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Pleasant View Nursing Center

475 Washington Street, Metter, GA 30439 · For profit - Corporation · 120 certified beds · (912) 685-2168 Medicare & Medicaid certified

Call the home — (912) 685-2168 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 2025Behavioral-health or dementia-care citations — no harm found (F0741, F0758)
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)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
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
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (60%) 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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
380 Cedar St · (912) 685-1215 · Call to confirm hours
Pharmacy
150 S Leroy St · (912) 685-2803 · Call to confirm hours
Grocery
535 NE Broad St · (912) 685-7226 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship
307 N Trapnell St · (912) 685-5831

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased39.0%15.3%15.4%worse
Long-stay residents who lose too much weight0.3%5.6%5.4%better
Long-stay residents with a catheter left in their bladder0.2%0.9%0.9%better
Long-stay residents with a urinary tract infection1.4%2.5%2.0%better
Long-stay residents with depressive symptoms24.5%11.3%6.5%worse
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury8.0%3.2%3.3%worse
Long-stay residents whose ability to walk worsened30.1%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication31.8%20.5%18.9%worse
Long-stay residents given the seasonal flu vaccine86.7%95.0%95.3%typical
Long-stay residents with pressure ulcers4.3%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control17.0%15.8%21.2%better
Short-stay residents who newly got an antipsychotic medication4.3%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine24.0%78.4%79.4%worse
Short-stay residents rehospitalized after admission17.4%25.0%22.6%better
Short-stay residents with an outpatient ER visit10.4%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days1.792.151.67typical
Long-stay outpatient ER visits per 1,000 resident days2.361.901.80worse

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.

11.0%U.S. median 10.7%
Went back to hospital
48.0%U.S. median 56.6%
Met the expected recovery
0.20U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 48.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 25 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 21% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 46% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.0%CMS range 6.9–16.410.7%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 discharge48.0%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 discharge44.0%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 discharge40.0%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 identified96.4%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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 worsened0.0%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 hospitalization7.4%CMS range 3.4–14.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 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

0.22
RN hours/ resident / day
0.98
LPN hours/ resident / day
1.84
Aide hours/ resident / day
3.04
Total nurse hours/ resident / day
0.14
RN hoursweekends
60.0%
Total nursing turnover
77.8%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 96.8 residents a day — about 81% occupied, or roughly 23 beds typically open. It usually has some room. 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 3.04 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.22 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.67 hrs/resident/day on weekends vs 3.19 on weekdays — 16% thinner on weekends. RN hours go from 0.25 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% 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

0
deficiencies at the latest standard inspection (2026-01-15)
11
at the previous standard inspection (2024-08-21)

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 · E2025-09-10 · tag F0610 — failed to investigate and act on abuse reports — pattern
    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 record review, interviews, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts, the facility failed to ensure a complete and thorough abuse investigation was conducted for six of nine Residents (R) (R2, R3, R4, R6, R5, and R9) reviewed for abuse investigations out of a total sample of 22 residents. This failure had the potential to result in additional residents to be abused by the same perpetrator.Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation, Abuse Prevention: Fast Alerts, dated 10/2023, revealed All alleged violations involving mistreatment, sexually inappropriate behaviors, and abuse or neglect will be thoroughly investigated…An immediate investigation into the alleged incident, during the shift it occurred on …2. Interview the resident or other resident witness.' 1.Review of R2's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, indicated R2…

    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 · D2025-09-10 · 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 record review, interview, and review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to notify the State Survey Agency (SSA) of an allegation of physical abuse for one of seven Residents (R) (R9) reviewed for abuse out of 22 sampled residents. Specifically, there was no documentation that the SSA was notified of an allegation of physical abuse when the Director of Nursing (DON) was notified of bruising to R9's body by the hospital's Social Worker. This failure had the potential to contribute to further abuse or injury, which could result in mental anguish, physical harm, or fear.Findings include: Review of the facility's policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, dated October 2023, indicated . Reporting-All employees are required to immediately notify the administrative.staff of any complaint, allegation.of resident abuse.as soon as the facility is aware of a situation.they…

    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 · F2024-08-21 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose 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 three of three garbage dumpsters were maintained in sanitary conditions, free from trash and debris on the ground, and with secure fitting lids. The deficient practice had the potential to promote the harboring of pests, rodents, insects, and other organisms. The facility census was 101 residents. Findings include: Observation of the dumpster on 8/18/2024 at 3:15 pm with the Dietary Manager (DM) and Maintenance Director revealed trash piled up high and spilling over to the ground in three of three dumpsters. Further observation revealed opened bags of trash, exposing dirty briefs with fecal matter, wipes covered in feces were observed scattered on the ground surrounding the dumpsters. Continued observation revealed swarms of flies and at least 50 large clear white trash bags on the ground around the dumpsters. The large clear bags contained food, trash, and soiled personal care items. An interview at the time of observation on 8/18/2024 at 3:16 pm was conducted with the DM and Maintenance Director. Both staff…

    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 · E2024-08-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled, F-689 Accidents -Water Temperatures, the facility failed to maintain safe water temperatures at the hand washing sink in 12 of 28 resident bathrooms and two of three resident shower rooms. In addition, the facility failed to ensure an environment free from chemical and environmental hazards in one of three shower rooms. This deficient practice placed the residents residing in the affected rooms and using the affected shower rooms at risk of avoidable injuries and a diminished quality of life. The census was 101 residents. Findings include: 1. A review of the facility's undated policy titled, F-689 Accidents - Water Temperatures, revealed the section titled F - 689 Description stated, The facility must ensure that the resident environment remains free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents. The section titled Purpose included, The purpose of recording your water temperatures is to assure the Surveyor…

    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 · E2024-08-21 · 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 observations, interviews, and a review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure that one of two medication carts was locked and secured when unattended by the nurse. The deficient practice had the potential to allow unauthorized persons, including residents and visitors, to access medications. The census was 101 residents. Findings include: A review of the facility policy titled, Medication Administration Guidelines, dated August 2021, revealed the section titled Safe Medication Administration included, Medication carts are to be kept locked at all times and under the vision supervision of the licensed nurse. During observation on 8/18/2024 from 12:15 pm to 12:21 pm, Medication Cart 2 was parked in the hallway, unattended, and unlocked. The medication drawer was pulled, and it opened without a problem. Registered Nurse (RN) JJ approached the cart and locked it. During an observation on 8/18/2024 at 6:41 pm, Medication Cart 2 was parked in the hallway, unattended, out of sight of a nurse, and unlocked. Licensed…

    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 · E2024-08-21 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policies titled, Laundry Linen: Handling of, and Biohazardous/Infectious Waste, the facility failed to follow acceptable infection control practices to prevent cross-contamination during a glucometer check for one resident, during the storage of linen in one linen storage room, during the storage of soiled linen in two shower rooms, and during the storage of washbasins and urinals in three resident restrooms. These deficient practices had the potential to increase the risk of cross-contamination and spread infections. Findings include: 1. During observation of the glucometer procedure on 8/19/2024 at 10:30 am, Licensed Practical Nurse (LPN) GG performed a fingerstick blood sugar on one resident. Observation revealed LPN GG placed the supplies on the surface of the cart before entering the resident's room without sanitizing or placing a barrier on the cart. She performed the procedure and placed the used supplies (including the glucometer, used…

    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 · Dcited before2024-08-21 · 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, and record review, the facility failed to place a privacy bag over the indwelling urinary catheter drainage bag of one of two residents (R) (R251) reviewed with a urinary catheter. This failure had the potential to diminish R251's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A policy was requested and not provided. A review of the clinical record revealed that R251 was admitted to the facility on [DATE], and the Minimum Data Set (MDS) was in progress. A review of the Physician's Orders revealed an order dated 8/9/2024 for a urinary catheter. A review of R251's care plan dated 8/19/2024 revealed a focus area of an indwelling urinary catheter due to urinary retention. There were no interventions for placing the drainage bag in a privacy bag. An observation on 8/18/2024 at 2:23 pm revealed R251's urinary catheter drainage bag was not in a privacy bag and was uncovered. An observation on…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure two of 54 residents (R) (R49 and R1) reviewed did not have unsecured, unauthorized medications and over-the-counter medication products stored at the bedside. This failure placed R49 and R1 at risk for inappropriate and unsafe medication use and had the potential to allow unauthorized access to medications to other residents and visitors in the facility. Finding include: 1. Record review revealed R49 had diagnoses including, but not limited to, vascular dementia, moderate without other behavioral disturbances, chronic obstructive pulmonary disease with acute exacerbation, and hypokalemia. A review of R49's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). A review of the Physician's Orders revealed an order dated 4/4/2024 for Ventolin HFA (high-flow aerosol) solution 108 mcg/act (micrograms/actuation) (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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0607 — failed to have anti-abuse policies — isolated
    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 staff interviews, record review, and review of the facility policy titled, New Hire Checklist, the facility failed to ensure pre-employment screenings, specifically reference checks and fingerprinting, were conducted prior to employment for four of 10 employees reviewed. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 101 residents. Findings include: A review of the facility policy titled New Hire Checklist, revised December 21, 2023, revealed information obtained upon hire included employee references (at least two), background checks to include sex offender state and nationwide, and fingerprint if applicable. The section titled Background and Criminal Checks stated, A background check will be conducted including, but not limited to, consumer credit history, criminal history, fingerprints, driving record, employment, military, education, and general public records, which will provide information concerning these areas, and your character and general reputation. Your…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled RAI (Resident Assessment Instrument)/Care Planning Management, the facility failed to implement the person-centered comprehensive care plan for one of 12 residents (R) (R78) with a care plan for fall mats and two of two R (R49 and R68) with a care plan for oxygen (O2). This failure had the potential for R78, R49, and R68 to not receive treatment and/or care according to their needs. Findings include: A review of the facility's undated policy titled RAI/Care Planning Management revealed the section titled Process for Completing the MDS (Minimum Data Set), CAAs (Care Area Assessments), and Care Plans stated, Standard: It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Objective: 1. To identify resident's individual needs and care requirements. 2. To assure [sic] that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. 1. 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-08-21 · 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, staff interviews, and record review, the facility failed to follow the physician's orders for two residents (R) (R43 and R78). Specifically for an evaluation for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) for R43 and for gastrostomy tube (G-tube) water flushes for R78. This failure had the potential for R43 and R78 to not receive medical treatment according to their needs and placed them at risk for adverse consequences. Findings include: 1. A review of R43's Face Sheet revealed R43 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, contracture of left hand. A review of the admission Minimum Data Set (MDS), dated [DATE], and the quarterly MDS, dated [DATE], revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive PT, OT, or ST. A…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · 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 observations, staff interviews, and record review, the facility failed to provide services to increase or prevent a decrease in range of motion (ROM) for one of 52 sampled residents (R) (R43). The deficient practice had the potential to place R43 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of R43's Face Sheet revealed that R43 was admitted to the facility on [DATE] with a diagnosis including, but not limited to, contracture of the left hand. A review of the admission Minimum Data Set (MDS), dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status Score (BIMS) of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented the resident did not receive Physical Therapy (PT) or Occupational Therapy (OT). A review of R43's Physician Orders revealed an order dated 5/2/2024 for evaluations for PT, OT, and Speech Therapy. A review of 43'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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-21 · 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 policy titled, Respiratory System Management Standard, the facility failed to ensure two residents (R) (R49 and R68) receiving oxygen (O2) therapy were administered O2 in accordance with the physician order. The deficient practice had the potential to increase the risk of respiratory complications for R49 and R68. The sample size was 52 residents. Findings include: A review of the facility's undated policy titled, Respiratory System Management Standard, revealed the section titled Oxygen Therapy Protocol stated, Standard oxygen therapy is the administration of oxygen at concentrations greater than ambient air to: Treat or prevent hypoxemia, decrease work of breathing, decrease myocardial work. Procedure to follow in order (1). Check the physician's orders in the resident's clinical record. 1. A review of R49's medical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with acute…

    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 · F2023-02-23 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff and resident interviews, and record review the facility failed to serve food that was hot and/or well-seasoned to four of five sampled residents (R) (#48, #82, #57, and #75) reviewed for food palatability. This failure had the potential to affect all 99 residents who consumed food from the kitchen. Findings include: 1. Review of the electronic medical record (EMR) for R#75 revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2022 located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated the resident was cognitively intact. Interview on 02/20/2023 at 12:45 p.m., R#75 stated that the hot foods did not taste hot and that the vegetables were not seasoned. 2. Review of R#72's EMR revealed a quarterly MDS with an ARD of 01/20/2023 located under the MDS tab revealed a BIMS score of 13 of 15 which indicated the resident was cognitively intact. Interview on 02/20/2023 at 1:05 p.m. R#72 stated that the hot foods did not taste hot and that cold foods did not always taste…

    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 · F2023-02-23 · 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 a review of the facility's policy titled, Food storage, the facility failed to cover stored food, keep scoops and cups out of stored dried foods, store meat, vegetables, nutritional supplements, and bread products in a kitchen reach-in freezer at zero degrees Fahrenheit (F) or lower, and date nutritional supplements when removed from freezer storage. This failure had the potential to affect all 99 residents who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Food storage, revealed Temperatures for freezer should be 0 degrees or below and must be recorded daily., Scoops are not to be stored in the food containers but are kept covered in a protected are near the containers. and Leftover food is stored in covered containers or wrapped carefully and securely. Review of the facility's undated policy titled, Shelf Life of House Supplements and Thickened Liquids, specified the shelf life of frozen shakes was 14 days (with an internal temperature of) 41 degrees or below & unopened. 1. Observations…

    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 · F2023-02-23 · tag F0925 — failed to control pests — widespread
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff and resident interviews, record review, and a review of the facility's policy titled, Pest Control, the facility failed to maintain an effective pest control program so that the facility was free of rodents. This failure had the potential for all the residents of the facility to be at risk for diseases caused by rodent infestations. Findings include: Review of facility policy titled, Pest Control dated 03/2016 revealed The facility strives to protect the residents, staff, and visitors from insects and other pests by controlling infestation through contracts with outside pest control agencies. It is the responsibility of all staff members to detect and report immediately the presence of pests to their supervisor. Actual Presence .In the event that insects and or pests are noted in a resident's room or on the resident, immediate steps will be taken to prevent or decrease the risk for actual or potential harm. Remove resident(s), immediately, from the vicinity. If there is no potential for harm . Place resident(s) in an area free of insects/pests until…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-23 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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, staff interviews, and a review of the facility's policy titled, Homelike Environment, the facility failed to ensure the secure unit was in good repair, and free from odors. Additionally, the facility failed to ensure that dressers were kept in good repair in the secure unit for four residents (R) (#2, #15, #48, and #82). This failure had the potential to affect all 51 residents who resided in the secure unit. Findings include: Review of the facility's policy titled, Homelike Environment dated August 2021Residents are provided a safe, clean, comfortable, and homelike environment and encourage using their personal belongings to the extent possible .The facility staff and management will maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. During the initial tour and the daily observations from 02/20/2023 through 02/23/2023 revealed there was a pervasive odor of urine and/or body odor throughout the secure unit. Interview on 02/21/2023 at 10:00 a.m. Housekeeping Staff 1 said she used an air freshener…

    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 · E2023-02-23 · tag F0741 — failed to have staff trained for behavioral health — pattern
    Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
    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 adequate staffing to provide routine care and adequate supervision for the 51 residents on the secure unit out of a total of 99 residents in the facility. Findings include: All the residents in the secure unit were observed to be ambulatory, either by wheelchair or with/without assistive devices such as walkers. All of the residents in the secure unit were required to get up, get dressed, and out of their bed/room for at least part of the day. Several of the residents wandered and walked constantly. A few of the residents in the secure unit could answer general satisfaction questions about their care, but they could not provide specifics or reliable in-depth interviews. Interview on 02/21/2023 at 3:50 p.m. with Activity Staff 1 (ACT)1 revealed that activity staff did not assist in Activities of Daily Living (ADLs) or resident hygiene, however, were assigned to the secure unit, specifically, to increase resident supervision and help redirect resident behaviors when needed. Observation and interview on…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-02-23 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and a review of the facility's policy titled, Mobility Aids: Conduct wheelchair Inspection, the facility failed to provide wheelchairs and geri-chairs that were functional, clean, and in good repair for 10 of 49 sampled Residents (R) (#3, #22, #42, #61, #63, #9, #27, #87, #5, and #11) who used wheelchairs or geri-chairs. This failure had the potential to affect residents' mobility and have a negative impact on their quality of life. Findings include: Review of the undated facility policy titled, Mobility Aids: Conduct wheelchair Inspection revealed Inspect wheelchairs for damaged or missing components .Check wheelchairs for the following: Hand grips, Brakes, Casters, Wheels, Seats, Leg rests, Backs, Arm pads, check for cracks . Repair or replace as necessary. Items identified as poor condition should be removed from service. During the initial facility observation on 02/21/2023 at 12:10 p.m. the following was observed: 1. R#22's wheelchair had dried food, crumbs, and liquid stains on the arm rests and chair pad. 2. R#3 and R#61's geri-chairs…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-02-23 · 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

    Based on observations, staff and resident interviews, the facility failed to promote a dignified dining experience at meals by serving residents food and beverages on disposable Styrofoam plates, disposable Styrofoam cups, small disposable plastic cups, and disposable plastic eating utensils for three of four sampled residents (R) (#48, #76, and #82) reviewed for dignity while dining. This failure had the potential to affect all 51 residents who resided in the facility on hallways A, B, and C. Findings include: The facility did not have a policy regarding dignity while dining for residents. Observations on 02/20/2023 from 12:18 p.m. to 12:52 p.m. of the resident's lunch meal service in the facility's main dining room revealed that resident beverages were served in disposable Styrofoam cups and resident desserts were served in small disposable plastic cups. Observations on 02/22/2023 from 12:05 p.m. to 12:36 p.m. revealed that dietary staff was preparing and serving resident lunch meals from the kitchen tray line to residents who resided in the facility's A, B, and C hallways. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure one of three residents (R) (#22) reviewed for the Pre-admission Screening and Resident Review (PASRR) process, who was admitted with a mental health diagnosis, was referred for a Level II screening. This failure had the potential to increase the risk for a resident with a mental illness diagnosis from not receiving specialized services. Findings include: Review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR) dated August 2022 revealed, .Social Worker's responsibility to see that all residents within the nursing facility with MI/MR [mental illness/mental retardation] are to have PASRR documentation of pre-admission screen with identified specialized services .If one of the above condition is identified, the Social Worker will make a referral for a level II assessment . Record review of the admission Record 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · 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

    Based on observations, staff interviews, record review, and a review of the facility's policy titled, Resident Hygiene-Bath and Shower Standards, the facility failed to ensure baths/showers and consistent Activities of Daily Living (ADLs) were provided to a resident who was dependent on staff for personal hygiene needs. This affected one of six residents (R) (#83) reviewed for ADLs on the secure unit. This failure had the potential to affect the quality of care by residents not receiving bathes/showers according to the facility policy. Findings include: Review of the facility's policy titled, Resident Hygiene-Bath and Shower Standards revised August 2021 revealed; Bathe each resident daily, to include sponge and/or bed bath five times a week (or more often if needed). Include a tub bath or shower at least twice weekly .Bathing includes cleaning and trimming fingernails and toenails, shaving facial hair, washing the entire body, and shampooing the resident's hair . Review of the most recent quarterly Minimum Data Set (MDS) for R#83 dated 01/18/2023 and found in the EMR under the MDS…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and a review of the facility policy titled, Behavior Monitoring, the facility failed to identify target behaviors for monitoring of effectiveness of antipsychotic medication for three of five residents (R) (#22, #42 and #72) reviewed for unnecessary medications. This failure had the potential to contribute to unnecessary antipsychotic medication use for residents who used the medication to treat the behavioral symptoms of dementia. Findings include: Review of the undated facility's policy titled, Behavior Monitoring indicated, Targeted behaviors need to be monitored to determine how often the resident demonstrates the behavior; are the define interventions . effective and are the psychoactive medications effective. Behavior monitoring is completed daily and reviewed weekly. 1. Review of R#22's undated admission Record located in the profile tab of the electronic medical record (EMR) revealed R#22 was admitted to the facility on [DATE] with diagnoses which included…

    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 · D2023-02-23 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to provide an angled rocker knife and evaluate a resident's need for other special eating utensils for one of one sampled residents (R) (#2) reviewed for assistive eating devices. Findings include: Review of an admission Record located in R#2's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] and had diagnoses including cerebral vascular accident with left hemiplegia and left-hand contracture. Review of the resident's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/2023 revealed R#2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment. The MDS also indicated R#2 required supervision and set up help with eating. Review of R#2's Care Plan located in the EMR under the Care Plan tab dated 01/02/2023 contained a Focus of At risk for alteration in nutrition related to fluctuating PO (by mouth) intake.…

    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 · D2023-02-23 · tag F0920 — isolated
    Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interviews, the facility failed to provide an adequately furnished dining room for resident dining by utilizing two overbed tables and two folding tables in the dining room. This affected two of 28 residents (R) (#2 and #48) who ate their meals in the facility's main dining room. Findings include: Observations on 02/20/2023 at 12:31 p.m. of the back section of the facility's main dining room revealed that six residents were eating their meals in that area. Observations of the two folding tables in this area of the dining room where residents were seated and eating their meals revealed that both tables could not be adjusted to be positioned higher or lower. Observations on 02/20/2023 at 12:31 p.m. revealed that R#2 was seated at a folding table in the back section of the main dining room eating her lunch meal. R#2 was seated in her wheelchair and was positioned away from the table and her meal. Observations revealed that R#2 could not position herself closer to her meal because her wheelchair was hitting directly against the folding table. R#2 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-02-23 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, record review, and review of the facility's policy titled, Clinical Staffing Standard dated August 2021 revealed, the facility failed to ensure the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This failure had the potential to affect all residents and visitors to the facility. Findings include: Review of the facility's policy titled, Clinical Staffing Standard dated August 2021 revealed, .2. Staffing will follow .federal regulations. Facility clinical staffing will be posted daily to indicate employees/hours working . Observation on 02/21/2023 at 01:40 p.m. revealed the nurse staff posting was located on a bulletin board inside the nurses' station located between hallways B and C. The entrance to the nurses' station had a swinging door that could only be unlocked from the inside. Review of the nurse staff posting document dated 02/21/2023 revealed that the document did not include the name of the facility. Interview on 02/21/2023 at 2:15 p.m., the Administrator confirmed that 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to BEACON HEALTH MANAGEMENT — 11 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 1 of 51.5-0.5 vs chain
Health inspection 3 of 51.8+1.2 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 1 of 52.1-1.1 vs chain
The other 10 homes this chain runs (chain average 1.5★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
RWC HEALTHCARE LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2016
PWW HEALTHCARE, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 07/01/2016
WILLIAMS, BERRYIndividualW-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROLsince 03/15/2022
WERTHEIM, BRUCEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2016
BEACON HEALTH MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2016

CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$7.1M
Net patient revenuemost recent cost report
-8.6%
Operating marginrevenue minus expenses
$495K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 93%Medicare 6%Other / private 2%

About 93% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $495K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$214per resident / day
operating cost
$6,514per month
≈ monthly operating cost
$197per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

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 115411. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-15, 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.

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