Blossom Healthcare & Rehabilitation Center
3051 Whiteside Road, Macon, GA 31216 · For profit - Limited Liability company · 143 certified beds · (478) 788-1421 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- 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
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- 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 (70%) 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 | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 12.9% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.2% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.4% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 19.5% | 11.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.4% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.6% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 11.0% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.1% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.3% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 92.7% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.2% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.7% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.79 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.32 | 1.90 | 1.80 | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
33.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 22% 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 | 33.9%CMS range 20.7–48.8 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.0%CMS range 7.2–15.3 | 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 | 56.0% | 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 | 56.0% | 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 | 48.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 4.3% | 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 | 8.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.0–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.32 | 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 143 beds and averages 83.1 residents a day — about 58% occupied, or roughly 60 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.01 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.73 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 2.67 hrs/resident/day on weekends vs 3.15 on weekdays — 15% thinner on weekends. RN hours go from 0.30 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 70% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Fcited before2026-01-08 · 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 observation, staff interviews, and review of the facility policy titled Dating & Expired Food Items Policy, the facility failed to ensure that food items were dated when opened. In addition, the facility failed to ensure that food items were not stored or made available for use beyond their expiration dates. The deficient practices had the potential to place the 81 residents who received food and hydration from the kitchen at increased risk of foodborne illness. Findings include: Review of the facility's undated policy titled Dating & Expired Food Items Policy revealed the Policy Statement included, The facility will ensure all food is identifiable, within allowed dates, and safe for service to prevent use of expired, undated, or questionable items. Every food item will be labeled and dated at receipt and when opened/ prepared, with a clear discard date. No item may be served past its use-by/discard date. Updated, unlabeled, or questionable items will be discarded immediately. Observation during the initial kitchen tour on 1/6/2026 from 8:35 am to 9:05 am, with the Dietary…
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 · E2026-01-08 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policies titled Medication Storage in the Healthcare Centers and Medication Administration: General Guidelines, and Medication Administration: General Guidelines, the facility failed to ensure one of three medication carts and one of one wound care cart were locked and secured when out of the direct sight of the nurse. In addition, the facility failed to discard expired medical supplies in one of four supply rooms. Additionally, the facility failed to ensure that medications on two of three medication carts were stored in a sanitary manner. These deficient practices have the potential to place residents residing in the facility at risk of unauthorized access to medications, use of expired medical supplies, and avoidable infection related to cross-contamination. The census was 80 residents. Findings include:Review of the facility's policy titled Medication Storage in the Healthcare Centers, revised [DATE], revealed that the Policy Statement…
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 · D2026-01-08 · tag F0554 — isolatedAllow 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 Based on observations, staff interviews, record review, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure three of 34 sampled residents (R) (R61, R19, and R43) were assessed for medication self-administration before allowing medications at the bedside. This deficient practice has the potential to place R61, R19, and R43 at risk of unsafe medication use and not receiving medication according to the prescriber's order.Findings include: Review of the facility policy titled Medication Administration: General Guidelines, reviewed 7/28/2025, revealed the Procedure section included, .4. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. Review of the Electronic Medical Record (EMR) for R61 revealed diagnoses including, but not limited to, legal blindness, as defined in the USA, and combined forms of age-related…
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 · D2026-01-08 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigation, the facility failed to report an allegation of verbal/mental abuse to the State Survey Agency (SSA) for two of 34 sampled residents (R) (R20 and R46). This deficient practice had the potential to place residents at increased risk of abuse. Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating revealed the Policy Statement included, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Policy Interpretation and Implementation section included, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation…
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 · D2026-01-08 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations of verbal and physical abuse were thoroughly investigated for two of 34 sampled residents (R) (R20 and R46). This deficient practice had the potential to place the residents at increased risk of abuse. Findings include:Review of the facility's undated policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revealed the Policy Statement included, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies . and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Policy Interpretation and Implementation section included Investigation Allegations: 1. All allegations are thoroughly investigated. The Administrator initiates the investigation. 7.…
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 before2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record review, and review of the facility's policy titled [facility name] Care Plans Policy, the facility failed to develop or implement a comprehensive person-centered care plan for four of 34 sampled residents (R) (R21, R46, R76, and R4). This deficient practice had the potential to place R21, R46, R76, and R4 at risk of unmet needs, medical complications, and diminished quality of life.Findings include: Review of the facility's policy titled [facility name] Care Plans Policy revealed that the facility's interdisciplinary team is responsible for the development of resident care plans. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. 1. Review of the Quarterly Minimum Data Set (MDS) for R21, dated 11/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional…
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 · D2026-01-08 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility document titled PICC Lines Procedures, the facility failed to ensure one of one resident (R) (R87) with a peripheral inserted central catheter (PICC) [a long, thin tube inserted into a small arm vein, threaded to a large vein near the heart] from a total sample of 34 residents received care in accordance with professional standards. This deficient practice had the potential to place R87 at increased risk of medical complications. Findings include:A review of the facility's undated document titled PICC Lines Procedures revealed the PICC Maintenance and Care section included, . Aspirate to assess blood flow before every flush and infusion.Review of the physician's orders for R87 revealed an order dated 1/6/2026 for daptomycin (an antibiotic medication used to treat infections) intravenous solution 750 milligrams (mg) every 24 hours. Further review revealed an order dated 1/6/2026 for: Flush single-lumen PICC line to RUE (right upper extremity) using SASH (saline, antibiotic, saline, heparin) protocol…
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 · D2026-01-08 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Therapy Policy, the facility failed to ensure four of 29 residents (R) (R43, R46, R76, and R4) with oxygen orders received oxygen as ordered by the physician. This deficient practice has the potential to place residents R43, R46, R76, and R4 at increased risk of respiratory complications.Findings include: Review of the facility's policy titled Oxygen Therapy Policy, revised 4/2024, revealed the policy statement was, It is the policy of the facility that oxygen therapy was administered per a physician's order or as an emergency measure until a physician's order can be obtained. The Follow the steps below to administer oxygen therapy section included, .8. Turn on the oxygen supply and set the flow meter to the rate ordered by the physician. 1. Review of the Quarterly Minimum Data Set (MDS) assessment for R43, dated 10/13/2025, revealed Section I (Active Diagnosis) documented diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive hypertrophic…
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 · D2026-01-08 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, review of the facility's policy titled Side Rail Usage Policy, and review of the facility's protocol titled Restraint- Least Restrictive, the facility failed to ensure that one of 34 sampled residents (R) (R 21) was free from bedrail restraint. This deficient practice had the potential to place R21 at risk of medical complications and a decreased quality of life. Findings include:Review of the facility's undated policy titled Side Rail Usage Policy revealed the Policy section stated, The facility discourages the use of side rails because of the potential safety and dignity issues associated with side rail usage. The Procedure section included, .2. Side rails will only be used if a resident needs the side rail(s) as an enabler to enhance bed mobility. 3. Procedure for side rail usage: a. A physician's order must be obtained for the use of any rail(s). b. The order must include type of rail and location (i.e., resident's right, left, or both). c. The reason for use of the rail(s). 7. The Side Rail Screen Assessment is to be…
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 before2026-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and review of the facility's policy titled Soiled Laundry and Bedding Policy, the facility failed to ensure that laundry staff followed infection control processes while performing laundry services. In addition, the facility failed to ensure infection control measures were followed for one of 16 sampled residents (R) (R76) receiving oxygen. These deficient practices had the potential to place residents at risk for infections due to contamination. The census was 80 residents.Findings include:Review of the facility policy titled Soiled Laundry and Bedding Policy revealed that Soiled Laundry and bedding shall be handled, transported, and processed according to best practices for infection prevention and control. The Onsite Laundry Processing section included 1) hand hygiene procedures as well as appropriate personal protective equipment (PPE), includes gloves and gowns are available and used while sorting and handling contaminated linens.1. Observation on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · F2024-10-03 · tag F0940 — failed to train staff — widespreadDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and a review of the In-Service Deficiency Report, the facility failed to ensure an effective training program for all new and existing staff was implemented and maintained. The failure to ensure an effective training program was in place had the potential to impact all of the residents in the facility related to safety, person-centered environment, and the number of adverse events or other resident complications. Findings include: Review of the In-Service Deficiency Report (undated) provided by the facility revealed 19 training topics that should be provided to employees annually. Training topics included: Elopement, EOP (Emergency Operation Plan) Training, Performance Evaluation, Abuse Policy and Procedure (provided quarterly), Communication Training, Fire Safety, Trauma Informed Care, CPR (Cardiopulmonary Resuscitation) Care Verification, Employee Health and Safety, Elope Drill, Tornado Drill, Dementia Management, Disaster Drill based on HVA (Hazard Vulnerability Analysis), Behavior Health…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-10-03 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 interviews and observation, the facility failed to ensure three residents (R) (R52, R6, and R285) of 30 sampled residents had enough clean linen, specifically pillowcases, to ensure every resident had enough for all of their pillows. This had the potential for the residents not to have a home-like environment. Findings include: A request was made for a policy related to linens, and was not provided prior to the exit of the survey. 1. Review of R52's admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R52 had an admission date of 08/11/22. Review of R52's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/24, located in the EMR under the MDS tab, revealed R52 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R52 was cognitively impaired. During an interview on 10/01/24 at 11:03 AM, Family Member (FM)2 said she saw the facility was out of pillowcases several weeks ago when she came to visit R52. She said she bought pillowcases for R52 and wrote his name all over…
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 · D2024-10-03 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two residents (R) (R24 and R78) and/or the resident representative (RR) of five residents reviewed for unnecessary medications out of a total sample of 30 residents was informed of the risk and benefits of physician ordered antipsychotic medications. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of medications. Finding include: 1. Review of R24's admission Record dated 10/03/24, located in the resident's electronic medical record (EMR) under the Resident Summary tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. Review of R24's Physician Order dated 08/02/23, located in the Orders tab of the EMR revealed, Depakote [to treat certain psychiatric conditions and seizures] 125 mg [milligrams] two times a day and Risperdal [to treat certain mental/mood disorders] 0.5 mg [milligrams] two times a day. Review of R24's…
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 · D2024-10-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to provide one of three residents (R) (R134) reviewed for Notice of Medicare Non-Coverage (NOMNC) of 30 sampled residents, a NOMNC 48 hours before the end of a Medicare-covered Part A stay. This had the potential for the resident to not have the opportunity to appeal the decision to end the Medicare Part A stay. Findings include: Review of the admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R134 had an admission date of 05/15/24 and a readmission date of 05/22/24. The resident discharged from the facility on 06/16/24. Review of the NOMNC provided by the facility, revealed R134's Medicare services would end on 06/16/24. The NOMNC revealed R134 was notified of his last covered day on 06/16/24 when he signed the document. During an interview on 10/01/24 at 9:32 AM, the Social Worker (SW) said she would always have the resident or their family member sign the NOMNC within 48 hours of their last covered day. She confirmed she did not issue R134's NOMNC until 06/16/24, which was his…
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 before2023-07-16 · 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 a review of the facility's policies titled Food Storage and Procurement, and Diet/Food Handling, the facility failed to ensure that food items in the two refrigerators and two freezers were properly labeled, dated, and securely wrap opened food items and discarded foods when expired; failed to properly use the three-compartment sink to properly sanitize dishware. Additionally, the facility failed to thaw frozen meat and fish properly to prevent bacterial growth; failed to store stacked pans free from wet nesting to prevent bacterial growth; failed to have soap in the soap dispenser and paper towels in the towel dispenser so staff could properly wash and dry hands; failed to clean the can opener and free from debris buildup to prevent cross contamination; and failed to maintain a clean and sanitary kitchen. The facility census was 86, with 83 residents consuming an oral diet. These failures had the potential to support bacterial growth associated with foodborne illness. Findings include: Review of the policy titled Food Storage and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 4. Observations on 7/14/2023 at 10:00 a.m. and 4:20 p.m., 7/15/2023 at 7:58 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER] revealed a loose night light fixture cover on the wall near resident in 309A. Observation and interview on 7/16/2023 at 10:00 a.m. with Administrator and Maintenance Supervisor verified the loose light fixture cover on the wall. The Maintenance Supervisor has fixed the night light cover in the past. He indicated it gets caught on the bed when they lower it, and the bed is kept against the wall. He indicated he was not aware of the problem. They usually use verbal communication or electronic communication on an app to report problems. He checks the electronic report daily. 3. Observations on 7/14/2023 at 10:00 a.m. and 4:20 p.m., 7/15/2023 at 7:58 a.m. and 7/16/23 at 10:00 a.m. of room [ROOM NUMBER] revealed a loose night light fixture cover on the wall near resident in 309A. Observation and interview on 7/16/2023 at 10:00 a.m. with the Administrator and Maintenance Supervisor…
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 · E2023-07-16 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and record review, the facility failed to ensure that dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected six of 83 residents receiving an oral diet. Findings include: Observation on 7/15/2023 at 9:25 a.m. of Dietary [NAME] HH preparing puree black-eyed peas revealed that no recipes were seen or used as a reference during preparation. Dietary cook HH started with hot cooked black-eyed peas by placing 14 four-ounce (oz) scoops in the food blender. Using an unlabeled scoop, the cook then added one scoop of food thickener and an unmeasured amount of liquid from the pot of cooked peas and pureed until well blended. The Dietary [NAME] HH placed the pureed black-eyed peas in a steam table pan. When placed in the pan, the pureed black-eyed peas had a thick like consistency. Next, the Dietary [NAME] HH pureed cooked beef patties in a brown gravy liquid by placing 14 beef patties along with an unmeasured amount of the brown gravy liquid and one unlabeled scoop of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-07-16 · 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 2. Review of the policy titled Laundry Dyer Vent Cleaning policy dated 1/15/2023 revealed: Environmental staff-laundry staff will check and clean out the dryer vent after each load. Laundry staff will notify maintenance if there are other areas that need cleaning or minor maintenance. Review of the Tumble Dryers __ Operation Maintenance manual for dryer number one. Safety Information: This tumble dryer must not be activated without lint screen filter. When you perceive a gas odor, immediately shut off the gas supply and ventilate the room. Do not power on electrical appliances and do not pull electrical switches. Do not use matches or lighters. Do not use a phone in the building. Warn the installer, and if so desired, the gas company, as soon as possible. To avoid fire and explosion, keep surrounding areas free of flammable and combustible products. Regularly clean the cylinder and exhaust tube should be cleaned periodically by competent maintenance personnel. Daily remove debris from lint screen filter and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-07-16 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interview, record review, and review of the facility's policy titled Foley Catheter Care, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of six residents (R) (R#16) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility policy titled Foley Catheter Care, reviewed 1/2022, revealed catheter bags would be placed in a dignity bag or cove. A review of the CNA Mandatory Clinical Meeting Form dated 11/14/2023 revealed that the facility provided training to ensure that staff placed Foley catheter bags in a privacy bag. A review of the most recent Minimum Data Set (MDS) Quarterly Assessment for R#16 dated 5/22/2023 revealed in section C-Cognition that R#16 had a documented Brief Interview for Mental Status (BIMS) score of 15. Section H-Bowel & Bladder revealed R#16 had an indwelling catheter and was always…
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 · D2023-07-16 · 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 and staff interviews, the facility failed to ensure a reasonable accommodation of need by keeping the call within reach of residents when in their room to call for staff assistance for three of sixteen Residents (R) (#41, #4, #14) in the 300 Hall. Observations on 7/14/2023 at 11:28 a.m. and 4:25 p.m., 7/15/2023 at 7:45 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER]A R#4 and 311B R#14 revealed call lights for both bed A and B were wrapped around the call box and not in reach of the resident. Both residents were sitting up in a chair beside the bed during observations or in the bed. Observations on 7/14/2023 at 11:36 a.m. and 4:35 p.m., 7/15/2023 at 7:55 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER]B R#41 revealed call light for bed B was on the floor and not in reach of the resident. The resident was asleep in bed during observations. Interview on 7/16/2023 at 9:40 a.m. with Certified Nursing Assistant (CNA) GG revealed she is responsible for keeping a call light within…
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 · D2023-07-16 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Review of the most recent Significant Change Minimum Data Set (MDS) for R#27 dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13, indicating minimum cognitive deficit. Record review of the care plan R#27 revealed: No care plan in place related to advanced directives. The resident has a terminal prognosis and is on Hospice services dated [DATE]. Record review of Physician orders for R#27 revealed no order or indication on the Electronic Medical Record (EMR) documenting the resident's advanced directive wishes. Record review of the EMR revealed an Advanced Directive Checklist-Georgia that indicates R#27 has executed an advanced directive as indicated below and will provide copy to the facility, dated, and signed by responsible party [DATE]. A review of R#27's Hospice binder revealed a document titled Authorization for Allow of Natural Death dated and signed by her responsible party [DATE] and Physician indicated resident wishes to be a Do Not Resuscitate (DNR).…
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 before2023-07-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
2. Record review of the most rececent Significant Change Minimum Data Set (MDS) for R#27 dated 5/22/2023 revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13, indicating minimum cognitive deficit. Record review of the care plan for R#27 revealed: No care plan in place related to advanced directives. Record review of the medical record revealed an Advanced Directive Checklist-Georgia that indicates R#27 has executed an advanced directive as indicated below and will provide copy to the facility, dated, and signed by Responsible Party (RP) 1/3/2022. A review of R#27's Hospice binder revealed a document titled Authorization for Allow of Natural Death dated and signed by her RP 5/12/2023 and Physician indicated resident wishes to be a Do Not Resuscitate (DNR). Interview on 7/15/2023 at 2:18 p.m. with R#27 revealed she leaves all the questions and decisions to her family. Interview on 7/15/2023 at 2:48 p.m. with Licensed Practical Nurse (LPN) LL indicated she could not find the R#27's code status and could not find an order. She indicated if she needs to find…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2023-07-16 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility policy titled, Fountain Blue Rehab and Nursing Bed Hold Policy, the facility failed to ensure one of 16 Residents (R) (#382) that was discharged in the last 30 days received notification of the facility bed hold policy upon transfer to the Acute Hospital; reviewed for bed hold policy. Findings: A review of the facility undated policy titled, Fountain Blue Rehab and Nursing Bed Hold Policy, revealed: The resident may need to be absent from the facility temporarily for hospitalization or therapeutic leave. The resident may request that the facility hold open the resident's bed during this time. This is known as a bed hold. The resident and family member or legal representative shall be given notice of the bed hold options at the time of hospitalization or therapeutic leave. Record review of the medical record for R#382 revealed there was no evidence of bed hold policy noted in the residents' chart. Interview on 7/16/2023 at 10:50 a.m. with Social Services Director (SSD) revealed that the bed hold policy is signed by…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MACON HOLDINGS GROUP LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 08/01/2017 |
| BRECHER, LIBBY | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 08/01/2017 |
| BRECHER, MENDEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 26% | since 08/01/2017 |
| LICHTMAN, CHANA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 14% | since 08/01/2017 |
| LICHTMAN, SARA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | since 08/01/2017 |
| ZIMMERMAN, JACOB | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 12% | since 08/01/2017 |
| SERVISFIRST BANK | Organization | 5% OR GREATER SECURITY INTEREST | — | since 08/01/2017 |
| JILES, RENEE | Individual | W-2 MANAGING EMPLOYEE | — | since 08/01/2017 |
CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $242K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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 115636. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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.