Lake City Center for Nursing and Healing LLC
2055 Rex Road, Lake City, GA 30260 · For profit - Limited Liability company · 242 certified beds · (404) 361-1028 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 11.2% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.0% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.1% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.0% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.1% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 10.9% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 88.6% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.3% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.0% | 15.8% | 21.2% | better |
| Short-stay residents who newly got an antipsychotic medication | 3.1% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 36.4% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 34.4% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.1% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.30 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.84 | 1.90 | 1.80 | better |
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.
47.1% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 33.3% 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 24 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 47.1%CMS range 31.4–71.6 | 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 | 11.5%CMS range 7.9–16.3 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 33.3% | 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 | 29.2% | 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 | 29.2% | 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 | 54.5% | 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 | 50.0% | 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 | 4.5% | 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 | 2.3% | 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 | 10.0%CMS range 6.1–15.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.19 | 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 242 beds and averages 211.0 residents a day — about 87% occupied, or roughly 31 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 2.84 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.18 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 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 2.59 hrs/resident/day on weekends vs 2.93 on weekdays — 12% thinner on weekends. RN hours go from 0.17 to 0.20 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%. 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.
- Potential for harm · Fcited before2026-04-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure food safety protocols and maintain sanitary conditions for two of two resident refrigerators on Hall 100 and Hall 800 and failed to discard expired food in the dry storage area. The deficient practices had the potential to place 201 residents (R) who received an oral diet from the kitchen at risk of contracting a foodborne illness.Findings Include:Review of the facility's policy titled Food Receiving and Storage, issued April 2025, documented: POLICY: Foods shall be received and stored in a manner that complies with safe food handling practices. GUIDELINES: .6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in first out system. 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated.During the initial tour of the kitchen on 04/17/2026 at 8:05 AM with the Certified Dietary Manager (CDM), the dry storage area contained five…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-19 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure that nail care was provided for one resident (R) (R92) of 35 sampled residents. This failure could lead to skin impairment resulting from toenail overgrowth.Findings include:Review of the electronic medical record (EMR) revealed R92 was admitted to the facility on [DATE] with diagnoses that included but was not limited to spinal stenosis, cervical region and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the orders revealed Podiatry/Oral/Dental Care as needed with a start date of 01/21/2025.During an interview and observation on 04/17/2026 at 12:40 PM, R92 reported that staff were not cutting toenails.During an interview and observation on 04/18/2026 at 8:43 AM, R92 reported that his toenails and fingernails were as long as they will get. R92 further reported that if someone offered to cut his toenails he would allow it. The toenail on the left great toe was jagged with the other nails…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-19 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and staff interview, the facility failed to ensure a medication error rate was less than five percent during medication administration review. Three errors were identified from 38 opportunities, resulting in a 7.89 percent (%) medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.Findings include:1. On 04/18/2026 at 8:50 AM, Licensed Practical Nurse (LPN) FF was observed giving R216 his morning medications. The medications included citalopram 20 mg (milligrams) tablet and hydralazine 50 mg tablet.Review of the Physician Orders dated 04/14/2026 revealed an order for citalopram 10 mg, give one tablet by mouth one time a day for depression; and hydralazine HCl (hydrochloride) 50 mg, give one tablet by mouth every 8 hours related to essential hypertension.Review of the Medication Administration Record (MAR) dated 04/18/2026 revealed a different nurse had already given the hydralazine 50 mg at 6:00 AM.Observation and interview on 04/19/2026 at 9:00 AM, Registered Nurse (RN)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-19 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and a review of the facility policy titled Medication Storage, the facility failed to properly lock, secure and discard medications on two of seven medication carts (500 Hall and 200 Hall.) The deficient practice increased the risk of unauthorized access and potential medication diversion.Findings include:Review of the facility policy titled Medication Storage, with a revised date of 10/01/2025 documented under the section Policy Explanation and Compliance Guidelines (1) General Guidelines (a). all drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerator, medication rooms) under proper temperature controls.During an observation and interview on 04/18/2026 at 3:09 AM with Licensed Practical Nurse (LPN) KK revealed the medication cart on the 500 Hall was unlocked and unattended while LPN KK was sitting behind the nurse's station on the computer. In addition, an unsecured round pink pill was observed sitting on top of the medication cart. LPN KK confirmed the medication cart was unlocked…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-19 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and review of facility policy titled Resident Nutrition Services, the facility failed to ensure that meal preferences were followed for one resident (R) (R165) of 35 sampled residents. The deficient practice had the potential to affect the quality of life for R165. Findings includeReview of the electronic medical record (EMR) for R165 revealed diagnoses that included but not limited to cerebral infarction, chronic kidney disease stage 5, and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema left eye.Review of the EMR revealed a Minimum Data Set (MDS) quarterly assessment dated [DATE], Section C: Brief Interview of Mental Status score of 15, which indicated little to no cognitive impairment.During an interview and observation on 04/17/2026 at 8:11 AM, R165 reported that she was sent grits all the time and she did not like hot cereal. Review of the breakfast tray revealed a bowl of grits. Further review of the breakfast tray…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-07 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, staff, and family interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide ADLs for four of 16 sampled residents (R) (R1, R8, R7, and R6) dependent of staff for care related to: scheduled showers for R1, R8, R7, and R6; nail care for R1 and R8; and shaving facial hair for R1 and R8. This deficient practice had the potential to place R1, R8, R7, and R6 at increased risk of unmet needs. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs), with a reviewed/revised date 10/2025, revealed: Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. A review of the Grievance Missing Property log…
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 · F2024-07-18 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and review of the Facility Assessment Tool and the Payroll-Based Journal (PBJ) Staffing Data Report Quarter (Q) 2 2024, the facility failed to ensure there were adequate nursing staff to serve their residents. The deficient practice had the potential to adversely affect the care and services provided to the facility residents. The facility census was 212 residents. Findings include: Review of The Facility Assessment Tool (FAT) 2024 revealed the facility was licensed for 242 beds. The facility's current census was 212 residents. The FAT revealed the average hourly staffing needs per day were 84 hours for licensed nurses providing direct care, 233 hours for nurses' aides. Review of the PBJ Staffing Data Report Quarter 2, 2024 revealed based on the data submitted, the facility triggered Excessively Low Weekend Staffing and for a One-Star Staffing Rating (Failure to submit PBJ data by the deadline, more than 4 days in the quarter without RN (Registered Nurse) Staffing hours, failure to respond to, submit documentation for, or failure to pass a CMS audit…
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 before2024-07-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policies titled, Labeling and Dating Foods, Refrigerator and Freezer Temperatures, Cleaning Instructions: Conventional Oven (2020), Hair Restraints, and Cleaning Instructions: Floors, the facility failed to ensure dietary staff contained hair in hair nets, ensure that food was properly labeled, stored and prepared in a sanitary condition to prevent foodborne illness, and failed to monitor and log daily temperature of refrigerator and freezer temperatures to ensure food was preserved per recommended guidelines. In addition, the facility failed to ensure the cleaning of appliances (stove, refrigerator), countertops, floor tiles, and ceiling vents. Additionally, the facility failed to ensure that needed repairs were done for an identified plumbing issue with the drainage system, kitchen exterior door disrepair to prevent access of pests, missing floor tiles, and rust buildup of the stove hood. The deficient practice had the potential to affect 198 residents receiving an oral diet. Findings include: 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 · E2024-07-18 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of R73's EMR revealed she was admitted to the facility with diagnoses including but not limited to drug-induced subacute dyskinesia, extrapyramidal and movement disorder, poisoning by unspecified drug/meds biological substance/accidental, major depressive disorder, conversion disorder with seizures or convulsions, bipolar disorder with current hypomanic, anxiety disorder, other psychoactive substance abuse, intentional self-harm by other specific means, poisoning by unspecified drug/meds/biological substance, self-harm substance. Further record review revealed no evidence that an assessment for self-administration of medications was completed, there were no physician orders for the resident to have medications at the bedside for self-administration, and there was no care plan addressing R73's ability to self-administer medications. Review of R73's admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating the resident was cognitively intact. Observation 7/14/2024 at 2:01 pm and 2:19…
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 · E2024-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility policy titled, Storage of Items in Resident Rooms, the facility failed to ensure resident personal care items were stored in a manner to prevent cross-contamination in five of 11 bathrooms on the 400 Hall. The deficient practice had the potential to expose residents to infections due to cross-contamination. Findings include: A review of the undated facility policy titled Storage of Items in Resident Rooms revealed the Policy stated Resident's personal items will be orderly and properly stored. The Procedure section stated, 1. Personal items will be clean and stored appropriately. 2. No items shall be stored on floors in resident rooms. 4. Store in bathrooms: b. resident leg bags, bedpans, or graduate cylinders. A basic infection control policy was requested but was not received. Observations on 7/14/2024 at 1:47 pm and 7/15/2024 at 1:25 pm of the shared bathroom between rooms [ROOM NUMBERS] revealed one bedpan on the shelf above the toilet and a…
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 11 citations
- Potential for harm · D2024-07-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to provide a resident with food preferences for one of 55 sampled residents (R) (R58). Review of the facility policy titled Resident [NAME] of Rights reviewed January 2023 revealed under Facility residents shall have the right to: . 10. Reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.15. Self-determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interests, assessments and plan of care and make other choices about aspects of his or her life in the facility that are significant to the resident. Including but not limited to: activities, health care schedules (including sleeping, waking, bathing and eating times) and how she or he spends…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-18 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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, staff interviews, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for two of seven halls, with one room (room [ROOM NUMBER]) on the 300 Hall and three rooms ( room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on the 400 Hall. These rooms had missing paint on the doors and walls; holes, punctures, and dents in the walls; crumbling walls with rocks exposed, dirty floors, and broken and or soiled air conditioning vents. Findings include: Review of the facility policy titled Resident [NAME] of Rights last reviewed in January 2023 revealed under A. Facility residents shall have the right to: . 32. A safe, clean, comfortable home like environment. Observation on 7/14/2024 at 1:23 pm revealed room [ROOM NUMBER]'s bathroom floor with dirt and debris as well as a dead cock roach on the floor. Observation on 7/14/2024 at 1:59 pm revealed the walls of room [ROOM NUMBER]…
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 · D2024-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two of two residents (R) (R73 and R47) reviewed for PASRR Level II. This deficient practice had the potential to affect the level of care and services provided to R73 and R47. Findings include: 1. A review of the electronic medical record (EMR) revealed that R73 was admitted to the facility with diagnoses including but not limited to drug-induced subacute dyskinesia, extrapyramidal (involuntary and uncontrollable movement disorders caused by certain drugs), and movement disorder, poisoning by unspecified drug/meds biological substance, accidental, major depressive disorder single episode, bipolar disorder with current hypomanic, anxiety disorder, other psychoactive substance abuse, and intentional self-harm by other specific means. A review of R73's admission Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented 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 · Dcited before2024-07-18 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the EMR revealed R261 was admitted into the facility with diagnoses including but not limited to major respiratory failure, intracranial hemorrhage, and medical history of chronic obstructive pulmonary disease (COPD), anemia, and cervical disk myelopathy. A review of R261's admission Minimum Data Set (MDS) revealed the MDS was in process. A review of R261's active Physician Orders, dated July 2024, revealed no physician's orders for the care of the PICC line. Observation on 7/15/2024 at 1:17 pm of R261 revealed a PICC line was inserted in R261's left arm. During observation and interview on 7/15/2024 at 1:27 pm, LPN II confirmed the date on R261's PICC line dressing was 7/3/2024. She also confirmed there were no physician orders for the care of the PICC line or dressing changes. She stated the nurse was responsible for ensuring physician orders were obtained for the resident's care needs. In an interview on 7/18/2024 at 3:40 pm, the Assistant Director of Nursing (ADON) confirmed that R261 did not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-07-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy titled, Oxygen Therapy, the facility failed to follow Physician Orders for two of 12 residents (R) (R65 and R187) with orders for oxygen. The deficient practice had the potential to place the residents at risk for medical complications such as respiratory distress, unmet needs, and a diminished quality of life. Findings include: Review of the undated facility policy titled Oxygen Therapy revealed the following under Procedure: 1. Oxygen therapy is to be provided under the direction of a written physician order. A Physician's Order for O2 therapy is to contain liter flow per minute via mask or cannula/timeframe. 4. Adjust delivery rate as ordered. 1. Review of the electronic medical record (EMR) for R65 revealed the resident was admitted to the facility with diagnoses of but not limited to bipolar disorder, chronic obstructive pulmonary disease (COPD), unspecified, and type two type 2 diabetes mellitus. Review of R65's most…
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 before2022-10-28 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, staff interview, and policy review, the facility failed to label/date open food items in the walk-in freezer and dry storage, failed to discard expired food items in the cooler, and failed to ensure baking sheets and serving trays were stacked and stored dry. Findings include: Review of the undated facility policy titled, Food Storage (Dry, Refrigerator, and Frozen), revealed the following: Procedure: 1. General storage guidelines to be followed: a. Label food item held for longer than 24 hours. The label should include the name of the food if not in original packaging, the date by which it should be sold, consumed, or discarded. (1) See Date Marking Guidelines in this section for exceptions to dating individual dry storage food items. 2. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. (1) (3) Observation of the kitchen on 10/25/22 beginning at 9:20 a.m. with the Registered Dietician (RD) revealed the following: Walk-in freezer: opened/unlabeled…
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 before2022-10-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
Based on observation and staff interview, the facility failed to maintain a clean environment in the laundry washer area related to two of two dirty sinks. Finding include: During a tour and an observation of the laundry room on 10/26/22 at 9:00 a.m., the following was observed in the washer room. Upon entering the laundry room is a small room that lead to the washers. The small room was cluttered, the room had two old sinks that were dirty and filthy, the Housekeeping/Laundry supervisor stated that one sink was used by maintenance to wash off their paint brush and that they used the other sink to soak soiled items. The room was cluttered with bins /boxes /tools. There were holes on the wall and a rusted vent. The room had a strong malodorous odor upon entrance. During an interview on 10/28/22 at 11:00 a.m. with Housekeeping /Laundry Supervisor regarding the condition of the washer room, she revealed that that washer room is cleaned everyday by the laundry attendants. She revealed that some of the items belongs to the maintenance and floor tech. During an interview on 7/31/22 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 · Dcited before2022-10-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of facility policies, the facility failed to follow physician's orders for two of 63 sampled residents (R) (R#55 and R#208). Findings include: Review of the facility policy titled, Prescriber Medication Orders, (History August 2016) revealed: Policy: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses, pharmacists, or other persons authorized by state law to do so and confirmed in writing by the prescriber. Responsibility: All Nursing Staff. Procedure: 2. Documentation of the medication order: b. The following steps are initiated to complete documentation: 3. Call and/or fax the medication order to the dispensing pharmacy, if needed. Review of the policy titled, Medication Administration-General Guidelines. (History 8/16) revealed the following: Responsibility: All Licensed Nursing Personnel. Procedure: 10. Medications are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-10-28 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to ensure appropriate services and assistance was provided to maintain or improve mobility for one of 63 sampled residents (R) (R#75). Findings include: Review of the clinical record for R#75 revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to Cerebral infarction, unspecified, Hemiplegia following cerebral infarction. The Quarterly Minimum Data Set (MDS) assessment for R#75 dated 8/23/22, revealed a Brief Interview for Mental Status (BIMS) was coded three out of 15, indicating severe cognitive impairment. Resident required extensive assistance from staff for activities of daily living (ADLs) such as bed mobility, bathing, dressing, personal hygiene, and toilet use. Resident has a limitation in range of motion for impairment on one side of the upper extremity and on both sides of the lower extremities. Section O revealed R#75 did not receive any therapy or restorative nursing…
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 before2022-10-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, medical record review, and review of the facility policy, titled Oxygen Therapy, the facility failed to obtain a physician's order for oxygen therapy and establish a process for cleaning filter of oxygen concentrator for one of 63 sampled residents (R#112). Findings include: A review of the clinical record revealed that R#112 was admitted on [DATE] with diagnoses to include but not limited to Primary Hypertension, Chronic Diastolic (congestive) heart failure, Unspecified Asthma, uncomplicated, Anemia, unspecified, Atrioventricular Block, complete and Dependence on Renal Dialysis On 10/25/22 at 3:16 p.m. and 10/27/22 at 3:22 p.m. R#112 was observed sitting on the bed with oxygen via nasal cannula intact at 4 liters via nasal cannula. The filter of the concentrator has a white / grayish accumulation at the time of this observation. During an interview with R#112 on 10/27/21 at 3:22 p.m., he stated that he has worn oxygen daily for over a year, and he needs it for his heart…
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 · D2022-10-28 · 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 and staff interviews the facility failed to document the intended rationale and duration of therapy for two of five sampled residents (R) (R#75 and R#208), that had an as needed order (PRN) for antianxiety and hypnotic medication beyond 14 days. Findings include: 1. Review of the clinical record for R#75 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety disorder. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three out of 15, which indicated severe cognitive impairment. Review of the Physician orders for R#75 for October 2022 revealed the following medication: lorazepam 2 mg may one tab by mouth three times a day as needed, with an order start date of 5/23/22. During an interview with Licensed Practical Nurse (LPN) BB on 10/28/22 at 11:22 a.m., she stated that the R#75 does have a current order for the PRN lorazepam. Nurse BB looked in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to NORBERT BENNETT & DONALD DENZ — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 1 of 5 | 1.0 | ≈ chain avg |
| Quality measures | 1 of 5 | 2.5 | -1.5 vs chain |
The other 1 home 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 |
|---|---|---|---|---|
| D&N, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/2006 |
| DTD HC LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 50% | since 01/01/2006 |
| DONAD T DENZ IRRV TR | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/23/2008 |
| NORBERT A BENNETT IRRV TR FBO CHILDREN | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/23/2008 |
| NORBERT A BENNETT IRRV TR FBO GRANDCHILDREN | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 05/23/2008 |
| BENNETT, NORBERT | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2006 |
| DENZ, DONALD | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2006 |
| SARJU, PAULA | Individual | W-2 MANAGING EMPLOYEE | — | since 06/07/2021 |
5 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 90% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115535. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-19, 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.