confirmed the malfunctioning call light. The Administrator asked the Maintenance Director to immediately replace the light bulb, which did not correct the problem. The Maintenance Director contacted a repairman to repair or replace the call light. On 10/26/2023 at approximately 2:00 pm, the repairman was observed replacing the bathroom emergency call system in room [ROOM NUMBER].

    Environmental 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

$16,801 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $4,017 — penalty dated 2023-10-26
  • $6,284 — penalty dated 2023-10-26
  • $6,500 — penalty dated 2023-10-26
  • Medicare payment denial — starting 2024-01-18 for 29 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$13.3M
Net patient revenuemost recent cost report
-10.2%
Operating marginrevenue minus expenses
$1.8M
Related-party expense12% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 11%Other / private 19%

This home reported $1.8M paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$336per resident / day
operating cost
$10,224per month
≈ monthly operating cost
$305per 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 115545. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, 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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