Resorts At Pooler INC
508 South Rogers Street, Pooler, GA 31322 · For profit - Limited Liability company · 122 certified beds · (912) 748-6840 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,017 in federal fines (most recent 2024-06-16)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (57%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 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 | 11.4% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.2% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.9% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 0.4% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.2% | 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 | 2.6% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.8% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 16.0% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 87.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.3% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.2% | 15.8% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.5% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 84.3% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 25.7% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 10.6% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.35 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.48 | 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.
43.3% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.0% 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 53 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 0.33 therapist hours per resident per day in 2026Q1 — more than 54% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 18% 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 | 43.3%CMS range 31.9–57.7 | 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 | 11.9%CMS range 7.6–17.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 66.0% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 50.9% | 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 | 39.6% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 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 | 4.4% | 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 | 8.2%CMS range 4.1–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.18 | 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 122 beds and averages 85.1 residents a day — about 70% occupied, or roughly 37 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.68 hrs/resident/day on weekends vs 3.87 on weekdays — 5% thinner on weekends. RN hours go from 0.45 to 0.65 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 57% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · F2025-12-07 · 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 policies titled Dietary Services: Food brought in the facility by Family or Visitors and Food Storage Guide: Food Dating and Labeling Guidelines, the facility failed to ensure food items were labeled, dated, and not beyond their expiration date. This deficient practice had the potential to adversely affect 84 of 84 residents receiving an oral diet from the kitchen. Findings include:Review of the undated facility's policy titled Dietary Services: Food brought in the facility by Family or Visitors included, . 2. All food items that are already prepared by the family or visitor brought in will be labeled with name and dated. A. The Facility will refrigerate, label, and date prepared items in the nourishment refrigerator. B. The prepared food must be consumed in 3 days. C. If not consumed within 3 days, food will be thrown away.Review of the undated facility's policy titled Food Storage Guide: Food Dating and Labeling Guidelines included, . 1. Put the 'delivery date' on the cardboard case and on individual items when…
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 · F2025-12-07 · 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 outdoor garbage and refuse area was free from debris. This deficient practice had the potential to attract pests and rodents and transfer harmful microorganisms to food, leading to foodborne illness for the 84 residents residing in the facility.Findings include:During observation of the dumpster area on 12/7/2025 at 8:12 am, a chair, a bed frame, a wheelchair, a countertop, a trash can, pallets, and other wood pieces were observed in the dumpster area. On 12/7/2025 at 12:44 pm, an observation and interview were conducted with the Maintenance Director. He reported that the dumpsters were emptied every Monday, Wednesday, and Friday. The Maintenance Director confirmed that the trash cans were open and stated that they should be closed. The Maintenance Director reported that the bed frame, chair, countertop, trash can, wheelchair, and pallets had been at the dumpster site for two to three days. He stated that someone normally picked up the items, but had not been able to contact the person. He further…
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 · D2025-12-07 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, resident and staff interviews, record review, and review of the facility policy titled Nursing Home and Resident Rights, the facility failed to ensure resident privacy during incontinent care for one of 37 sampled residents (R) (R90). This deficient practice had the potential to place R90 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.Findings include:Review of the facility's undated policy titled Nursing Home Resident Rights included, Right to a Dignified Existence -Be treated with consideration, respect, and dignity, recognizing each resident's individuality. Record review of the electronic health record (EHR) for R90 revealed diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Record review of the Quarterly Minimum Data Set (MDS) for R90, dated 10/1/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status (BIMS) score of three (indicating severe cognitive…
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 before2025-12-07 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Resident Self-Administration of Medication, the facility failed to ensure that one of 37 sampled residents (R) (R61) did not have unauthorized and unsecured medication and medicated treatment products at the bedside. This deficient practice had the potential to cause adverse effects for R61 and allow unsecured medication and medicated treatment products to be accessible to other residents.Findings include:Review of the facility's policy titled Resident Self-Administration of Medication dated 1/8/2025, revealed the section titled Policy stated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. The Policy Explanation and Compliance Guidelines section included, . 7. Bedside medication storage is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-07 · 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 observations, staff interviews, record reviews, and the facility policy titled Comprehensive Care Plans, the facility failed to follow the plan of care for one of 37 sampled residents (R) (R44). This deficient practice had the potential to place R44 at increased risk of unmet needs and a diminished quality of life. Findings include:Review of the facility's policy titled Comprehensive Care Plans, dated 1/18/2025 revealed the Policy section stated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The Policy Explanation and Guidelines section included . 8. 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,…
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 before2025-12-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure infection control measures were followed for one of 37 sampled residents (R) (R55) by not storing a Continuous Positive Airway Pressure (C-PAP) [a non-invasive mechanical ventilator] mask properly. In addition, the facility failed to ensure that the oxygen flow rate was set correctly for one of 10 R receiving oxygen (R44). These deficient practices had the potential to place R55 and R44 at increased risk of medical complications. Findings include: Review of the facility policy titled Oxygen Administration, dated 1/8/2025, revealed the Policy Explanation and Compliance Guidelines section included, 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such a case, oxygen is administered, and orders for oxygen are obtained as soon as practicable when the situation is under control.7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. 8.…
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 · D2025-07-02 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to follow professional standards of practice in regard to following a physician's order to obtain a blood pressure prior to the administration of a blood pressure medication for one of six residents (R) (R16) reviewed for medication administration out of 16 total sample residents. This failure had the potential for R16 to be administered blood pressure medication unnecessarily and to experience adverse effects by receiving the blood pressure medication when not needed. Findings include: Review of the facility's policy titled, Medication Administration Overview, dated 2/1/2024, indicated . Verify physician's orders for medication to be administered . Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose) . Review of Lippincott Manual of Nursing Practice, dated 2018, page 75, revealed .Departure from Standards of Care . Failure to monitor . a patient's clinical status…
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 · D2025-07-02 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 a physician-ordered antibiotic was available for administration from the pharmacy for one of two residents (R) (R3) out of a total sample of 16 residents. This failure had the potential for R3 to have adverse effects from not receiving the antibiotic as ordered by the physician. Findings include: Review of R3's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R3 was admitted to the facility on [DATE] with the diagnosis of osteomyelitis of the vertebra in the thoracic region. Review of R3's admission Minimum Data Set (MDS) located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 9/14/2024 indicated R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact. Review of R3's Physician Orders located under the Orders tab in the EMR indicated R3 had an order, dated 9/7/2024, for Cefazolin Sodium Solution Reconstituted 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-02 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to follow the parameters order for a blood pressure medication in which the medication was given to one of six residents (R) (R3) reviewed for medication administration out of 16 total sample residents. This failure had the potential for R3 to receive unnecessary medications. Findings include: Review of the facility's policy titled, Medication Administration Overview, dated 2/1/2024, stated, To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route .Verify physician's orders for medications to be administered . Perform needed evaluations prior to the administering specific medications (e.g., pulse, blood pressure, blood glucose) . Review of R3's undated Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated R3 was admitted to the facility on [DATE] with 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 · Dcited before2025-07-02 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and facility policy review, the facility failed to place a resident with an open wound in Enhanced Barrier Precautions (EBP) and failed to follow infection control guidelines for EBP during a dressing change for one of one resident (R) (R9) reviewed and observed for pressure wounds out of a total sample of 16 residents. This failure had the potential to increase the risk and spread of infections throughout the facility to a vulnerable population. Findings include: Review of the facility's policy titled, Enhance Barrier Precautions, dated August 2022, indicated . Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply . Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs . wound 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.
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- Potential for harm · Fcited before2024-06-16 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of facility policy titled Infection Control, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. This deficient practice had the potential to increase all residents' exposure to communicable illnesses. The facility census was 77. Findings include: A review of the facility's undated policy titled Infection Control revealed the Policy section stated, It is the policy of our facility to adhere to the basic infection control guidelines to limit or prevent residents and staff from the onset of or spread of microorganisms. The Purpose section stated, To comply with the Department of Health Guidelines and prevent the spread of infection, and maintain a safe, sanitary, and comfortable environment. The Policy Interpretation and Implementation section titled Objectives of Infection Control Policies and Procedures stated, The objectives of our infection control policies…
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 · E2024-06-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews, and review of the policies titled Maintenance Department Policy and Procedures and Cleaning and Disinfection of Environmental Surfaces, and review of the facility document titled Room Cleaning Step by Step, the facility failed to ensure that resident rooms were clean, homelike, and in good repair on two of three halls (Hall B and Hall C). The deficient practice placed residents at risk of residing in an unsanitary living environment and the potential for a diminished quality of life. Findings included: A review of the facility's undated policy titled Maintenance Department Policy and Procedures revealed the Objectives stated 1. Direct and coordinate the operations and activities of the physical plant maintenance, including but not limited to: . building and grounds maintenance; . and environmental compliance. A review of the undated facility policy titled Cleaning and Disinfection of Environmental Surfaces revealed the Policy Interpretation and Implementation stated, 9. Housekeeping surfaces (e.g. floors, tabletops) will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-06-16 · tag F0625 — patternNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, family interview, record reviews, and a review of the facility policy titled Bed Hold Acknowledgement Form: Georgia, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for four of six residents (R) (R50, R66, R13, and R11) reviewed for transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings included: A review of the facility's undated policy titled Bed Hold Acknowledgement Form: Georgia under Policy: Bed Holds revealed, Two notices related to the healthcare center's bed hold policy will be issued. The first notice of the bed hold policies is given during the admission, which is well in advance of any transfer. The second notice, which specifies the bed hold policy's duration, will be issued at the time of any transfer. 1. Record review for R50 revealed the resident was transferred to the local hospital on 6/6/2024. A review of 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 · Dcited before2024-06-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policies titled Medication Orders and Storage of Medications, the facility failed to ensure unauthorized medications at the bedside were safely stored and failed to obtain a physician order for self-administration of medications for one of three residents (R) (R223) observed during medication administration. This deficient practice placed R223 at risk for unsafe medication use. Findings include: A review of the facility's undated policy titled Medication Orders revealed the section titled Supervision by a Physician stated, 4. If resident regularly self-administers medication and requests to continue, a self-administration of medication assessment must be completed, and MD [Medical Doctor] must write order as such. The section titled Recording Orders stated, 8. Self-Administration of medication, after assessment completed MD must write order enabling resident to self-administer. A review of the facility's undated…
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 · D2024-06-16 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and a review of the facility policy titled Preadmission Screening and Resident Review (PASRR) Level I and II Policy, the facility failed to submit for a PASRR Level II for one resident (R) (R32) after a new mental illness diagnosis was added and failed to implement recommendations of a PASRR Level II for one resident (R16). This deficient practice had the potential to affect the appropriate level of care and services provided for R32 and R16. The sample size was 42. Findings included: A review of the facility policy titled Preadmission Screening and Resident Review (PASRR) Level I and II Policy revealed the Policy Statement of (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that all applicants to a Medicaid-certified nursing facility: 1. Be evaluated for mental illness, intellectual disability, and/or related condition 2. Be offered the most appropriate setting for their…
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 before2024-06-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, record review, and review of the facility policy titled Oxygen Therapy Policy, the facility failed to ensure oxygen equipment was safely stored for two of 19 residents (R) (R50 and R223) who received oxygen therapy. The deficient practice had the potential to increase the probability of respiratory infection for R50 and R223. Findings include: Review of the facility policy titled Oxygen Therapy Policy, last review date 8/23/2023, revealed the Procedure section included 11. When not in use, the nasal cannula or oxygen mask will be placed in a plastic bag. 1. Record review for R50 revealed the resident was admitted to the facility with the diagnoses of, but not limited to, acute and chronic respiratory failure with hypoxia, pneumonia, dysphagia, bronchitis, disease of the jaw, paralysis of vocal cords and larynx. Observation on 6/14/2024 at 9:50 am revealed a nebulizer mask was noted in the recliner on the seat and not covered. 2. Record review for R223 revealed resident was admitted to the facility with diagnoses of, but not limited to,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-04-22 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of facility menus, the facility failed to ensure the planned menu was followed related to portion sizes for nine residents that had physician's orders for a pureed diet. Findings include: Observation of the lunch meal service on 04/19/2022, beginning at 11:58 AM in the facility kitchen, revealed the following portions were being served for the pureed diets: one yellow #20 scoop (1/5 cup) of the pureed chili; one gray #8 scoop (1/2 cup) of the pureed rice; one light blue #16 (1/4 cup) scoop of pureed green beans; no pureed bread was observed to be served. On 04/19/2022 at 12:12 PM, a copy of the menus with the special diet extensions was requested from Dietary Manager (DM) RR. A review of the facility menu extensions for the lunch meal on 04/19/2022 revealed residents on pureed diets were to receive: one cup of pureed turkey chili; 1/2 cup of pureed green beans; 1/2 cup of pureed rice; and pureed bread. The portions on the menu did not match the portions being served during the observation on 04/19/2022. Observation of the lunch…
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 before2022-04-22 · 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, interviews, and record reviews, it was determined that the facility failed to implement an infection prevention and control program (IPCP) designed to provide a safe and sanitary environment to help prevent the possible development and transmission of Coronavirus (COVID-19) as well as other communicable diseases and infections. Specifically, the facility failed to ensure visitors were screened for COVID-19 before gaining access to the facility and failed to ensure unvaccinated residents were encouraged to wear masks and/or socially distance from other residents throughout the facility. This deficient practice had the potential to affect all residents of the facility and occurred during the COVID-19 pandemic. Findings include: 1. According to the Centers for Medicare and Medicaid Services (CMS) memorandum (memo) QSO-20-39-NH, last revised on 03/10/2022 and retrieved on 04/28/2022 from https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf, revealed, Core Principles of COVID-19 Infection Prevention. Visitors who have a positive viral test for COVID-19,…
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
$4,017 in federal fines across 1 penalty.
- $4,017 — penalty dated 2024-06-16
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ROSENBERG, MINDY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNF | 100% | since 08/01/2019 |
| 508 ROGERS LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; 5% OR GREATER SECURITY INTEREST; ADP OF THE SNF | — | since 10/01/2019 |
| ROSENBERG, ZVI | Individual | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | — | since 10/01/2019 |
| LANCASTER-EPPS, RAMONA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/27/2025 |
| MOHAN, AMAR | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2023 |
CMS files one row per role, so the 12 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
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.
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
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115293. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-07, 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.