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Sgmc Health Villa

138 West Thigpen Ave, Lakeland, GA 31635 · Government - Hospital district · 62 certified beds · (229) 433-8425 Medicare & Medicaid certified

Call the home — (229) 433-8425 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Oct 2024Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations
Insights

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

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (18% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
116 W Thigpen Ave · (229) 433-8909 · Call to confirm hours
Pharmacy
42 W Main St · (229) 482-3677 · Call to confirm hours
Grocery
115 E Main St · (229) 482-1070 · Call to confirm hours
Park
4497 W Fox Farm Rd · (231) 398-9616 · Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 4 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 rating4★
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 increased4.8%15.3%15.4%better
Long-stay residents who lose too much weight8.8%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder4.5%0.9%0.9%worse
Long-stay residents with a urinary tract infection0.5%2.5%2.0%better
Long-stay residents with depressive symptoms0.0%11.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.8%3.2%3.3%better
Long-stay residents whose ability to walk worsened6.3%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication20.9%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine89.6%95.0%95.3%typical
Long-stay residents with pressure ulcers4.7%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control13.4%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table24.0%19.9%17.1%worse
Long-stay hospitalizations per 1,000 resident days3.102.151.67worse
Long-stay outpatient ER visits per 1,000 resident days4.451.901.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Staffing

0.55
RN hours/ resident / day
1.21
LPN hours/ resident / day
2.08
Aide hours/ resident / day
3.84
Total nurse hours/ resident / day
0.31
RN hoursweekends
17.6%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 62 beds and averages 58.4 residents a day — about 94% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.84 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.549 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.21 hrs/resident/day on weekends vs 4.09 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.64 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 18% is below the national median of 45%.

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

Inspection trend

5
deficiencies at the latest standard inspection (2025-06-04)
7
at the previous standard inspection (2023-02-12)

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.

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.

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

  • Actual harm · G2021-08-13 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to review and revise the Comprehensive Care Plan for four of 24 residents (R#210, #49, #2 and #28) whose care plans were reviewed. Failure to revise the Care Plan for each resident resulted in the nursing staff being unaware of the current status of each resident, which resulted in a fall with a major injury for R#210. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell, while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery. The findings include: Review of the facility policy titled, Villa Interdisciplinary Plan of Care dated 11/13/19 revealed documentation that stated: Procedure Section B 2 The interdisciplinary plan of care includes, but is not limited to, the following. a. Services and activities to be furnished to attain or maintain the individuals highest practical physical, mental, and psychosocial well-being as well as such services offered but 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2021-08-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and resident and staff interviews the facility failed to use a two-person transfer for one of four residents (R#210) transferred with a Hoyer lift. Actual harm was identified to have occurred on 6/29/2021 when R#1 fell, while being transferred with a mechanical lift, and sustained an intertrochanteric fracture of the right hip that required surgery. The findings include: Review of the facility Job Aid titled, Mechanical Lift dated 11/1/2019 revealed Purpose: To provide direction on the proper and safe use of mechanical lifts at SGMC Lakeland villa. Mechanical lifts include but are not limited to Hoyer, car extractor, and stander. At least two nursing staff members are needed to transfer an individual when using any lift. Record review revealed that R#210 was admitted to the facility on [DATE]. A review of the Resident's medical record revealed diagnoses that included weakness, other specified hypothyroidism, essential (primary) hypertension, gastroesophageal reflux disease…

    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
  • Actual harm · G2021-08-13 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    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 reviews, and interviews, the facility failed to provide staff with the necessary education and skill set to perform resident transfers; the facility staff improperly transferred one of four residents (R#210). This resulted in actual harm that required surgery. The findings include: Review of the facility policy titled Villa Safe Lifting dated 11/13/2019 revealed, 2. Evaluation of nursing staff use of lifting equipment is accomplished through in-service post-test, return demonstration, as well as on-the-job performance reports. R#210 was admitted to the facility on [DATE]. A review of the resident's medical record revealed diagnosis of weakness, other specified hypothyroidism, essential (primary) hypertension, gastroesophageal reflux disease without esophagitis, major depressive disorder, type 2 (two) diabetes mellitus, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side, unspecified macular degeneration, shortness of breath, urinary tract…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of R2's EMR revealed diagnoses including, but not limited to, age-related nuclear cataract, primary open-angle glaucoma, and hemiplegia and hemiparesis of the right side. Review of R2 's Quarterly MDS, dated [DATE], revealed Section C (Cognitive Patterns) documented a BIMS score of 15 (indicating little to no cognitive impairment). Review of R2's clinical record revealed no assessment for self-administration of medications. Review of R2's Clinical Physician Orders revealed no orders for self-administration of medications. Observation on 6/2/2025 at 12:18 pm of R2 's room revealed a package of throat lozenges in a clear storage container on the floor, visible to anyone entering the room, one three-ounce container of Resinol medicated ointment, and one bottle of hydrogen peroxide on the resident's overbed table. During an interview, at the time of the observation, R2 reported using the throat lozenges occasionally. She further stated that a certified nursing assistant (CNA) applied the peroxide and cream…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-04 · 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

    Based on staff interviews, record review, and review of the Resident Assessment Instrument 3.0 (RAI) Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for eight of 31 sampled residents (R) (R27, R38, R25, R44, R14, R12, R4, and R23). Findings include: Review of the RAI Manual revealed Section 5.2 Timeliness Criteria included, For all non-admission OBRA (Omnibus Budget Reconciliation Act of 1987) and PPS (Prospective Payment System) assessments, the MDS Completion Date must be no later than 14 days after the Assessment Reference Date (ARD). 1. Review of R27's MDS assessment revealed that a Quarterly assessment with an assessment reference date (ARD) of 4/2/2025 was submitted on 6/3/2025. 2. Review of R38's MDS assessment revealed that a Quarterly assessment with an ARD of 3/10/2025 was submitted on 6/2/2025. 3. Review of R25's MDS assessments revealed that an Annual…

    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 before2025-06-04 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of R2 's EMR revealed diagnoses including, but not limited to, unspecified asthma and morbid (severe) obesity due to excess calories. Review of R2 's Quarterly MDS, dated [DATE], revealed Section N (Medications) documented R2 received an anticoagulant, and Section O (Special Treatments, Procedures, and Programs) documented that R2 received oxygen. Review of R2's Clinical Physician's Orders revealed an order dated 9/30/2022 for oxygen via a NC at two LPM as needed (PRN) and an order dated 9/29/2023 for Eliquis oral tablet 5 mg (a medication used to prevent and treat blood clots), one tablet by mouth two times a day. Review of R2's Care Plan Report revealed no care plan for oxygen use or anticoagulant medication use. Observations on 6/2/2025 at 12:18 pm and 6/3/2025 at 10:00 am revealed R2 receiving oxygen via a NC at two LPM. In an interview on 6/4/2025 at 10:45 am, the MDS Coordinator confirmed there were no care plan areas for oxygen or anticoagulant use on R2's care plan and confirmed the physician…

    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 before2025-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of the facility policy titled Falls Assessments/ Falls Risk Policy, the facility failed to ensure post-fall assessments were conducted for one of 10 residents (R) (R39) with falls. This deficient practice had the potential to place R39 at risk of falls, medical complications, and a diminished quality of life. Findings: Review of the facility policy titled Falls Assessments/ Falls Risk Policy, dated 2/20/2024, revealed the Purpose section stated, The purpose of this Policy is to provide guidelines for identifying patients at risk for falling and implementing safeguards to minimize patient falls. The Procedure section included . C. Interventions . 2. Any resident who experiences a fall will receive an assessment weekly for a period of twelve weeks. If the resident experiences no additional falls, they will be placed into the appropriate Fall Risk category, and assessments will be performed as required. If the resident experiences an additional fall during this period, the twelve 12 weeks assessment period will reset and weekly…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-22 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record reviews, and review of the facility's policy titled, Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals, the facility failed to ensure that an allegation and suspicion of abuse was reported to the State Survey Agency (SSA) within the required time frame for one of 14 sampled residents (R) (R A). Findings include: Review of the facility's policy titled Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals dated 8/1/2022, under the Policy section revealed, 8. In response to allegations of abuse, neglect, exploitation, or mistreatment of an individual, [facility name] ensures that the allegations are immediately reported to the [facility name] Administrator. If the event(s) that caused suspicion result in serious bodily injury, it must be reported to The Georgia Department of Community Health no later than (2) hours after forming the suspicion. If the event(s) causing suspicion did not result in serious bodily injury, it must be reported to 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-22 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policy titled, Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals, the facility failed to implement thorough protective measures following an allegation of staff to resident abuse. Specifically, the facility failed to remove a staff member from the schedule and allowed the staff member to work in the area where the resident/victim resided during the investigation of abuse, for one of 14 sampled residents (R) (R A). Findings include: Review of the facility's policy Villa Abuse, Neglect, Exploitation, Mistreatment of Individuals dated 8/1/2022, revealed the Procedure portion of the policy included a section on Protection and documented that the facility would take all necessary steps to protect individuals from harm during an investigation and steps may include, but are not limited to the following: suspension of the suspected abuser, reassignment of staff member to another section, reassignment of the individual to…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-02-12 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and review of facility policy, the facility failed to develop a care plan for five dependent residents (R) (#31, #40, #12, #48, #58) reviewed for Activities of Daily Living (ADLs); and failed to implement the care plan related to providing contracture management/braces/range of motion (ROM) services for one resident (R#41) of 30 sampled residents. Findings include: Review of facility policy titled Villa Interdisciplinary Plan of Care revised 11/1/2019 revealed the facility develops and implements a comprehensive interdisciplinary plan of care for each individual with seven days after the completion of the individual's comprehensive assessment and that includes measurable objective and timeframes to meet an individual's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . The interdisciplinary plan of care should be reviewed after the comprehensive and quarterly resident assessment. 1. Review…

    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 · E2023-02-12 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    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 observation, staff and resident interviews, record review and review of facility policy, the facility failed to ensure six residents (R) (R#31, R#40, R#12, R#48, R#54, and R#58) received showers and personal hygiene needs of 30 sampled residents. Findings include: Review of the facility policy titled Villa Activities of Daily Living revised 11/1/2019 revealed the facility provides an individual who is unable to carry out ADLs with the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Activities of daily living include a) bathing c) grooming. 1. Review of Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#31 with a Brief Interview of Mental Status (BIMS) score of 12 indicting moderate cognitive impairment. The resident required two person extensive assistance with transfer, one person total dependance with bathing and personal hygiene. Review of the bathing schedule revealed R#31 is scheduled for Tuesday/Thursday/Saturday on the 3 p.m. - 11 p.m.…

    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 · E2023-02-12 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident interviews, staff interviews, family interviews, and review of facility document titled, SGMC Lakeland Villa Facility Assessment 2022, the facility failed to ensure that the facility had adequate nursing staff. The deficient practice affected the care provided to the 58 residents that resided in the facility. Findings include: Observation on 2/11/2023 at 9:30 a.m. revealed there were four Certified Nursing Assistant (CNAs) and three licensed nurses working in the facility at time of observation for the 7-3 p.m. shift, with a census of 58. Observation on 2/11/2023 at 3:10 p.m. revealed there were two CNAs and two licensed nurses working in the facility for the 3-11 p.m. shift, with a census of 58. Observation on 2/12/2023 at 8:40 a.m. revealed for 7- 3p.m. there were two licensed nurses, and four CNAs for the entire facility with a census of 58. Review of facility document titled, Adequate Staff to Meet needs dated 12/18/2022 revealed (Per Patient Day) PPD of 1.8, 12/24/2022 PPD…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-12 · tag F0880 — failed to prevent and control infections — pattern
    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, interviews, and review of facility documents titled Daily Patient Room Cleaning Steps, Housekeeping Orientation Skills Validation Form, and Tray Presentation Standards the facility failed to maintain sanitary and clean conditions related to cross contamination when mopping resident rooms and bathrooms. In addition, the facility failed to ensure food items on meal trays were covered when delivered. This deficient practice impacted two of four hallways. Findings include: Review of document titled Daily Patient Room Cleaning Steps (undated) revealed 12 steps listed under instructions which included the following: 8. Dust Mop 9. Damp Mop Restroom 10. Damp Mop Patient Area using New Mop Head 1.Review of the Housekeeping Orientation Skills Validation Form dated 10/12/2022 for Housekeeper (HSK) JJ revealed a verbalization of the process for duties but the form did not indicate that there was observation of duties. Observation on 2/11/2023 at 10:56 a.m. Housekeeper (HSK) JJ was observed mopping…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2023-02-12 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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 observation, interview and record review, the facility failed to notify the physician and responsible party timely of a newly developed pressure ulcer for one resident (R) (R A) of two residents reviewed for pressure ulcers. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R A had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The resident had diagnoses including Diabetes Mellitus, Hypertension, and Cognitive Communication Deficit. The resident required two-person total dependance with Activities of Daily Living (ADL's) and had no pressure ulcers but was care planned for risk for pressure ulcers. Review of Progress Notes dated 12/21/2022 revealed resident had a stage 1 pressure ulcer to the coccyx (non-blanchable erythema of intact skin). There was no documented evidence that the responsible party or physician were notified. Review of Progress Note dated 12/28/2022 revealed R A had an unstageable pressure…

    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 · D2023-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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 facility policy, the facility failed to ensure weekly wound measurements were obtained for one of two residents (R) (R A) reviewed for pressure ulcers. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R A had a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The resident required two-person total dependance with Activities of Daily Living (ADL's) and had no pressure ulcers but was care planned for risk for pressure ulcers. Review of Progress Notes dated 12/21/2022 revealed resident had a stage 1 pressure ulcer to the coccyx (non-blanchable erythema of intact skin). There were no measurements documented. Review of Progress Note dated 12/28/2022 revealed R A had an unstageable pressure ulcer to the coccyx (back of body above buttocks) - obscured full thickness skin and tissue loss. There were no measurements documented. Review of Progress Note dated 1/10/2023…

    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 · D2023-02-12 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for 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 observation, interviews and record review, the facility failed to ensure that one of 30 sampled residents (R) (R#57) received routine dental services as needed. Findings included: Review of the clinical record revealed that R#57 was admitted to the facility on [DATE] with diagnosis of, but not limited to, Alzheimer's Disease and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted that R#57 presented with a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficit and presented with obvious likely cavity or broken teeth. Review of the Dental Care Plan revealed that R#57 had oral/dental health problems related to poor oral hygiene. It noted that the facility would coordinate arrangements for dental care, transportation as needed/as ordered; will monitor/document/report as needed signs and symptoms of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-08-13 · tag F0756 — failed to review each resident's drug regimen — widespread
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of policy titled, Villa Drug Regiment the facility failed to ensure the pharmacist provided documentation to the attending Physician, the facility's Medical Director and the Director of Nursing (DON) regarding any irregularity (including excessive dose, duplicate therapy, excessive duration, without adequate monitoring, without adequate indications for its use, the presence of adverse consequences or any combinations of the previous reasons) identified during the pharmacist's review of the drug regimen and medical chart for each resident for five of five residents reviewed (Resident (R) #2, R#28, R#43, R#48 and R#49). Findings included: Review of the facility policy titled Villa Drug Regimen Review, dated 11/13/19, revealed the following: Procedure: A. Drug Regimen Review 3. The Consultant Pharmacist documents the date each drug regimen review is completed in the Individual's healthcare record on the appropriate form and briefly notes the findings. B. Results 1.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-08-13 · 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 and interview, the facility failed to ensure that foods were used by the expiration date and failed to ensure kitchen equipment was clean and sanitary. This deficient practice affected 53 of 58 residents that received an oral diet. The findings include: A review of the policy received to address expired foods was entitled Villa Food Brought in By Visitors revised on 11/1/19. The policy stated that food brought in by visitors should not be stored in common areas or served by SGMC Lakeland Villa Food and Nutrition Services. Storage the policy: All foods that require refrigeration will be stored in the designated refrigerator closed tightly and properly, be clearly labeled with the date. Disposal: SGMC Lakeland Villa nursing staff monitors Individual's rooms and designated refrigerators for food and beverage disposal. During the initial tour of the kitchen with Dietary Manager (DM) on 8/10/21 at 10:04 a.m. the following was observed: 1. In the walk-in cooler there were three containers with molded strawberries. 2. In the walk-in cooler there was one half withered…

    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 · F2021-08-13 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview the facility failed to ensure that the area around the garbage dump was clean and free of debris. This deficient practice had the potential to affect all 58 residents at the facility. The findings include: During observation of the garbage dumpster area with Dietary Manager (DM) AA the following was revealed: 1. On 8/10/21 at 10:30 a.m., debris and broken carts were observed around the dumpster area. 2. On 8/13/21 at 12:33 p.m. revealed the same debris and broken carts around the dumpster in addition to disposable gloves and paper being present. During an interview on 8/10/21 at 10:30 a.m. with DM AA she reported that she did not know who was responsible for cleaning around the dumpster. During the Quality Assurance (QA) meeting on 8/13/2021 5:04 p.m. with the Administrator it was reported that he was not aware of the dumpster area not being cleaned.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2021-08-13 · tag F0849 — widespread
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 record review, staff interviews, and review of the Hospice Services Agreement the facility failed to meet components of the written agreement with hospice for four of four residents receiving hospice services. The findings include: Review of the facility's Hospice Services Agreement dated 8/25/2017 revealed Article I: Definitions Hospice plan of care means the written plan of care developed for a resident who has elected Hospice care by the Hospice interdisciplinary team in cooperation with the Resident, the resident's family members or individuals designated by the Resident to participate in such activities, and the facility. Article II: Services Provided by hospice 2. Design and Maintenance of the Plan of Care a. Plan of Care: In accordance with applicable federal and state laws and regulations, Hospice shall coordinate with the Resident, the Resident's family members or individuals designated by the Resident to participate in developing a plan of care for each new residential Hospice patient for the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-13 · 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 and staff interview, the facility failed to complete a significant change assessment for one of 24 residents (R#59) reviewed. The findings include: Record review revealed that R#59 was admitted to the facility on [DATE] with the diagnoses that included dementia hypertension subdermal hematoma rhabdomyolysis, traumatic rhabdomyolysis, hemi-neglect of left side, hyperglycemia, moderate protein-calorie malnutrition, macrocytic anemia, sacral decubitus ulcer stage IV (4). Review of R#59 Physician Orders revealed and order end of life care, comfort measures with the start date of [DATE]. Review of the Physician Progress Note for R#59 dated [DATE] revealed the following documentation: briefly this very pleasant a demented [AGE] year-old female was (sic) to the nursing home and placed on Hospice. Patient had multiple reasons to be placed on Hospice including CVA (cerebrovascular accident) and old subdermal hematoma protein calorie malnutrition and dementia. Patient had a stage IV decubitus ulcer…

    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 · D2021-08-13 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews the facility failed to ensure the comprehensive assessment accurately reflected the status of each resident for two of 24 residents (R#28, R#43). Findings include: Interview with the Assistant Director of Nursing (ADON) on 8/11/2021 at 2:30 p.m. revealed the facility does not have a policy to address Minimum Data Set (MDS) accuracy and completion. 1. Review of the Face Sheet in the medical record for R#28 revealed he was admitted to the facility on [DATE]. Diagnoses included but were not limited to cerebrovascular accident (CVA), benign prostatic hypertrophy (BPH), coronary arteriosclerosis, deep vein thrombosis (DVT), hyperlipidemia, hypokalemia, insomnia, shoulder joint pain, diabetes mellitus type two (2), visual impairment, dyspnea on exertion, heart failure, aphasia, gastroesophageal reflux disease (GERD), rosacea, chronic alcohol abuse, major depression, anxiety disorder, and a history of falls. Review of the Physician's Orders for R#28 revealed an order for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-08-13 · 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 record review, staff interview, and review of facility policy, the facility failed to develop and implement a comprehensive person-centered care plan for one of one residents (R#49) admitted to Hospice. The findings include: Review of the facility policy titled, [Name of Facility] Interdisciplinary Plan of Care dated 11/13/19 revealed, The interdisciplinary plan of care includes, but is not limited to, the following: a. Services and activities to be furnished to attain or maintain the individual's highest practical physical, mental, and psychosocial well-being as well as such services offered but not provided due to the individuals exercising his/her rights, including his/her right to refuse treatment; .c. the frequency in which services are to be provided; d. individual problems which cause or create or may cause or create distress for the individual or interferes with the individual's adjustment or involvement with others; or e. individual needs which require some sort of supply or relief; individual…

    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 · D2021-08-13 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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 record review and interview with facility staff, the facility failed to ensure one of one residents (R#15) reviewed for End Stage Renal Disease with Hemodialysis received services consistent with professional standards of practice by failing to have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Findings included: Review of the dialysis contract between the facility and the dialysis center dated 2/26/14 and renewed annually, noted 7. Center will notify Nursing Facility of changes in resident's condition, while at the dialysis center, and will transport to the nearest hospital, as the resident's medical needs dictate. 8. Center will notify Nursing Facility of changes in doctor's orders and/or issues related to resident's care and related care planning issues. The contract does not address communication from the facility to the dialysis center. On 8/12/21 at 1:30 p.m. the Assistant Director of Nursing (ADON) stated the facility does not have 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure that PRN [as needed] orders for psychotropic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) #49) reviewed for medication management. The findings include: Multiple requests were made during the survey for the facility policy on unnecessary medications, but a policy was not provided. Resident (R)#49 was admitted to the facility on [DATE] with diagnosis that included dementia in Alzheimer's disease with early-onset, chronic obstructive pulmonary disease (COPD), essential primary hypertension, congestive heart failure, muscle weakness, presence of colostomy, anxiety disorder, arthritis, cognitive-communication deficit. Review of R#49's Physician Orders revealed end of life care, comfort measures with the start date of 7/8/21. Further review of R#49's Physician Orders revealed haloperidol 2 (two) mg/ml [milligrams/milliliters] solution 1 (one) mg…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2025-06-04 · tag F0576 — widespread
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interviews and review of the facility policy titled Individual Rights and Responsibilities, the facility failed to ensure mail delivery service was provided to residents on Saturdays. This deficient practice had the potential to affect all residents in the facility. The facility census was 55. Findings include: Review of the facility policy titled Individual Rights and Responsibilities, dated 12/6/2019, revealed the Residents' Rights section included, . I. Mail and Electronic Mail: 1. Residents have the right to privacy in written communications, including the right to send and promptly receive unopened mail. During an interview on 6/4/2025 at 10:30 am with members of the resident council, the resident council members stated that residents did not receive mail on Saturdays and had not done so for a while. During an interview on 6/4/2025 at 10:30 am, the Activities Director (AD) confirmed that mail was not delivered to the residents on Saturdays. The AD stated she was responsible for delivering mail, did not work on Saturdays, and delivered the mail once…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
SOUTH GEORGIA MEDICAL CENTER INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 11/01/2023
HODGES, JULIEIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/06/2015
MOORE, JOHNIndividualW-2 MANAGING EMPLOYEE; CORPORATE OFFICERsince 07/19/2021

CMS files one row per role, so the 5 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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

What families pay in GA

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 115707. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-04, 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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