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Macon Rehabilitation And Healthcare

505 Coliseum Drive, Macon, GA 31217 · For profit - Limited Liability company · 100 certified beds · (478) 743-8687 Medicare & Medicaid certified

Call the home — (478) 743-8687 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Sep 2025$8,822 in federal fines
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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 (F0607, 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 (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,822 in federal fines (most recent 2023-08-28)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (58%) 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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
380 Hospital Dr · (478) 330-7200 · Call to confirm hours
Pharmacy
Grocery
901 Maynard St · (478) 256-1960 · Call to confirm hours
Park
100 Spring St · (478) 722-0007 · 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
Short-stay residentsrehab / post-hospital 2 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 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.9%15.3%15.4%better
Long-stay residents who lose too much weight1.1%5.6%5.4%better
Long-stay residents with a catheter left in their bladder2.4%0.9%0.9%worse
Long-stay residents with a urinary tract infection1.0%2.5%2.0%better
Long-stay residents with depressive symptoms0.7%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury1.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened10.3%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.1%20.5%18.9%typical
Long-stay residents given the seasonal flu vaccine96.9%95.0%95.3%typical
Long-stay residents with pressure ulcers7.1%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control9.4%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table7.0%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication2.5%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine31.6%78.4%79.4%worse
Short-stay residents rehospitalized after admission18.3%25.0%22.6%better
Short-stay residents with an outpatient ER visit12.7%11.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days3.262.151.67worse
Long-stay outpatient ER visits per 1,000 resident days2.801.901.80worse

§ 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.

44.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

44.0%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
34.3%U.S. median 56.6%
Met the expected recovery
0.39U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.25hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 34.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 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 0.39 therapist hours per resident per day in 2026Q1 — more than 68% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF44.0%CMS range 30.5–59.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.2–15.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.3%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge40.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge25.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.8%CMS range 4.2–14.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.231.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.36
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.39
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.29
RN hoursweekends
57.5%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 88.4 residents a day — about 88% occupied, or roughly 12 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 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 3.71 on weekdays — 14% thinner on weekends. RN hours go from 0.39 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% 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

4
deficiencies at the latest standard inspection (2025-08-21)
7
at the previous standard inspection (2024-04-21)

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 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · Dcited before2025-09-02 · 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 staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA), specifically an alleged head injury, within the required time frame for one of three sampled residents (R) (R1).Findings include:Review of the facility's policy titled Abuse Prevention Policy, with a reviewed date of [DATE], revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in seriously bodily injury, to the Administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term facilities in accordance with State Law).Review of the Facility Incident Report…

    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 · D2025-09-02 · 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 staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to thoroughly investigate an allegation of injury of unknown origin for one of three sampled residents (R) (R1).Findings include:Review of the facility policy titled Abuse Prevention Policy, with a reviewed date of [DATE], revealed Injury of unknown source means source of injury was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury (e.g. injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs or torso, skin tears on sites other than arms/legs) or the number of injuries observed at one point in time or the incidence of injuries over time.Review of the Facility Incident Report Form revealed the State Survey Agency (SSA) was notified on [DATE] and indicated an off-campus injury at dialysis.…

    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 · F2025-08-21 · 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 observations, staff interviews, and review of the facility policy titled Food Storage: Cold Foods, the facility failed to ensure food items were covered/wrapped, labeled, and dated when opened. In addition, the facility failed to ensure sanitary conditions for two of two ice machines used by the kitchen. Additionally, the facility failed to ensure sanitary conditions in the kitchen. These deficient practices had the potential to place the 89 residents receiving food and hydration from the kitchen at risk of foodborne illness. Findings include:Review of the facility policy titled Food Storage: Cold Food, revised 2/2023, revealed the Procedures section included, . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination.1. Observations on 8/18/2025 at 10:02 am, during the initial kitchen tour with the Dietary Manager (DM), revealed the cooler contained:One unwrapped piece of ham. One unwrapped half of a tomato. One 5-pound (lb.) bag of shredded cheddar cheese that was unlabeled and undated. Five…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of the facility policy titled Behavioral Management Program, the facility failed to refer one of two residents (R) (R5) reviewed for Preadmission Screening and Resident Review (PASRR), from a total sample of 46, for evaluation by the appropriate State-designated authority. This deficient practice has the potential to place R5 at risk of not receiving necessary care and services.Findings Include:Review of the facility policy titled Behavioral Management Program, revised June 2024, revealed the Policy Statement stated, It is the policy of the facility that each resident must receive, and the facility must provide the necessary behavioral health care and services and medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-08-21 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    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 policy titled Activities of Daily Living, the facility failed to ensure two of 46 sampled residents (R) (R53 and R72) received assistance with Activities of Daily Living (ADL) care. This deficient practice had the potential to place R53 and R72 at risk of unmet care needs and a diminished quality of life. Findings include: Review of the facility policy titled Activities of Daily Living, revised June 2025, revealed the Policy Statement included, To ensure that all residents receive appropriate assistance with Activities of Daily Living (ADLs) in a manner that promotes dignity, independence, and quality of life. The Definition section included, Activities of Daily Living (ADLs) are basic self-care tasks essential for maintaining health and well-being. These include: Bathing Dressing Grooming and personal hygiene . 1. Review of the electronic medical record (EMR) for R53 revealed the most recent admission date of 4/22/2025 with diagnoses including, but not limited to, displaced intertrochanteric fracture…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of facility policy titled Infection Prevention and Control Program, the facility failed to follow infection control procedures for one resident (R) R68 on Enhanced Barrier Precautions (EBP). This deficient practice had the potential to increase the risk of the spread of infection in the facility. The census was 94. Findings include:Review of the facility policy titled Infection Prevention and Control Program, dated June 2025, revealed the Policy Statement section included, To have a comprehensive program that addresses detection, prevention, and control of infections among residents and staff. This facility's infection prevention and control policies/practices are intended to facilitate in maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Precaution Guidelines section included, All staff should wear appropriate personal protective equipment (PPE) as necessary to prevent exposure to spills or splashes of blood or body fluids or other…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-21 · 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 observations, resident and staff interviews, record review, and review of the facility's policy titled Care Plan Policy, the facility failed to ensure a care plan was developed or implemented for six of 37 residents (R) (R46, R51, R61, R4, R54, R67). Specifically, the facility failed to ensure the care plan was implemented for R46 and R51 for Activities of Daily Living (ADL), R61 for providing a privacy bag for a urinary catheter, R4 for oxygen use, and R54 for tube feeding. In addition, the facility failed to develop a care plan for R67 for the use of antipsychotic and anticoagulant medications. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised April 10, 2024, revealed the Policy Statement of Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the facility…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-21 · 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 observations, resident and staff interviews, record review, and review of the facility's policies titled Activity of Daily Living, Quality of Life, Special Rehabilitative Services, and Nail Care (Finger and Toe), the facility failed to ensure five residents (R) (R51, R29, R21, R56, and R46) were provided care and services in accordance with their personal needs. Specifically, the facility failed to ensure R51 and R29's nails were clean and trimmed, R46's beard was trimmed and clean without food particles present, and R21 and R56 received baths and removal of facial hair. These failures placed R51, R29, R21, R56, and R46 at risk for unmet needs and a diminished quality of life. The sample size was 37 residents. Findings include: Review of the facility's policy titled Activity of Daily Living, Quality of Life, Special Rehabilitative Services, dated November 2022, revealed the Policy Statement included Each resident shall receive, and this facility will provide necessary care and services to attain 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 · D2024-04-21 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Urinary Catheter Care, Anchoring and Changing, the facility failed to ensure a urinary catheter privacy bag was provided for one of four residents (R) (R61) with a 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's policy titled Urinary Catheter Care, Anchoring and Changing, revised April 2, 2024, revealed the Policy Statement was Each resident who is incontinent of bladder and has an indwelling catheter receives appropriate treatment of services to prevent urinary tract infections and to restore as much bladder function as possible. In order to avoid mucosal damage, catheter tubing will be anchored to prevent tension on the {name of catheter} insertion site. The Standards of Practice section stated, 16. Catheter drainage bags will…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-21 · 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

    Based on observation, resident and staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to update the care plan for one resident (R) (R56) related to an indwelling urinary catheter that had been removed and discontinued. The sample size was 37 residents. This failure placed R56 at risk for unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Care Plan Policy, revised April 10, 2024, revealed a Policy Statement of Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the facility will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Standards of Practice section stated, 12. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representative party if so desired. A review of R56's Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, revealed Section C…

    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
Show the remaining 16 citations
  • Potential for harm · D2024-04-21 · tag F0687 — failed to care for feet properly — isolated
    Provide appropriate foot care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Nail Care (Finger and Toe), the facility failed to obtain a podiatry appointment for one resident (R) (R39) of 37 sampled residents. This deficient practice had the potential to cause R39 unnecessary discomfort and decreased quality of life. Findings include: Review of the facility's policy titled Nail Care (Finger and Toe), last reviewed April 1, 2024, revealed the section titled Standard of Practice stated, 4. Stop and report any evidence of ingrown toenails, infection, pain, or if nails are too hard or thick to cut with ease. The Step and Action section stated, 24. Report the condition of the resident's nails: . Complaints or problems with hands or feet. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating intact cognition), and Section GG (Functional Abilities and Goals)…

    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 · D2024-04-21 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 interview, record review, and review of the facility's policy titled Enteral Nutrition Policy, the facility failed to provide enteral (a method of supplying nutrients directly into the gastrointestinal tract) nutrition according to physician orders for one resident (R) (R54) of 10 residents receiving enteral feeding in the facility. This deficient practice placed R54 at risk for medical complications and a diminished quality of life. Findings include: Review of the facility's policy titled Enteral Nutrition Policy, last reviewed April 16, 2024, revealed the Policy Statement included Adequate nutritional support through enteral feeding will be provided to residents as ordered. Review of R54's admission Minimum Data Set (MDS) assessment dated [DATE] revealed section K (Swallowing and Nutrition) documented R54 received tube feeding while a resident in the facility. Review of the medical record revealed R54's diagnoses included, but were not limited to, cerebrovascular accident,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Tracheostomy Policy, Emergency Management, Tracheostomy Care and Services, and Oxygen Therapy Policy, the facility failed to ensure two residents (R) (R71 and R14) had a written physicians order for the tracheostomy tube sizes in use. In addition, the failed to ensure respiratory supplies for R71 were available at the bedside. Additionally, the facility failed to ensure two residents (R24 and R4) receiving oxygen (O2) therapy had written physician orders for oxygen use, ensure oxygen was administered as ordered by the physician, and failed to ensure oxygen concentrator filters were free of dust and debris. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. The sample size was 37 residents. Findings include: Review of the facility's policy titled Tracheostomy Policy, Emergency Management, dated March 2024, revealed the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-14 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident representative interviews, record review, and review of facility policies titled Resident Grievance Policy, and Resident Rights, the facility failed to appropriately resolve a resident's grievance related to lost personal items and keep the resident informed of the progress towards resolution for one resident (R) (R2) of 15 sampled residents. Findings include: A review of the facility policy titled Resident Grievance Policy, with the last review date of December 2021, revealed the policy statement: The intent of this policy is to support each resident's right to voice grievances of any nature with the assurance that the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress towards resolution. The Procedure section, line number 1 stated: The facility must provide each resident with documentation of the grievance process. Line number 3. The grievance process must include: d. The grievance review period will be completed within 72 hours unless…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-14 · 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 staff and resident representative interviews, record review, and review of the facility policy titled Incident Report-Documentation, Investigating, and Reporting, the facility failed to ensure a reportable incident for one of 15 sampled residents (R) (R8) to the State Agency (SA) in a timely manner. Specifically, the facility failed to report an incident of a mechanical device failing to operate and hitting R8 in the face. Findings include: A review of the facility policy titled Incident Report-Documentation, Investigating, and Reporting, with a revision date of November 2022, revealed the Policy Statement stated: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Procedure section line numbered 4 stated: The Administrator or Director of Nursing will notify the appropriate Regulatory Agency in the event the incident is reportable. A review of R8's Quarterly Minimum Data Set (MDS) dated…

    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 · Fcited before2022-07-31 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, interviews, review of the facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to implement effective infection control program to prevent the spread of infections. Specifically, the facility failed to follow isolation procedures; facility failed to ensure signage was posted for use of personal protective equipment (PPE) and failed to ensure that PPE was worn appropriately on two of two Halls (North Hall and South Hall) to prevent the spread of SARS-CoV-2 infection. Findings include: Review of CDC guidance, dated 2/22/22, indicated . HCP [Health Care Professional] caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of a policy provided by the facility titled Infection Prevention and Control Program Overview, revised date of November 2019, indicated . Prevention of spread 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-31 · tag F0607 — failed to have anti-abuse policies — pattern
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, the facility failed to attempt to obtain background checks for eight of 11 files reviewed and reference checks for nine of 11 employee files reviewed. Findings include: Review of the employee files with the Human Resources (HR) representative began on 7/31/22 at 11 a.m. It was determined that there were no background checks for staff who did not require completion of the GCHEXS (fingerprint background check). In addition, there were also no reference checks completed for nine of the 11 staff reviewed. 1. Director of Nursing (DON) started on 4/12/22 and no evidence of a background check and no references. 2. Certified Nursing Aide (CNA) BBB started on 3/3/22 and no evidence of a background check and no references. 3. Medication Aide YY started on 6/21/22 and no evidence of a background check and no references. 4. CNA CCC started on 6/18/22 and no evidence of a background check and no references. 5. Medication Aide DDD started on 7/25/22 and no evidence of a background check and no references. 6. CNA EEE started on 7/25/22 and no references.…

    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 before2022-07-31 · 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 observations, interviews, and record review the facility failed to (1) ensure the care plan was followed for one of 28 sampled residents (R#35) related receiving oxygen as ordered; (2) failed to develop an Activities of Daily Living (ADL) care plan for one of 28 sampled residents (R#1) related to grooming and dressing; (3) failed to implement an Activities of Daily Living (ADL) care plan for two of 28 sampled residents (R#2 and R#39) related to grooming and dressing; (4) failed to implement the activities care plan for three of three residents (R#1, R#16, R#39) reviewed for activities. Findings include: 1. There was an oxygen order with a start date of 1/31/2020 for: OXYGEN AT (2) LITERS PER (MASK OR NASAL CANNULA) CONTINUOUSLY. Every shift related to ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] R#35 received oxygen therapy. Review of the care plan revealed a focused area related to impaired air…

    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 · E2022-07-31 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to provide an individualized activities program to meet the needs of three of three residents (R#1, R#16, and R#39) reviewed for activities. Findings include: 1. A review of the admission Minimum Data Set (MDS) dated [DATE] noted R#1 was admitted on [DATE]; BIMS of five; Activities MDS completed with resident. It was noted that the resident indicated that it was very important for him to go outside when the weather is good and be around animals. A review of the Care Plan for R#1 with last revised date of 4/5/22 noted, When the resident chooses not to participate in organized activities, turn on TV, music in room to provide sensory stimulation. On 7/29/22 at 9:00 a.m. R#1 was observed in his room, in bed. There was no television on or music playing or any signs of activities in the room. On 7/29/22 at 2:32 p.m. R#1 was observed still in bed. There was still no television on or music playing or any signs of activities in the room. On 7/29/22 at 5:13 p.m. R#1 was observed still in bed. There was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-07-31 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and review of the facility's policy, the facility failed to ensure an expired medication was not available for use and that controlled substances (narcotics) were stored under double lock in one (1) of one (2) medication refrigerators. Findings include: Observation on 7/30/22 at 4:02 p.m. of the Medication Storage Room, located behind the nurse's station on South Wing, with Licensed Practical Nurse (LPN) BB, revealed that the medication refrigerator does not have a lock in place. The refrigerator contained narcotics to include four bottles of lorazepam oral concentrate solution and one blister/bubble pack containing 12 Dronabinol 2.5 milligrams (mg) capsules. There is also one expired vial of tuberculin vaccine (Tuberculin Purified Protein Derivative- Mantoux) with an open date of 6/26/22 in the refrigerator. The manufacture instructions on the box read Date the tuberculin vial when opening and discard it after 30 days. The expiration date calculated with LPN BB to be 7/26/22. There is a huge buildup of ice in the refrigerator. On 7/30/22 at 4:11 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident interview, and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure residents toilets were in good repair in one (N18) of 64 resident toilets. Findings: Observation in Room N18 on 7/29/22 at 5:26 p.m. revealed the toilet in the bathroom for this room was observed to be full of stool, there was a hole in the wall under the sink, and there was a blue bucket with an unidentified liquid in it. Observation of bathroom in Room N18 on 7/30/22 at 7:15 a.m. revealed toilet continued to be filled with stool, blue bucket with liquid substance, and hole in the wall as evidenced by missing tile pieces from the wall under the sink. Interview on 7/29/22 at 5:20 p.m. with an unnamed staff person who reported that surveyors needed to check the bathroom in N18 and N21 because they have not been flushing for weeks. It was further reported that the facility is aware, but nothing has been done. Staff person later returned to report that the bathroom in room N21 is…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-31 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) care for four of 28 samples residents (R) (R#2, R#39, R#1, and R#129). Findings include: 1. A review of the Quarterly MDS assessment dated [DATE] revealed that R#2 was admitted to the facility on [DATE]; has a BIMS of eight and requires extensive assistance with dressing and total assistance with grooming. A review of the Care Plan, last revised date of 11/14/19, revealed that R#2 requires assistance with personal hygiene and extensive one person assistance with dressing. On 7/29/22 at 8:50 a.m. R#2 was observed in bed, in hospital gown. On 7/29/22 at 3:08 p.m. R#2 was observed still in bed in hospital gown. On 7/29/22 at 5:13 p.m. R#2 was observed still in bed in hospital gown. On 7/31/22 10:14 a.m., interview with Certified Nursing Assistant (CNA) MM, she stated that she was aware she is supposed to sign off on the shower sheets, but she forgot. She confirmed that she has been at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-31 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure that one resident (R) (R#49) received treatment and care in accordance with professional standards of practice related to timely care and treatment of a newly identified impairment of skin integrity. The sample size was 28 residents. Findings include: Review of the clinical record for R#49 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Type 2 diabetes mellitus without complications, morbid obesity due to excess calories and end stage renal disease. The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed R#49's Brief Interview for Mental Status (BIMS) score was 15, which indicated cognitively intact. Record review revealed R#49 has current physician orders to include the following: Cleanse sacrum/left/right buttock with Normal Saline, pat dry, apply thin layer of skin barrier ointment, cover with dry dressing every day shift on Tuesday, Thursday…

    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 · D2022-07-31 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to provide treatment and assessments to monitor and prevent a reduction in Range of Motion for one of 28 sampled residents (R) (R#2). Findings include: A review of the clinical record for R#2 revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominate side. A review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed R#2's Brief Interview for Mental Status (BIMS) score was eight, which indicated moderate cognitive impairment. The assessment revealed no restorative nursing services. A review of the Care Plan last revised date of 11/22/19 revealed that R#2 was admitted with contracture of left upper arm. A review of the Restorative Referral from Occupational Therapy (OT) dated 12/30/19 revealed that R#2 was referred for Restorative Nursing Program (RNP) for Left Upper Extremity (LUE) orthotic. A review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-07-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of policy titled Oxygen Therapy Policy the facility failed to ensure one of four residents (R#35) receiving oxygen received oxygen as ordered. Findings include: Oxygen Therapy Policy (date of issue November 28, 2017) last review date October 2021 revealed 1. Oxygen therapy is to be used with a written order by a physician. A physician's order for 02 (oxygen) therapy is to contain liter flow per minute via mask or cannula. On an emergency basis, 02 may be used at 2L/minute until physician is notified. There was an oxygen order with a start date of 1/31/2020 for: OXYGEN AT (2) LITERS PER (MASK OR NASAL CANNULA) CONTINUOUSLY. Every shift related to ACUTE RESPIRATORY FAILURE, UNSPECIFIED WHETHER WITH HYPOXIA OR HYPERCAPNIA. On 7/29/22 at 11:13 a.m. R#35 was observed laying in bed with oxygen via nasal canula. The oxygen level was noted to be between on notch between 2 liters per minute (lpm) and 4 lpm. On 7/29/22 at 5:14 p.m. R#35's oxygen observed between 2 lpm and 4 lpm. On 7/30/21 at 5:50 p.m. R#35 observed in bed wearing oxygen. The…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-07-31 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 28 medication opportunities were observed, and there were two errors for one of three residents (R) (R#39), by one of two nurses and one certified medication aide (CMA) observed giving medications, for an error rate of 7.14%. Findings include: On 7/30/22 at 9:36 a.m., Licensed Practical Nurse (LPN) DD was observed giving R#39 his morning medications. Observation revealed that during administration of R#39 medications, 1 tablet was dropped into resident's wheelchair and 1 tablet was dropped onto resident's bedside table. LPN DD picked the 2 tablets up and attempted to administer the medication to the R#39, surveyor intervene and stopped her. LPN DD told surveyor that when if medications are dropped that she administers them. LPN DD stated, That's what I do. LPN DD told surveyor that she did not know she could not administer medications that had been dropped outside of the medication cup. LPN DD exit R#39's room and…

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

    Pharmacy Service 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

$8,822 in federal fines across 2 penalties.

  • $4,587 — penalty dated 2023-08-28
  • $4,235 — penalty dated 2023-08-21

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

Part of a chain

This home belongs to WELLINGTON HEALTH CARE SERVICES — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 51.9+1.1 vs chain
Health inspection 3 of 52.0+1.0 vs chain
Staffing 2 of 52.0≈ chain avg
Quality measures 3 of 52.1+0.9 vs chain
The other 13 homes this chain runs (chain average 1.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
WHS APS HOLDING COMPANY II, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/01/2018
ANDWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2018
PARKWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2018
STAFFWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2018
WELLINGTON HEALTHCARE SERVICES- APS I, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2018
WHS APS HOLDING COMPANY I, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2018
ANDREWS, JAMESIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 12/21/2018
CLEMENTS, JACQUELYNIndividualW-2 MANAGING EMPLOYEEsince 04/05/2021
STAFFORD, ANNETTEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/01/2018

CMS files one row per role, so the 12 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

6 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.

$9.3M
Net patient revenuemost recent cost report
-9.8%
Operating marginrevenue minus expenses
$493K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 10%Other / private 90%

This home reported $493K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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

$324per resident / day
operating cost
$9,838per month
≈ monthly operating cost
$295per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.

Typical monthly cost in Georgia
$8,821/mo
Nursing home (semi-private)
$9,429/mo
Nursing home (private)
$5,300/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115362. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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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