Hospital Authority Of Brooks County, Georgia, The
1901 West Screven Street, Quitman, GA 31643 · Government - Hospital district · 188 certified beds · (229) 263-6100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (19) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 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.
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 | 14.9% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.9% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.7% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.9% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.5% | 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 | 4.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 11.8% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 25.6% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 14.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 24.3% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.6% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 58.1% | 78.4% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 15.3% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.0% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.88 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.48 | 1.90 | 1.80 | worse |
§ 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.
43.9% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 10.9% 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 46 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 47% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% 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 | 43.9%CMS range 34.8–59.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 13.8%CMS range 10.2–17.6 | 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 | 10.9% | 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 | 13.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 19.6% | 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 | 86.2% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 | 1.5% | 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 | 6.2% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 3.9–12.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.45 | 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 188 beds and averages 133.4 residents a day — about 71% occupied, or roughly 55 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.00 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 2.54 is at or above 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 3.60 hrs/resident/day on weekends vs 4.17 on weekdays — 14% thinner on weekends. RN hours go from 0.54 to 0.43 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · F2025-08-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to discard expired foods and to ensure food items were properly labeled and dated in the dry pantry and in the refrigerator/freezers to prevent foodborne illness. The deficient practice had the potential to affect 133 out of 140 residents receiving an oral diet.Findings include:Review of the facility's undated policy titled, Food Receiving and Storage revealed under Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated during a first in-first out system. Under Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use by date, frozen, or discarded.During a tour of the kitchen on 8/26/2025 at 9:00 am with the Assistant Director of Food Service, revealed, the following concerns:1. Observation of the dry pantry revealed four one gallon of red cooking wine with an expiration date of 8/4/2025.2. Observation of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · 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, Self-Administration of Medications by Patients/Residents, the facility failed to ensure two Residents (R) (R96 and R125) did not have unauthorized, unsecured medications at bedside. In addition, the facility failed to ensure authorized medications for self-administration was securely stored at bedside for R129. This deficient practice had the potential to allow unauthorized access of medications to other residents and visitors in the facility. The sample size was 56 residents.Finding include:Review of the undated facility's policy titled Self-Administration of Medications by Patients under the Intent statement revealed, Each patients who desires to self-administer medication is permitted to do so if the nursing centers' interdisciplinary team has determined that the practice would be safe for the patient and other patients of the nursing center and that the patient is able to accurately…
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 before2025-08-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled Environmental Services Policy-cleanliness and homelike environment, the facility failed to ensure vents were free from dust and grime build up in eight residents rooms on two of six halls, A and B (Rooms 37, 38, 39, 40, 68, 66, 70, 71). Findings include: Review of the facility's undated policy titled Environmental Services Policy-cleanliness and homelike environment revealed, .3. Inspection and Oversight: Routine inspections of resident rooms and common areas will be conducted to ensure compliance with cleanliness and homelike standards. Environmental services supervisors will complete weekly rounds and document findings. Concerns identified during nursing or administrative rounds will be communicated and addressed within 24 hours. 1. Observation on 8/26/2025 at 12:05 pm and on 8/27/2025 at 10:43 am of room [ROOM NUMBER] revealed, a dirty vent grate/grille with a black substance on the front slats. 2. Observation on 8/26/2025 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Care plans, Comprehensive Person-Centered, and Self-Administration of Medications by Patients, the facility failed to develop and implement a person-centered, comprehensive care plan for three of 18 Residents (R) (R59, R101, and R129). Specifically, they failed to implement the care plan for oxygen (O2) therapy related to not administering O2 per the physician order for R59; failed to develop a care plan for O2 use, water humidification, and posting signage for R101; and failed to develop a care plan for self-administration of medication for R129. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.Findings include: Review of the facility's policy titled, Care plans, Comprehensive Person-Centered revised March 2022 revealed, Policy Statement, A comprehensive, person-centered care plan that included measurable…
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 · D2025-08-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Smoking Policy, the facility failed to ensure that precautions were in place for the safety of two of four Residents (R) (R118 and R58) during smoke breaks. Specifically, the facility failed to ensure that an uncovered ash tray was not filled with trash and R58's extinguished cigar butts was not placed in a N-95 (disposable facepiece respirator) mask hanging from a rollator. This had the potential to place residents in designated smoking areas at risk for safety.Findings include:Review of the facility's policy titled Smoking Policy, with a revision date of 3/25/2023 under the Purpose statement revealed, To provide a source for evaluation of the resident's ability to safely hold, light, smoke, and extinguish their cigarette.1. Review of the Electronic Medical Record (EMR) for R118 revealed that he was admitted to the facility on [DATE] with diagnoses that included but were not limited to sequelae of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, staff interviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure that the physician's order for oxygen administration was followed for one Resident (R) (R59), failed to post proper signage outside of residents' rooms informing that oxygen was in use for three residents (R101, R145 and R11), failed to have an oxygen order for one resident (R11), and failed to ensure a humidification bottle was used for one resident (R145) out of 18 residents that received oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs and a diminished quality of life.Findings include: Review of the facility's undated policy titled Oxygen Administration under the section Preparation revealed, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under the section, equipment and supplies: 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 · D2025-06-24 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews and review of the facility's policy titled Abuse/Neglect Prevention Program, the facility failed to ensure that one of nine sampled Residents (R) (R1) was protected from alleged abuse by staff as evidence that the staff continued to provide care for R1 and was not suspended during the allegation investigation. Findings include: Review of the facility's undated policy titled Abuse/Neglect Prevention Program revealed, 4. Reporting Practices: H. Facility action in mistreatment, neglect, abuse of residents , or misappropriation, exploitation of resident property . 2. Upon discovery of alleged abuse, the staff member(s) will be immediately suspended pending investigation. Review of medical records revealed, R1 was admitted with the following diagnoses that include but are not limited to emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebra infarction, dementia, and hypertension. Review of the Progress Notes dated 1/28/2025 which indicated a late entry for 1/27/2025 revealed that R1 had…
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 · D2025-06-24 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews and review of the facility's policy titled Abuse Reporting , the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one of nine sampled Residents (R) (R1). Findings include: Review of the facility's undated policy titled Abuse Reporting revealed, under the Policy Statement that All personnel must promptly report an incident or suspected incident of resident abuse, including injuries of an unknown source and misappropriation of resident property. This includes the facility's identification of residents whose person histories render them at risk for abusing other residents. Under the Policy Interpretation and Implementation revealed, 3. When an alleged or suspected case of mistreatment, neglect, or abuse is reported, the facility Executive Director, or his/her designee, will notify the following persons or agencies of such incident: a. Office of Regulatory Services, Long Term Care Section, Compliance Coordinator. b. Resident Representative and/or responsible party c. Ombudsman…
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 · E2024-03-28 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policy titled, Notice of Medicare Non-Coverage (NOMNC), the facility failed to correctly issue Medicare Part A beneficiaries completed form CMS (Centers for Medicare and Medicaid Services) 10123 Notice of Medicare Non-Coverage (NOMNC) and CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) when the residents' completed therapy or skilled nursing services for three of three residents (Resident (R) 61, R130, and R394) reviewed for beneficiary notices. Findings include: Review of the facility's undated policy titled, Notice of Medicare Non-Coverage (NOMNC) stated, .The effective date your {insert type} services.Fill in the type of services ending, {home health, skilled nursing.} Insert the name and telephone numbers (including TTY) of the applicable. Review of the facility's undated policy titled, Financial Liability Notices stated, . SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare…
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 before2024-03-28 · 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
Based on observation, staff interview, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for one of 32 sampled residents (Resident (R) 72). Specifically, the facility failed to ensure R72 did not have nystatin powder (a medication to treat yeast infection) on her bedside table unsecured. Findings include: Review of the facility' undated policy titled, Medication Administration revealed, under Procedural Guidelines number 2. Medications are administered in accordance with written orders of the attending physician. 3. Patients are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of R72's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R72 was admitted to the facility with diagnoses which included candidiasis (yeast infection). Review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 9 citations
- Potential for harm · D2024-03-28 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Staff interview, and review of the facility policy titled, Transfer/Discharge Policy, the facility failed to ensure the ombudsman was notified after residents were emergently transferred to the hospital for two of two residents reviewed for transfers (Resident (R) 70, and R124). This failure had the potential to affect the resident and/or their representative on their appeal rights if desired. Findings include: Review of the facility's policy titled, Transfer/Discharge Policy, dated 11/17/2017, revealed .Copies of emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices . 1. Review of R70's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R70 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Review of R70's Nurses Notes, dated 1/27/2024,…
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 · D2024-03-28 · tag F0625 — isolatedNotify 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policy titled, Bed-Hold Policy, the facility failed to ensure residents and/or their representative received a written bed hold notice after emergent transfers to the hospital for two of two residents reviewed for transfers (Resident (R) 70 and R124). 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 include: Review of the facility's policy titled, Bed-Hold Policy, dated 11/17/2017 revealed, .The facility notifies the resident at the time of admission and again prior to a hospital transfer or therapeutic leave of its bed-hold and return policies . 1. Review of R70's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R70 was admitted on [DATE] and readmitted to the facility on [DATE]. Review of R70's Nurses Notes, dated 1/27/2024, located in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interview, and record review, the facility failed to implement a comprehensive care plan regarding the use of a hand roll and splint for one of 32 sampled residents (Resident (R) 72). This placed the resident at risk for unmet care needs. Findings include: Review of R72's undated Face Sheet located in the resident's electronic medical record (EMR) under the Census tab revealed R72 was admitted to the facility on [DATE] with diagnoses which included stroke, hemiplegia, and contracture of left wrist. Review of R72's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/2024 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five out of score of 15 which indicated the resident was severely cognitively impaired. Review of R72's Plan of Care [comprehensive care plan] located in the resident's EMR under the Clinical Documentation tab revealed, .Apply splints/braces per MD [medical doctor] orders . Observations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-28 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration, the facility failed to clean respiratory equipment for two of two sampled residents reviewed for respiratory care (Residents (R) 115 and R83). Findings include: Review of the facility's undated policy titled, Oxygen Administration, revealed, under Intent: It is our intent to provide oxygen safely and accurately to appropriate patients/residents. Under Infection Control Policy of O2 (Oxygen) Humidifier Bottles number 6. The external black filter should be washed with soap and water once each week and PRN (as needed). Dry with towel and reinsert. Do not discard unless it is damaged. 1. Review of R115's undated Face Sheet located in R115's electronic medical record (EMR) under the Census tab revealed R115 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Review of R115's Physician Order, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-28 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policies titled, Maintaining Patency of a feeding Tube (Flushing) and Medication Administration-General Guidelines, the facility failed to ensure the medication error rate was less than five percent for two of five residents (Resident (R) 93 and R133) resulting from three errors out of 26 opportunities for a medication error rate of 11.54 percent. Findings include: Review of the facility's undated policy titled, Maintaining Patency of a feeding Tube (Flushing), revealed under General Guidelines number 3. Flush enteral feeding tubes with 15 ml [milliliters], or prescribed amount, of warm water before and after administration of medications. If administering more than one medication, flush with 15 ml, or prescribed amount, of warm water between each medication. Review of facility's policy titled, Medication Administration-General Guidelines, dated October 2017, revealed under Procedural Geuidelines: number 2. Medications are…
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 before2024-03-28 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, and review of the facility policy titled, Standard Precautions, the facility failed to ensure proper contact time after cleaning the glucose meter for one of 32 sampled residents (Resident (R) 67). Findings include: Review of the facility's undated policy titled, Standard Precautions revealed, under observations: number 10. Small non-disposable equipment such as glucose meter [glucometers], scissors, and thermometers (V/S [vital sign] machines) are cleaned and appropriately disinfected after each use for individual resident care. Under observation during point of care includes but not limited to 1. Glucose meters are to be cleaned after each use with hydrogen peroxide wipes. Review of the undated CloroxPro product catalog located at https://www.cloroxpro.com/products, revealed Clorox Hydrogen Peroxide healthcare wipes had a contact time of one minute. Observation on 3/28/2024 at 11:32 AM revealed Registered Nurse (RN) 1 obtained a fingerstick blood glucose on R67 by using the blood glucose strip that was placed into the glucometer to measure…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-14 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and review of the Maintenance Director's Job Description, the facility failed to ensure resident's furniture was in good and functional condition related peeling wallpaper in one bathroom (room [ROOM NUMBER]), missing drawer handles, broken drawer handles, loose drawer handles, and broken drawers that would not open on one of six units observed. Findings include: Review of the Property Management Director Job Description dated revised 5/2008, revealed: 6. Administers and implements the preventive maintenance program to ensure uninterrupted operation of the entire facility. Monitors its applications to assure maximum effectiveness and provides appropriate documentation of this program. 7. Coordinates the repair of equipment and/or recommends the replacement of, additions to, equipment or physical plant as necessary. Room observations held on 7/12/22 at 9:00 a.m. and 7/13/22 at 11:00 a.m. on the facility E hall revealed: 1. In room [ROOM NUMBER] revealed peeling wallpaper on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-07-14 · 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 observations, staff interviews and review of the facility policy titled, Environmental Cleaning and Disinfection the facility failed to store patient care equipment (wash basins, bed pans, and urinals) in a sanitary manner in the residents' bathrooms, to prevent the spread of infection on one of six units observed. Finding include: Review of the facility policy titled Environmental Cleaning and Disinfection not dated revealed: 16. g. An appropriate disinfectant that is registered with the EPA .is being used. Disinfectants used for cleaning after each use, known contamination includes bed pans, washbasins, urinals, or any other care item used for direct resident care. Items after cleaning should be placed in the bedside stand or shelf in the closet. Room observations held on 7/12/11 at 9:00 a.m. and 7/13/2022 at 11 a.m. on the facility E hall revealed the following in the shared bathrooms: 1. In room [ROOM NUMBER] bathroom there were two washbasins on the covered tub area that were not labeled or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2024-03-28 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to ensure daily staffing information was accurately completed, and readily available in a readable format to residents and visitors. Findings include: Review of the facility's untitled daily staffing documents dated 11/21/2023 through 11/26/2023, and 1/22/2024 through 1/27/2024, provided by the facility revealed the daily staffing documents were missing the total hours worked by Certified Nursing Assistants (CNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). Observations on 3/25/2024 at 10:40 AM, 3/26/2024 at 1:30 PM, and on 3/27/2024 at 1:00 PM of the staff posting which was posted on the bulletin board on the G/H hallways revealed the postings failed to include the staffing hours. Observations on 3/25/2024 at 11:00 AM, 3/26/2024 at 1:45 PM, and 3/27/2024 at 12:10 PM, of the staff posting which was posted on the whiteboard in the lounge revealed the postings failed to include the staffing hours. During an interview on 3/28/2024 at 12:35 PM, the Nursing Scheduler (NS) 1 stated, The Staff postings are…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115498. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-28, 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.