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Powder Springs Center For Nursing & Healing

3460 Powder Springs Road, Powder Springs, GA 30127 · For profit - Limited Liability company · 208 certified beds · (770) 439-9199 Medicare & Medicaid certified

Call the home — (770) 439-9199 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
2 immediate-jeopardy citations CMS recorded as corrected before the inspection ended (past non-compliance)$16,802 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • lower-than-typical staff turnover (23% vs 45% nationally) — better care continuity
Worth asking about
  • inspectors recorded 2 serious findings as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $16,802 in federal fines (most recent 2024-04-15)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS
Urgent care / clinic
4045 Lindley Cir · (770) 943-1636 · Call to confirm hours
Pharmacy
4045 Lindley Cir · (770) 943-3566 · Call to confirm hours
Grocery
1220 Richard D Sailors Pkwy SW · (770) 439-6001 · Call to confirm hours
Park
1220 Richard D Sailors Pkwy SW · (770) 943-1666 · Typically dawn to dusk
Place of worship
2958 Powder Springs Rd SW · (404) 647-3988

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased14.8%15.3%15.4%typical
Long-stay residents who lose too much weight6.8%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.9%0.9%better
Long-stay residents with a urinary tract infection1.2%2.5%2.0%better
Long-stay residents with depressive symptoms7.0%11.3%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened19.3%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication13.2%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine98.1%95.0%95.3%typical
Long-stay residents with pressure ulcers7.6%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control21.4%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.4%19.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.9%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine82.7%78.4%79.4%typical
Short-stay residents rehospitalized after admission22.5%25.0%22.6%typical
Short-stay residents with an outpatient ER visit16.3%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.982.151.67worse
Long-stay outpatient ER visits per 1,000 resident days1.001.901.80better

§ 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.

50.3% 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 268 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

50.3%U.S. median 51.5%
Got home and stayed home
11.9%U.S. median 10.7%
Went back to hospital
41.2%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 41.2% 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 119 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 35% 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 SNF50.3%CMS range 42.8–56.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.9%CMS range 9.2–14.510.7%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 discharge41.2%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 discharge49.6%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 discharge35.3%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 identified93.2%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 setting96.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge97.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened2.0%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 hospitalization7.3%CMS range 5.3–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.991.02Oct 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

0.44
RN hours/ resident / day
0.86
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.19
Total nurse hours/ resident / day
0.30
RN hoursweekends
22.9%
Total nursing turnover
18.8%
RN turnover

How full it usually is: this home is certified for 208 beds and averages 194.3 residents a day — about 93% occupied, or roughly 14 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 2.77 hrs/resident/day on weekends vs 3.36 on weekdays — 18% thinner on weekends. RN hours go from 0.49 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 23% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

3
deficiencies at the latest standard inspection (2026-01-09)
1
at the previous standard inspection (2024-06-27)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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.

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Immediate jeopardy · J2024-04-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 policy titled Urinary Tract Infections/Bacteriuria-Clinical Protocol, the facility failed to provide appropriate treatment and services to prevent a catheter associated urinary tract infection from worsening for one of 57 sampled residents (R) (R10). The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE]…

    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 · Past Non-Compliance
  • Immediate jeopardy · J2024-04-15 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 Laboratory Services and Reporting, the facility failed to provide critical laboratory tests for one of 57 sampled residents (R) (R10). The Nurse Practitioner ordered urine culture sensitivity (UA and CS) tests on [DATE]. The failure caused R10 to be sent to an acute care hospital with the diagnosis of shock, sepsis, and metabolic crisis (including acute kidney injury and acute renal failure). R10 expired in the hospital on [DATE]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's administrator was informed of the Immediate Jeopardy (IJ) for F690 and F770 on [DATE] at 10:08 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on [DATE]. An Acceptable IJ Removal Plan was received on [DATE] related 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.

    Administration Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2026-01-09 · 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, record review, and review of the facility's policies titled, Food Receiving and Storage and Appendix 14: Emergency Water Supply, the facility failed to ensure emergency drinking water was stored in safe and sanitary manner for residents in the facility. This deficient practice had the potential to cause contamination and compromise all facility resident's safety. The facility census was 195 residents. Findings include:Review of the facility's policy titled Food Receiving and Storage revised 4/1/2024 section; 1.150 revealed foods shall be received and stored in manner that complies with safe food handling practices.Review of the facility's policy titled Appendix 14: Emergency Water Supply dated/ revised 8/17/2022, further review of Emergency Preparedness Binder page 117 number 4 revealed, Primary water storage emergency water is stored away from kitchen in alternative location in AU (Alzheimer's unit) unit.Observation and Interview on 1/7/2026 at 10:09 am revealed multiple brown boxes stacked on top of each other up against the building…

    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 · Dcited before2026-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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, and review of the facility policy titled, Smoking Debris Protocol/Procedures, the facility failed to dispose of cigarette butts in the appropriate receptacle in the outdoor designated smoking area. This deficiency had the potential to cause a fire. The sample size was five residents reviewed for smoking.Findings include:Review of the undated facility policy titled, Smoking Debris Protocol/Procedures, revealed the following: Activities' staff is responsible for the general clean up and cleanliness of the assigned smoking areaActivities' staff to empty the individual smoking ash containers when smoking the session is overAsh containers are emptied into the step on red containerShould the red container be found full, activities is to contact maintenance immediately.After the last smoking session of the day, the maintenance department executes the following protocols:Maintenance will remove the red container from the smoking areaMaintenance floods the container with water or sand to ensure there are no red or smoking embers.Maintenance will then…

    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 · Ecited before2024-06-27 · 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

    Based on observations, staff interviews, record review, and review of the facility policy titled, Personal Protective Equipment (PPE), the facility failed to follow infection control protocol related to disposal of PPE in two out of five rooms with residents on Droplet Precautions (infection control measures used to prevent the spread of respiratory infections). The census was 183. Findings include: 1. Review of the facility policy titled Personal Protective Equipment date reviewed/revised January 2024, revealed under Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Under the section Policy Explanation and Guidelines revealed: Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. Do not reuse. Under the section Respiratory Protection: Wear a NIOSH [National Institute for Occupational Safety and Health]-approved N95 or higher-level respirator to prevent…

    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 · Fcited before2024-04-15 · 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 observation, interviews, and review of the facility's policy titled, Food Receiving and Storage, the facility failed to ensure the vents directly over the steam table were free from dirt and debris, a fan used in the kitchen area was clean, the frozen food items are kept off the freezer floor, and that hair nets were worn in the kitchen. The census was 178 residents. Findings included: A review of the undated facility's policy titled, Food Receiving and Storage documented that the refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded. During an observation on 3/18/2024 at 6:41 pm, the Dietary Manager was observed in the kitchen and was not wearing a hair net. During an interview on 3/19/2024 at 7:50 am, the Dietary Manager confirmed not wearing a hair net during the dinner service on 3/18/2024. The Dietary Manager stated that her hair net was on their desk in the office. During an observation on 3/19/2024 at 8:01 am, there were three vents over the steam table,…

    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 · F2024-04-15 · 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 observation, interviews, and review of the facility policy titled, Food-Related Garbage and Rubbish Disposal, the facility failed to ensure that the facility's outside garbage disposal area was free from trash and debris. The census was 178 residents. Findings included: A review of the undated facility's policy titled Food-Related Garbage and Rubbish Disposal, documented that all garbage and rubbish containing food waste should be kept in containers; all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use; and outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 3/19/2024 at 7:46 am, a kitchen tour was conducted with the Dietary Manager. Two trash compactors were observed outside and had several bags of trash on the ground, including gloves and several plastic bags of trash. The lid of one of the trash compactors was opened. The Dietary Manager confirmed that the lids should have been closed and stated that the cleaning 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-15 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, policy review, and interviews, the facility failed to maintain the tracking and trending of the Infection Control Program. The census was 178 residents. Findings included: A review of the policy entitled, Infection Prevention and Control Program with a reviewed/revision date of May 2023 revealed that the designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases; a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards; and the Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents,…

    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 · F2024-04-15 · tag F0883 — failed to offer flu and pneumonia vaccines — widespread
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, policy review, and interviews, the facility failed to ensure that residents were offered and/or consented to the pneumoccal vaccination for three of six residents (R) (R25, R44, and R46) reviewed for immunizations. Findings included: A review of the Pneumococcal Vaccine (Series) Policy with a date of reviewed/revised of December 2023 revealed that it is the facility's policy to offer residents and staff immunization against pneumococcal disease in accordance with current (infection control) guidelines and recommendations. Further review of the Pneumococcal policy under the Policy Explanation and Compliance Guidelines revealed that, Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted; the resident/representative retains the right to refuse the immunization. The facility will document in the clinical record the reason for refusal or the medical contraindication of the immunization. 1. A review of the clinical record…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-15 · 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, staff interviews, record review, and review of the facility policies titled, Medication Storage and Medication Administration, the facility failed to ensure medications securely stored and ensure expired medications were discarded appropriately on two of three Units (East Unit and Secured Memory Unit). Findings included: A review of the facility policy titled Medication Administration last updated January 2024 revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy explanation and compliance guidelines noted to identify expiration date and if expired, notify nurse manager. A review of the facility policy titled Medication Storage last updated June 2023 revealed that it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacture's…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-15 · tag F0557 — isolated
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, observations, staff and resident interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to promote dignity and independence for one of ten sampled residents (R) (R20) related to providing incontinence pull ups. Findings included: A review of the Activities of Daily Living (ADLs) policy with a date reviewed/revised of January 2024 revealed that the policy stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs for choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A review of the admission records for R20 revealed that the resident was originally admitted to the facility on [DATE] with diagnoses of gastrointestinal hemorrhage, unspecified, Rhabdomyolysis, unilateral inguinal hernia, repeated falls, personal history of other diseases of the nervous system and sense organs, and cerebral palsy. A review of the care plan for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-15 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and a review of the facility policy titled Resident and Family Grievances the facility failed to resolve a grievance related to missing glass for one of six sampled residents (R) (R17). Findings included: The facility's policy titled, Resident and Family Grievances documented that prompt efforts to resolve' include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance and that the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. A review of the Electronic Medical Record (EMR) for R17 revealed an original admission date of 6/26/2023. A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed R17 had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. A review of facility documents revealed that it 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · D2024-04-15 · 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 record review, staff interview, and review of the facility's policy titled Medication Administration, the facility failed to follow the physician orders to administer medications for one of three sampled residents (R) (R41). Findings included: A review of the facility policy titled Medication Administration with a review date of January 2024 revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines included obtaining and recording vital signs, when applicable or per physician orders; when applicable, hold medication for those vital signs outside the physician's prescribed parameters. A review of R41's quarterly Minimum Set Data (MDS) assessment dated [DATE] revealed the resident was admitted to the facility on [DATE] with diagnoses, including but not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the facility's policies titled, Fall Prevention Program and High Risk Medications- Anticoagulants, the facility failed to ensure that residents were supervised, fall incidents were documented, and neuro checks were completed for unwitnessed fall incidents for two of four sampled residents (R) (R4, and R17). Findings included: A review of the undated facility's policy titled, Fall Prevention Program documented that when any resident experiences a fall, the facility will assess the resident; complete a post - fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicted; document all assessment and actions and obtain witness statements in the case of injury. A review of the facility's policy titled High Risk Medications- Anticoagulants documented that anticoagulants refers to a class of medication that are used to prevent clot extension and formation. Examples include warfarin, heparin, Lovenox,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to keep accurate medical record of health status for one of 57 sampled residents (R) (R17). Findings included: A review of the Electronic Medical Record (EMR) for R17 revealed an original admission date of [DATE] with diagnosis of, but not limited to, malignant neoplasm of the brain, hydrocephalus, dysphagia, hypo-osmolality and hypernatremia, gastroesophageal reflux disease without esophagitis and anemia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R17 had a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. A review of R17's comprehensive progress notes which includes their Medication Administration Record (MAR) indicated the following events: A nursing note dated [DATE] documented that R17 was out of the building and was unable to receive intervenous (IV) hydration. An administration note documented by Licensed Practical Nurse (LPN) HH and dated [DATE] documented that…

    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 · D2024-04-15 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure that the nursing call system was functional for one of three sampled residents (R) (R37). Findings included: 1. A review of the Electronic Medical Record (EMR) for R37 revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of, but not limited to, multiple fractures of ribs, end stage renal disease, dependence on renal dialysis, muscle weakness, anemia, and diplopia. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R37 had a Brief Interview for Mental Status (BIMS) score of 15; indicating that R37 was cognitively intact. 2. A review of the EMR for R30 revealed the resident was originally admitted to the facility on [DATE] with diagnosis of, but not limited to, end stage renal disease, type 1 diabetes, dependence on renal dialysis, morbid obesity, hyperlipidemia, hypertension, hypoxia, acquired absence of the right [NAME] below the knee, and…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-04-22 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews and review of policy titled, Antibiotic Stewardship Program, the facility failed to provide evidence of a monitoring system to track and trend antibiotic use for seven months (September 2021 through March 2022) or the past 12 months reviewed. Findings include: Review of the facility policy titled Antibiotic Stewardship Program dated August 19, 2019, revised March 2020 revealed the Antibiotic Stewardship Program's (ASP) action is to improve antibiotic use adverse events, prevent emergence of resistance, and lead to better outcomes for patients and residents in this setting. The ASP is based on The Core Elements of Antibiotic Stewardship for nursing Homes, which include Leadership, Accountability, Drug Expertise, Action, Tracking, Reporting and Education. Core element 5. Tracking-monitor measures of antibiotic use by auditing available reports and patient medical records for adherence to: Clinical. Evaluation documentation, i.e., signs / symptoms., vital signs physical exam findings. Prescribing documentation (dose, duration, indication).…

    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 · F2022-04-22 · tag F0886 — failed to test for COVID-19 as required — widespread
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a review of the facility policy titled, Empire Care Centers Testing Plan/Policy, facility policy titled, Facility Testing Requirements for Staff and Residents, testing records and interviews, the facility failed to ensure consistent testing throughout the facility for residents and staff as required by the Center for Medicare and Medicaid (CMS) while the facility was experiencing an outbreak of COVID-19. Findings include: Review of the facility policy titled, Empire Care Centers Testing Plan/Policy Reviewed/revised 6/24/21, revealed Empire Care Centers monitor the local county positivity rates, and best testing frequency on the thresholds set forth, Further Empire Care Centers test associates and/or residents in the event of an identified outbreak, meaning one positive tested associate and/or one positive tested resident in the center. At which time, the center will test 100% of the residents' and/or associates who have not tested positive within the last 90 days of the outbreak. The center will continue to follow guidance of breakout testing as recommended by CDC and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-22 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure all components of the nurse call system was functional for one of two wings (West Wing). Findings include: During an observation on 4/20/22 at 9:20 a.m. on the [NAME] Wing, it was observed that the call light panel board behind the nursing station and the call lights above the room doors were not lighting up, but the sound could be heard for call lights being activated. Facility staff, including the Administrator was observed searching rooms to see which room needed assistance. After eight minutes, the staff was observed to locate the room that needed assistance. During an observation on 4/20/22 at 11:50 a.m. on the [NAME] Wing in room [ROOM NUMBER] was pressed by the resident and was observed to immite sound but the light above the door and at the nursing station panel was not activated. During an interview with Certified Nursing Assistant (CNA) NN, at that time, they confirmed the call light was not functional. An observation 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-04-22 · 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 a review of the facility policies, employee records, resident records and staff interviews, the facility failed to ensure all staff reporting for duty were screened for Coronavirus (COVID)-19 prior to working their shift and failed to ensure residents were screened daily for signs and symptoms of Covid-19 for five of 50 sampled residents (R) (R#582, R#577, R#623, R#580, R#625). Findings include: Review of the facility policy titled, Coronavirus (COVID19) (SARS-CoV-2) revised December 2021 indicated all associates will be actively screened at the beginning of their shift in accordance with current guidance from local and state health departments. This screening will include questions about COVID-19 symptoms, and if they are working another location where COVID-19 has been identified. The associate must also have their temperature actively taken to rule out fever. Associates who screen positive with a fever or symptoms consistent for COVID-19, should be excluded from work, and tested for COVID-19. 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 Policy (name) Automated Medication Cabinet Services, the facility failed to ensure one of 50 sampled residents (R) (R#228) received his pain medication as ordered. Findings include: Review of the facility policy (name) Automated Medication Cabinet Services dated September 2018 revealed the program is an automated medication cabinet and software program (the Cabinet) that provides immediate access to emergency and first-dose medications. Client's Responsibilities: Process and obtain all first-dose, (immediate) and emergency eligible prescriptions fills through the Cabinet. For those medications available through the Cabinet at the time of an order, any request for a (immediate) or other special delivery not a part of the regularly scheduled delivery for Client shall, at Pharmacy's sole discretion, incur a charge . plus the cost of the medication at the contracted rate. A review of the Automated Medication Cabinet Services inventory sheets revealed…

    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 · D2022-04-22 · 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, record review, staff interviews, and review of the policy titled Oxygen Administration, the facility failed to provide respiratory care consistent with professional standards of practice for two of 35 sampled residents (R) (R#573, R#585) related to ensuring humidification was provided and ensuring that humidification bottles and oxygen tubing were dated. Findings include: A review of the facility policy titled Oxygen Administration with revision date of 12/12/2020, revealed: Date and initial tubing and humidifiers when started each week. Pre-filled humidifier bottle need only be changed weekly or when empty if this is before week has been completed. 1. A review of the clinical record for R#573 revealed he was admitted to the facility with diagnoses including but not limited to chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), dyspnea, and obstructive sleep apnea. A review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed R#573…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-22 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, review of facility policy titled Medication Administration, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 27 medication opportunities were observed, and there were three errors for three of five residents (R) (R#90, R#31, and R#96) for an error rate of 11.11%. Findings include: Review of a policy titled Medication Administration revealed A licensed nurse, medication technician, or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. Medications will not be borrowed from another patient. Doses will be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. If medication(s) is not available, the nurse will: Coordinate with the pharmacy to procure the medication(s) as soon as possible and discuss possible substitution options with the pharmacist, if applicable; Notify the physician/APP of the unavailability of the medication(s); Discuss substitution…

    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
  • No harm found · C2026-01-09 · tag F0848 — widespread
    Provide a neutral and fair arbitration process and agree to arbitrator and venue.
    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's policy titled, Binding Arbitration Agreements, the facility failed to ensure the arbitration agreement specifically provided for the selection of a convenient venue: a location in which to carry out arbitration proceedings which should be agreed upon and was convenient and suitable to both parties for three of three residents (R) R246, R140 and R251 reviewed for arbitration.Findings include: Review of the facility's policy titled Binding Arbitration Agreements reviewed 9/12/2025 documented under Policy Explanation and Compliance Guidelines: . 2. The agreement must: . b. Provide for selection of a venue that is convenient for both parties.Review of the facility's arbitration agreement document revealed there was no mention of a venue nor specifically provided for the selection of a venue should be agreed upon and suitable to both parties.Interview on 1/8/2026 at 4:46 pm with the facility's Concierge II revealed she confirmed the venue was not documented on the arbitration agreement. She further stated that she 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.

    Administration 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

$16,802 in federal fines across 3 penalties. 1 Medicare payment denial on record.

  • $3,465 — penalty dated 2024-04-15
  • $5,636 — penalty dated 2024-04-15
  • $7,701 — penalty dated 2024-04-15
  • Medicare payment denial — starting 2024-05-18 for 2 days

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

Part of a chain

This home belongs to EMPIRE CARE CENTERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.2-0.2 vs chain
Staffing 2 of 51.5+0.5 vs chain
Quality measures 3 of 53.0≈ chain avg
The other 19 homes this chain runs (chain average 1.9★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleShareSince
POWDER SPRINGS OPERATING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 12/10/2020
SHULER, VALERIAIndividualW-2 MANAGING EMPLOYEEsince 01/01/2021
HELLER, SHLOMOIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/10/2020
NUSSBAUM, EPHRAIMIndividualOPERATIONAL/MANAGERIAL CONTROLsince 12/10/2020

CMS files one row per role, so the 5 rows in the source record cover these 4 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.

$21.6M
Net patient revenuemost recent cost report
+3.3%
Operating marginrevenue minus expenses
$1.7M
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 61%Medicare 9%Other / private 30%

This home reported $1.7M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$315per resident / day
operating cost
$9,585per month
≈ monthly operating cost
$326per day
avg. revenue, all payers

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

What families pay in GA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115538. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, 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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