Marietta Center For Nursing And Healing
811 Kennesaw Avenue, Marietta, GA 30060 · For profit - Limited Liability company · 154 certified beds · (770) 422-2451 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0602), cited Oct 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 3 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,901 in federal fines (most recent 2023-10-19)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
- about 20% of its spending goes to commonly-owned related companies
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 | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 5 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 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 | 8.4% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 10.2% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.2% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.9% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 3.0% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.5% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 89.8% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.2% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.9% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.7% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.9% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 79.8% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.8% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 14.2% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.41 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.12 | 1.90 | 1.80 | better |
§ 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.
55.6% 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 337 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.1% 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 104 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 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% 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 | 55.6%CMS range 49.3–62.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.0%CMS range 10.8–15.9 | 10.7% | Oct 2022–Sep 2024 | worse than 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 | 47.1% | 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 | 51.0% | 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 | 37.5% | 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 | 97.9% | 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 | 94.7% | 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 | 97.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.1% | 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 | 5.2% | 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 | 7.3%CMS range 4.8–10.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 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 154 beds and averages 144.0 residents a day — about 94% occupied, or roughly 10 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.27 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 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 2.93 hrs/resident/day on weekends vs 3.40 on weekdays — 14% thinner on weekends. RN hours go from 0.39 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 13 most serious are shown; the remaining 17 are one tap away and print in full.
- Actual harm · G2023-10-19 · tag F0557 — isolatedHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
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 ensure that three of 43 sampled residents (R) (R30, R24, and R4) were treated with dignity related to providing Activities of Daily Living (ADL) care. Psychosocial harm was identified for R30 related to her becoming tearful and expressing feelings of humiliation when she was ignored, and staff refused the resident incontinence care. Findings included: A review of the facility policy last updated December 2022 titled, Quality of Life-Dignity, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall always speak respectfully to residents. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents…
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.
- Actual harm · G2023-10-19 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview, the facility failed to ensure that one of five residents (R) (R16) reviewed for misappropriation was free from misappropriation of their personal property. Psychosocial harm was identified when R16 revealed facility staff took her keys and went to her house without her permission causing her fear of retaliation if reported. Findings included: A review of R16's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R16 presented with a Brief Interview for Mental Status (BIMS) score of 14 out 15, indicating that R16 was cognitively intact. A review of the facility policy, titled, Abuse and Neglect and Exploitation procedure Policy and last revised [DATE], documented, Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent, use of resident's belongings or money without the resident's consent. Exploitation means taking advantage of a resident for personal gain using manipulation. 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.
- Actual harm · Gcited before2023-10-19 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that five of 43 sampled residents (R) (R30, R24, R4, R25, and R31) were provided Activities of Daily Living (ADL) care. Psychosocial harm was identified for R30 related to her becoming tearful and expressing feelings of humiliation when she was ignored, and staff refused the resident incontinence care. Findings included: A review of the facility policy last updated December 2022 titled, Quality of Life-Dignity, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with dignity and respect. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall always speak respectfully to residents. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by, promptly…
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 before2025-09-29 · 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
Based on observations, staff interviews, record review, and review of the facility policies titled, Transmission-Based (Isolation) Precautions and Hand Hygiene, the facility failed to follow infection control protocols and precautions measures for one of eleven residents (R) (R2) with wounds. The deficient practice had the potential to spread microorganisms and infections.Findings include: Review of the facility policy titled, Transmission-Based (Isolation) Precautions date implemented 10/1/2022 and revised 9/12/2022 indicated under Policy, It is our policy to take appropriate precautions to prevent transmission of pathogens. f. The facility will have PPE (personal protective equipment) readily available near the entrance of the residence room and will don (put on) appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. Review of the facility policy titled, Hand Hygiene revised June 2025 indicated under Policy, staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, 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 · Fcited before2025-06-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policies titled Food Receiving and Storage and Refrigeration and Freezers, the facility failed to ensure opened food items in the dry storage area and walk-in refrigerator were labeled and dated, and failed to remove a dented can from the food storage rack to prevent usage. The deficient practices had the potential to place 117 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: Review of the facility policy titled Food Receiving and Storage, issued April 2024, revealed at bullet point seven, All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Review of the facility policy titled Refrigeration and Freezers, issued April 2024. revealed at bullet point seven, Use by or open dates will be labeled on food items once opened. Observation on 6/13/2025 at 8:24 am of the dry storage area revealed an open five-pound bag of egg noodles being stored with no open date. Continued observation of the dry storage area revealed a food…
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 before2025-06-15 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
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 Disposal of Garbage and Refuse, the facility failed to ensure two of two dumpster's side doors were closed and failed to ensure the ground surrounding the dumpsters was free from trash debris. The deficient practice had the potential to promote the harboring of pests, insects, and other organisms and create the potential for disease transmission by pests and rodents. The facility census was 124 residents. Findings include: Review of the facility policy titled Disposal of Garbage and Refuse, revised April 2024, revealed at bullet point seven that refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that the accumulation of debris and insect/rodent attractions are minimized. Observation on 6/13/2025 at 9:10 am of the dumpster area revealed the facility had two medium-sized dumpsters for general trash.…
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 before2025-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, the facility failed to maintain safe water temperatures to ensure residents were free from potential accident hazards, as evidenced by water temperatures exceeding 120 degrees Fahrenheit (F) in one of five shower rooms (South Hall Shower Room). The deficient practice had the potential to place residents who use the shower at increased risk of burns. Findings include: Review of a facility-provided document titled Instructions Testing and Logging Water Temperatures revealed the document included instructions of 1. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120 degrees Fahrenheit. Although 100 degrees Fahrenheit is considered a safe water temperature for bathing. Observation and interview with the Maintenance Director on 6/14/2025 at 9:12 am revealed that the water in the South Hall Shower…
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 before2025-06-15 · 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
Based on observations, staff interviews, record review, and review of facility policies titled Personal Protective Equipment and Transmission-Based (Isolation) Precautions, the facility failed to protect residents from infection by not wearing personal protective equipment (PPE), when providing care to one of two residents (R) (R328) on Contact Precautions. The deficient practice had the potential to cause the spread of infections to other residents, staff, and visitors. Findings include: Review of the facility policy titled Personal Protective Equipment, revised January 2025, revealed under Policy: The facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Under Policy Explanation and Compliance Guidelines: All staff who have contact with residents and their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Review of the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled, Use By Dating Guidelines, the facility failed to ensure food items were properly stored, labeled, and dated, and expired food items were disposed of in a timely manner. In addition, the facility failed to ensure the kitchen areas (tile and ceiling) were maintained in a sanitary condition free from debris, grease, and dirt build-up. The deficient practice had the potential to affect 123 residents receiving an oral diet. Findings include: Review of the undated facility policy titled Use By Dating Guidelines documented . In Dry Storage Areas all unopened items must be labeled with a receiving or delivery date. Once item opened, it must be dated with the open date and use by date. Refrigerate open items per guidelines. The tour of the facility kitchen on 2/13/2024 at 9:15 am with Dietary Manager (DM) KK revealed the following observations: Observation of the following items in the reach-in-refrigerator revealed a bag of French toast (cooked) dated 1/2/2024, a bag of garlic bread (uncooked removed from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-02-15 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to ensure that the dumpster area was maintained in sanitary condition as it relates to dumpster lids being secured tightly and fitted at all times The deficient practice had the potential to promote the harboring of pests, insects, and other organisms that could affect all residents in the facility. Findings include: Observation and interview on 2/13/2024 at 10:20 am of the facility dumpster with Dietary Manager (DM) KK revealed three of three dumpsters in the dumpster area were filled with trash to capacity. A closer observation of the dumpster lids revealed that each dumpster consists of two lids (a left lid and a right lid). All the lids were badly damaged, allowing trash exposure and preventing the trash from being securely contained. Three of three of the dumpsters had lids (either the right or left lid) that were folded downward/sunken into the dumpster resulting in large bags of trash and boxes piled high and resting on top of the lids. Three of three of the dumpster lids (either the right or left lid) were badly…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-15 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Resident Self-Administration of Medications and Medication Administration, the facility failed to ensure five of 41 sampled residents (R) (R22, R39, R90, R81, and R1) reviewed for self-administration of medications did not have medications stored at the bedside. This deficient practice had the potential to allow residents to administer the medications in an unsafe manner. Findings include: A review of the facility's undated policy titled Resident Self-Administration of Medication, revealed the Policy Statement: A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 7. Bedside medication storage is permitted only when it does not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide 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, resident and staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to change and date O2 tubing weekly for three of 41 sampled residents (R) (R36, R84, R54), to clean O2 and CPAP (continuous positive airway pressure device) filters for two of 41 sampled residents (R36 and R61), and to have orders for CPAP use for one of 41 sampled residents (R50). Findings include: Review of the facility policy titled Oxygen Administration date reviewed/revised December 2022, revealed under Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Under the subsection titled Policy Explanation and Compliance Guidelines revealed under number one: oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained…
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 before2024-02-15 · 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
Based on observations, staff interviews, record review, and review of the facility policies titled, Hand Hygiene, PPE Source Control, Standard Precautions Infection Control, and Infection Prevention and Control Program, the facility failed to utilize personal protective equipment (PPE) properly in an isolation room for one of one resident (R) (R95) on transmission based precautions and failed to perform hand hygiene between residents when delivering resident meals to resident rooms for seven of eight residents on the East-C hall. The deficient practice had the potential to spread infection to other residents and staff. The facility census was 127 residents. Findings include: Review of the facility policy titled Hand Hygiene date reviewed/revised June 2023 revealed under Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Under the section titled Policy Explanation and Compliance Guidelines number one revealed staff 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.
Show the remaining 17 citations
- Potential for harm · D2024-02-15 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and review of the facility policy titled, Activities of Daily Living (ADL), the facility failed to give a dependent resident the appropriate assistance with eating meals and to ensure meals in their room in a timely manner for one of 41 sampled residents (R) (R25). The deficient practice had the potiential to cause weight loss for R25. Findings include: Review of the undated facility policy titled Activities of Daily Living revealed under Policy: Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. Activities of daily living (ADLs) include: Hygiene-bathing, dressing, grooming, and oral care; Mobility-transfer and ambulation, including walking; Elimination-toileting;…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · 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 record review, staff interview, and review of the facility policy titled, Comprehensive Care Plans, the facility failed to follow a care plan for one of 41 sampled residents (R) (R42) related to wound care. The deficient practice had the potential to cause R42 to not receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Comprehensive Care Plans with a review date of 9/12/2022 revealed under Policy Explanation and Compliance Guidelines: The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of R42's electronic medical record (EMR) revealed that he had diagnoses including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Wound Treatment Management and Charting and Documentation, the facility failed to provided treatment and care in accordance with professional standards for two of 41 sampled residents (R) (R42 and R81) related to failure to document wound care was performed as ordered by the physician. The deficient practice had the potential to cause further decline and possible infection of wounds. Findings included: Review of the facility policy titled Wound Treatment Management dated August 2023 revealed under Policy Statement: To promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, resident and staff interview, and review of the facility's policy titled, Electrical Safety for Residents, the facility failed to ensure the environment was free from potential accident hazards by ensuring one of 41 sampled residents (R) (R111) was not exposed to a heating device. The deficient practice had the potential to cause skin damage not limited to but including burns specifically due to the use of an electrical blanket. Findings include: Review of facility's policy titled Electrical Safety for Residents dated February 2024 revealed Policy Statement: The resident will be protected from injury associated with the use of electric devices including electrocution, burns and fire. Policy Interpretation and Implementation: 11. The use of electric blankets and electric heating pads is discouraged. 12. When electric blankets are used, the following precautions must be taken to prevent thermal injury and fires: a. Follow manufacturer's instructions for use, b. Do not allow residents to sleep with electric blankets or heating pads turned on, c. Do…
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 · D2024-02-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility policy titled, Use of Psychotropic Medication, the facility failed to indicate a 14 day stop date for psychotropic medication for one of 41 sampled residents (R) (R35) and failed to ensure one of 41 sampled residents (R22) was evaluated for use of as needed (PRN) psychiatric medications beyond 14 days. Findings include: Review of the facility policy titled Use of Psychotropic Medication date reviewed/revised August 2023, revealed under Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident as demonstrated by monitoring and documentation of the resident's response to the medication(s). Under the subheading titled Policy explanation and Compliance Guidelines revealed under: PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record,…
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 · E2023-10-19 · tag F0585 — failed to handle grievances — patternHonor 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
Based on resident and staff interviews, record review, and review of the facility policy and the Grievances Logs from June 2023 to September 2023 the facility failed to take appropriate corrective action and failed to document and to make follow up resolutions for five of nine residents (R) (R21, R40, R41, R42, and R45) grievances reviewed per the facilities grievance policy titled, Resident and Family Grievances. Findings include: A review of the policy titled Resident and Family Grievances included it is the facility policy to support each resident and Family member's right to voice a grievance without discrimination or fear of reprisal. As the facility will make Prompt efforts to resolve which includes the facility's acknowledged of a complaint or grievance and to actively work towards its resolution. The facility will designate a Grievance Official who is responsible carryout overseeing the grievance process to include: Receipt and tracking the filed grievance through its conclusion; Leading any necessary investigation by the facility; Maintaining confidentiality; Issuing a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, the facility failed to ensure that all alleged violations involving misappropriation of resident property were reported immediately to the administrator of the facility and to other agencies for one of five residents (R) (R16) reviewed for misappropriation of resident property. Findings included: During an interview on [DATE] at 11:52 am, Certified Nursing Assistant (CNA) DD revealed she worked in Central Supply and had not performed CNA duties for over a year. She was familiar with R16 and called R16 grandmother. She confirmed that on several occasions, she took money from the resident, including a time in [DATE]. She stated that R16 wrote a check in the amount of $40.00 in her name, and she deposited the check in her own account. CNA DD stated that she took the money and bought a phone for the resident. She further confirmed that she did not inform anyone at the facility, including the administrator. CNA DD stated that she went to R16's house a few times. She stated that in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-03-24 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility failed to provide showers as scheduled and Activities of Daily Living (ADL) care according to the Plan of Care for seven residents (R) (R#44, R#50, R#84, R#57, R#209, R#90 and R#78) of 27 sampled residents. Findings include: 1.During an observation and interview on 3/22/22 at 12:40 p.m., R#50 stated that he has not had a shower since July until last week he had a shower. Observation of resident revealed half inch of facial hair. R#50 stated that he wants to shave once per week. Review of R#50's Electronic Medical Record (EMR) revealed the undated Face Sheet under the Resident tab indicated R#50 was admitted on [DATE]. Review of R#50's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/21/22, located in the resident's EMR under the RAI [resident assessment instrument] tab indicated that R#50 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated he was cognitively intact. Review of R#50's Care…
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 · E2022-03-24 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Resident Council Minutes, and policy review, the facility failed to have sufficient nursing staff to provide seven residents (R) (R#44, R#50, R#84, R#57, R#209, R#90 and R#78) and two supplemental residents (R#210 and R#211) with bed baths or showers as scheduled, failed to provide one of one resident (R#212) medications and Accu check timely, failed to provide sufficient nursing staff to ensure one of one resident (R#44)'s treatments and dressings were changed as ordered by the physician and failed to provide sufficient nursing staff to answer residents' call lights and provide the care the residents' requested for R#360, R#44, R#93,R#60, R#78, and R#6. Findings include: 1. On Sunday, 3/20/22 at 7:45 p.m., the surveyors entered the facility. During an interview on 3/20/22 at 8:35 p.m., R#57 stated that he was admitted to the facility on [DATE], and that there was no nursing staff when he puts on his call light. R#57 stated that he asked for a shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · 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 Based on observation, interview, record review and policy review, the facility failed to ensure advanced directives included a signature by the resident or her health care Power of Attorney (POA) for one of one resident (R) (R#64) out of a total sample of 27 residents reviewed for advance directives. Findings include: Review of the facility policy titled Advance Directives - Guidelines paper copy last revised on [DATE] and provided by the facility, revealed Upon admission to the facility, the Admitting department shall inform the resident that he/she has the right to accept or refuse medical treatment and the right to formulate an advance directive . The Clinical Staff (Licensed Nurse) will review the discharge summary/transfer sheet and review the code status with resident/legal representative to validate and document discussion . Clinical Staff will complete the admission documentation in the EMR .Note: Stakeholders may NOT sign advanced directives. Review of R#64's undated Resident Face Sheet located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to conduct a thorough investigation for one resident (R) (R#361) of two residents reviewed for abuse. R#361 alleged staff to resident abuse; however, the facility failed to obtain statements from staff who may have had knowledge of the incident. Findings include: Review of the facility' policy titled, Abuse, Neglect and Misappropriation of Property dated 5/8/19 and provided by the facility revealed, It is the organization's intention to prevent the occurrence of abuse . and to assure that all alleged violations of federal or State laws which involve abuse . are investigated, and . in accordance with Federal and State law . The Facility Administrator will investigate all allegations, reports, grievances, and incidents that potentially could constitute allegations of abuse The investigation should include interviews of persons who may have knowledge of the alleged incident. Review of R#361's undated Resident Face Sheet located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal 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 interview, record review, and policy review, the facility failed to provide written notification to the resident, the resident representative and/or state ombudsman of facility-initiated transfers/discharges to the hospital for two residents (R) (R#60 and R#80) of two sampled residents who were transferred to the hospital. The failure to notify resulted in the ombudsman not having the opportunity to review the appropriateness of these transfers. Findings include: 1. Review of the R#60's undated Resident Face Sheet located in the Electronic Medical Record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with a diagnosis that included peripheral vascular disease. Review of R#60's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/6/22 located in the EMR under the RAI [Resident Assessment Instrument] tab revealed the resident had a Brief Interview for Mental Statis (BIMS) of 15 out of 15 which indicated no cognitive impairment. Interview with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and facility policy review, the facility failed to develop a care plan for one of two residents (R)(R#48) reviewed for receiving hospice services. Findings include: Review of R#48's undated Resident Face Sheet found in the Electronic Medical Record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with a diagnosis that included senile degeneration of the brain, vascular dementia with behavioral disturbance, and major depressive disorder. Review of R#48's Physician Order found under the Orders tab of the EMR revealed the resident was admitted to hospice on 1/21/22. Review of R#48's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/28/22 located in the resident's EMR under the RAI tab revealed the resident was assessed as receiving hospice services. Review of R#48's Hospice care plan found under the RAI tab of the EMR found the resident care plan was created on 3/21/22 which indicated the care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to ensure one of 27 sampled residents (R) (R#43) participated in the care plan meeting. Findings include: Review of R#43's undated Resident Face Sheet located in the electronic medical record (EMR) under the Resident tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included encephalopathy, chronic kidney disease, morbid obesity due to excess calories, muscle weakness, unsteady on feet, need for assistance with personal care. Review of the most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/18/22 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated no cognitive impairment. During an interview with R#43 on 3/21/22 at 11:36 a.m., the resident stated, I have not had a care plan meeting since I was admitted . I had to request one. The meeting is scheduled for Thursday of this week. Review of R#43's Care Conference…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-24 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure medications and dressings were changed in accordance with physician's orders for one of five residents (R) (R#44) reviewed for wounds of a total sample of 27 residents. R#44's topical antibiotic ointment and wound dressings were not consistently changed on the weekends; R#44's left knee surgical site became infected during her stay in the facility. Findings include: Review of the facility's policy titled Administering Medications dated April 2019 and provided by the facility revealed, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including any required time frame . Topical medications used in treatments are recorded on the resident's treatment record (TAR). Review of R#44's undated Resident Face Sheet in the EMR under the Resident tab revealed R#44 was admitted to the facility on [DATE]. Diagnoses included fracture 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 · D2022-03-24 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide follow-up Psychiatric services for one of one resident (R) (R#84) reviewed for depression in the sample of 27. The failure to provide follow-up behavior health services, specifically Psychiatric services, had the potential to affect the resident psychosocial wellbeing. Findings include: Interview on 3/21/22 at 4:26 p.m., R#84 stated that he wanted to see a Minister or a Psychiatrist for his depression. R#84 stated that he had lost so much with having many strokes, friends dying, and that his life has changed so much. Review of R#84's Electronic Medical Record (EMR) revealed the undated Face Sheet under the Resident tab indicated R84 was admitted on [DATE]. Review of the Progress notes under the Resident tab revealed R#84 tested positive for COVID on 3/7/22 and was transferred to the COVID unit on 3/7/22. Review of R#84's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/2/22, located in the resident's EMR under the RAI…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-24 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a 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 record review and interview, the facility failed to provide one of three residents (R) (R#84) reviewed for rehabilitation services, physician ordered Speech Therapy (ST) once the resident tested positive for COVID and was transferred to the COVID unit. This deficient practice has the potential to affect the resident's ability to swallow foods and liquids. Findings include: During an interview on 03/21/22 at 04:24 p.m., R#84 and his sister both stated that [R#84] was seen by ST until the resident was moved to the COVID unit. Review of R#84's Electronic Medical Record (EMR) revealed the undated Face Sheet under the Resident tab indicated R#84 was admitted on [DATE]. Review of the Progress notes under the Resident tab revealed R#84 tested positive for COVID on 03/07/22 and was transferred to the COVID unit on 03/07/22. Review of R#84's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 03/02/22, located in the resident's EMR under the RAI [resident assessment instrument tab indicated…
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
$7,901 in federal fines across 2 penalties.
- $3,950 — penalty dated 2023-10-19
- $3,951 — penalty dated 2023-10-19
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 EMPIRE CARE CENTERS — 20 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 1 of 5 | 1.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 19 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| GA 2 HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2022 |
| AIBANGBEE, KRISTINE | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
| DONATH, BARRY | Individual | W-2 MANAGING EMPLOYEE | — | since 10/01/2022 |
| HELLER, SHLOMO | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
| EMPIRE CARE CENTERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
| NUSSBAUM, EPHRAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2022 |
CMS files one row per role, so the 8 rows in the source record cover these 6 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 $2.8M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
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
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
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 115206. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-15, 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.