Tattnall Healthcare Center
142 Memorial Drive, Reidsville, GA 30453 · For profit - Limited Liability company · 92 certified beds · (912) 557-4345 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2025
- 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
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- 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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 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 | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 32.3% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.6% | 5.6% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.5% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 40.6% | 11.3% | 6.5% | check this† — see note marked dagger below the table |
| 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 | 24.0% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 41.4% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 96.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.1% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 13.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 36.0% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.5% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.0% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.3% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.27 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.78 | 1.90 | 1.80 | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ 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.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.0–15.2 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 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 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.85 | 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 92 beds and averages 71.7 residents a day — about 78% occupied, or roughly 20 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 2.83 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.07 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.67 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 2.69 hrs/resident/day on weekends vs 2.89 on weekdays — 7% thinner on weekends. RN hours go from 0.05 to 0.14 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as 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
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.
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 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2025-08-21 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, record review, and review of the facility's policy titled, Infection Prevention 8.3, the facility failed to implement policies and procedures to ensure an effective antibiotic stewardship program when the Infection Preventionist (IP) did not complete an infection screening evaluation to determine if the correct antibiotics were ordered in order to reduce the development of antibiotic-resistance organisms for residents prescribed antibiotics in the facility. In addition, the Antibiotic Stewardship Program lacked documentation of the tracking or trending of antibiotic usage or where infections occurred in the facility. This failure had the potential to affect all residents' safety related to antibiotic usage and increased the risk of antibiotic-resistance. The facility census was 72 residents.Findings included:A review of the facility's policy titled, Infection Prevention 8.3, dated 9/1/2023 revealed, Infection prevention provides for a practical system of reporting, evaluating, and maintaining records of infections among residents/patients and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-21 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and record review, the facility failed to serve food that was palatable and hot for three of five residents (R) (R25, R26, and R47) reviewed for food palatability out of a total sample of 33 residents. This failure had the potential for the residents to skip meals and potential for weight loss. Findings included:1. A review of R25's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/6/2025 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 11:21 am, R25 stated the food served at the facility did not always taste good. R25 stated the food lacked flavor and could be hotter when served at meals.2. A review of R26's Annual MDS, with an ARD of 7/17/2025 and located in the EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 1:40 pm, R26 stated the food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-08-21 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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 interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines at https://www2a.cdc.gov/vaccines/m/pneumo/pneumo.html, and review of the facility's policy titled, Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4, the facility failed to offer and provide pneumococcal vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for pneumonia vaccinations and failed to ensure R25 received an influenza vaccine. This practice had the potential to increase the risk for these residents to contract pneumonia or influenza.Findings included:A review of the facility's policy titled Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4, revised 9/1/2023 revealed, The facility recognizes the major impact and mortality of both influenza and pneumococcal disease on residents of long-term care facilities and the effectiveness of vaccines in preventing illness, hospitalization, and death. The facility, as…
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 · E2025-08-21 · tag F0887 — patternEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy titled Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4.1, the facility failed to offer and provide COVID-19 vaccines for five of five Residents (R) (R25, R1, R29, R16, and R47) reviewed for COVID-19 vaccination out of a total sample of 33. This practice had the potential to increase the risk for these residents to contract COVID-19.Findings included:A review of the facility's policy titled, Infection Control Manual-Infection Prevention-Immunizations: Standing Order 7.4.1, revised 09/01/23 revealed, Procedure: Screen the resident on admission to determine if they have received the following adult immunizations: . Covid-19. Obtain a physician's order for the following immunizations on admission or after resident signs the information and request form, as applicable: . Covid-19.1. A review of R25's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R25 was admitted to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-21 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy titled Freedom of Abuse- Abuse Prevention: Fast Alerts, the facility failed to ensure two of four Residents (R) (R14 and R80) reviewed for abuse were free from resident-to-resident physical abuse. This failure had the potential to negatively impact all residents due to the facility's failure to prevent resident abuse.Findings included:A review of the facility's policy titled, Freedom of Abuse- Abuse Prevention: Fast Alerts, dated January 2025, indicated, Policy The purpose of this written Freedom of Abuse, Neglect, Exploitation: Abuse Prevention Standard is to outline the preventative and action steps taken to reduce the potential for abuse, mistreatment and neglect of residents and the misappropriation of resident property and to review practice and omissions which if allowed to go unchecked, could lead to abuse. This policy demonstrates a Zero Tolerance of Abuse of any type or manner and will address accordingly.A review of R14's admission…
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 · D2025-08-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two of five Residents (R) (R47 and R5) reviewed for accuracy of MDS assessment out of a total sample of 33 residents. This failure placed the residents at risk of having unmet care needs and services.Findings included:A review of the RAI Manual 3.0, dated October 2019, revealed .If a Minimum Data Set (MDS) assessment is found to have errors that incorrectly reflect the resident's status, then that assessment must be corrected . 1. A review of R47's medical diagnosis sheet found under the Med [Medical] Diag [Diagnosis], tab of the electronic medical record (EMR), revealed that R47 was admitted to the facility with diagnoses which included schizophrenia, delusional disorders, recurrent depressive disorder, and auditory hallucinations.A review of R47's Annual MDS assessment, located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 4/14/2025, indicated R47 had an active…
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 · D2025-08-21 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, the facility failed to ensure that the Pre admission Screen and Resident Review (PASARR) level screening was accurately completed prior to admission for one of one Resident (R) (R29) reviewed for PASARR out of 33 sampled residents. This failure had the potential not to identify the specialized services R29 may have needed and if R29 was appropriate for admission to the facility.Findings included: A review of R29's Electronic Medical Record (EMR) revealed an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/9/2024, located in the EMR under the MDS tab, revealed an admission date of 5/2/2024. A Brief Interview for Mental Status (BIMS) score of two out of 15 was noted, indicating severe cognitive impairment with diagnoses of anxiety disorder, altered mental status, suicidal ideations, hallucinations, depression, and unspecified psychosis. The MDS revealed no PASARR currently considered. A review of R29's Level 1 PASARR dated 5/1/2024 revealed that R29 did not have an anxiety disorder, depression, 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.
- Potential for harm · Dcited before2025-08-21 · 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, interview, record review, and review of the facility's policy titled Elopement Management, the facility failed to provide adequate supervision for one of four Residents (R) (R81) reviewed for accidents. Specifically, R81 eloped from the facility and the facility grounds without staff knowing the resident was missing, which placed him at risk for the resident to be in harm's way or a possible injury.Findings included:A review of the facility's policy titled, Elopement Management, dated January 2025, indicated, Clinical process that addresses a resident's risk of elopement from the premises or a safe area without authorization and/or necessary supervision to do so. A review of R81's admission Record, located in the Profile section of the electronic medical record (EMR), revealed R81 was admitted to the facility with diagnoses that included mild dementia with agitation and major depressive disorder.A review of R81's Elopement Evaluation, dated 3/17/2024 and provided by the facility, indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-28 · 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 observation, staff interview, record review, and review of the facility policies titled, Food Storage, and Sanitation & Food Production, the facility failed to ensure the kitchen was maintained in a sanitary manner for 64 out of 65 residents receiving an oral diet. Specifically, the facility failed to ensure dietary staff allow the clean dishware to air dry; change gloves after touching soiled dishes, removing clean dishware from dish washer without performing hand hygiene; label and date food stored in reach in cooler and freezer, bulk food item containers had a scoop properly stored; directly touching food items with contaminate gloves during meal service, chemicals were not labeled with the name of the product inside. This created the potential for the spread of foodborne illness. Findings include: Review of the facility's undated policy titled, Food Storage revealed, Chemicals must be clearly labeled . Scoops must be provided for flour, sugar, cereals, dried vegetables, and spices. Scoops are not to be stored in the food containers but are kept in covered in a protected…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-03-28 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure four out of 64 residents (Resident (R)34, R26, R13, R32) who received meals prepared by the dietary department were served palatable food, and approximately 35 residents in the dining room did not receive condiments of salt and pepper. Specifically, the food was not at the proper temperature when residents were served; the food lacked flavor; condiments were not provided; food presentation and texture were unappealing. Findings include: A policy on food palatability and temperatures was requested of the Administrator; however, it was not provided by the time the survey team exited the facility on 3/28/2024. During an interview on 3/25/2024 at 1:41 PM, R34 stated the food was unseasoned and cold when she was served meals in her room. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/14/2023 in the electronic medical record (EMR) under the MDS tab revealed a Brief…
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 14 citations
- Potential for harm · D2024-03-28 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, review of the facility policy titled, Change in Condition/Incident Reporting, and review of the American Heart Association website, the facility failed to notify the physician of a change in condition for one of six Residents (R)63). Specifically, the facility failed to ensure the physician for R63 was notified of residents' significantly elevated blood pressure readings. Findings include: Review of the facility policy titled, Change in Condition/Incident Reporting dated August 2021 revealed, under procedure number 3. If there is an actual change in condition, the resident's physician is notified promptly and validated as to information 4. Document the date/time of contacts and with whom you spoke. Document any new physician orders if indicated. Review of High Blood Pressure from the American Heart Association online https://www.heart.org/en/health-topics/high-blood-pressure, on 3/30/2024 revealed a normal blood pressure is a systolic reading (upper number) of less than 120 and diastolic reading (lower number) of less than 80. A hypertensive…
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, the facility failed to ensure two of two (Residents (R) 25 and R168) and their resident representatives had a written Bed-Hold Notice when the residents were transferred to the hospital. Findings include: Review of the facility's policy titled Bed-Hold, dated 3/03/2020, under Policy: All residents are given the option of reserving their bed when leaving the facility with the intent to return. This temporary absence may be for hospitalization or therapeutic leave. All residents or their responsible party are informed in writing about the facilities bed hold policy at the time of admission. A copy of the bed hold agreement is also provided to resident or responsible party prior to a resident's transfer to a hospital or start of a therapeutic leave. Under procedure number two 2. Bed hold Policy and Bed hold Authorization form: All residents/responsible parties are given a copy of the state specific bed hold policy and a bed…
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 F0678 — failed to provide CPR when needed — isolatedProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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, Advance Directives, the facility failed to ensure one of 34 residents (Resident (R)25) had clear and consistent information available regarding whether to perform cardiopulmonary resuscitation (CPR). Specifically, R25's status changed to Do Not Resuscitate (DNR) following admission to hospice; this information was not consistently documented in the resident's record, creating the risk staff would not know whether to attempt to resuscitate him in the event he had no pulse or he stopped breathing. Findings include: Review of the facility's policy titled, Advance Directives dated [DATE] revealed, under Process: A POLST or IPOLST (Physician Orders for Life Sustaining Treatment or Iowa Physician Orders for Life Sustaining Treatment) is a form developed as a more specific and detailed DNR. Like a DNR the form is completed with the resident's doctor and based on end-of-life decisions. Once signed, doctors and other medical professional…
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 F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interview, record review, and review of the facility policy titled, Respiratory System Management, Oxygen E-Tanks, the facility failed to ensure one of six residents (Resident (R)44) portable oxygen tank was securely stored while in residents room. Findings include: Review of the facility's policy titled, Respiratory System Management, Oxygen E-Tanks dated August 2021 revealed, Under Procedure number one d. Cylinders must be secured in racks or by chains, e. Provision must be made so that tanks cannot be knocked over. Must be chained to wall or on safety stand for large cylinders and racks used for small cylinders. Stands and carriers must be used, f. Never allow cylinder to be dropped or strike each other violently. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R44 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen. Review of Physician's Orders dated 8/01/2023 in the EMR under the Clinical tab 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.
- Potential for harm · D2024-02-07 · 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, resident and staff interviews, review of facility documents, and review of facility policy titled COVID-19 Protocol Phase IV, the facility failed to ensure infection control practices were followed to prevent the transmission and spread of COVID-19 related to cohorting a COVID positive residents (R1) and COVID negative resident (R2) in the same room on one of three halls. Findings include: Review of the facility policy titled COVID-19 Protocol Phase IV, Patient Placement: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. MDRO colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Review of the facility's line listing revealed that R1 tested positive on 1/28/2024. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-07-08 · 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, document review, staff interviews, and review of the facility's dishwasher procedure, the facility failed to ensure the dishwasher was operating per manufacturer's requirements to ensure dishes were sanitized and failed to ensure a fan was free of dust and debris while operating in one of one kitchen. The deficient practice affected 70 of 72 residents receiving an oral diet. Findings include: 1. A review of the facility's undated Dishwashing Temperature Procedure revealed, 1. If water is in machine lift drain plug, release all cold water. If there is no water in machine then run water until hot, then insert drain plug. 2. Fill hot water to correct level. 3. If water temp [temperature] is less than 120 degrees, repeat set 1 and 2. 4. If temp [temperature is 120 or above, sign temp [temperature] sheet and wash dishes normally. Note: If temp [temperature] is less than 120 degrees-call maintenance. A review of the National Sanitation Foundation (NSF) Machine Operational Requirements, revealed the wash and rinse temperature was required to be 120 degrees Fahrenheit…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-08 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
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 review of a facility policy titled, Resident Rights and Dignity Management, the facility failed to ensure that residents were afforded the opportunity to use a telephone in a private setting on two (Hall A and Hall B).of three halls. Findings include: A review of a facility policy titled, Resident Rights and Dignity Management, dated August 2021, revealed, Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include: (j). use a telephone in privacy. During a Resident Council meeting on 07/07/2022 at 9:30 AM with the facility Resident Council President, Resident (R) #54, and the Resident Council Members, R#4, R#71, R#61, R#35, and R#28, the residents reported concerns with the facility not providing a private setting to afford them the opportunity to use the telephone in privacy. They further reported having to stand or sit at the nurses' station to use…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-08 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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 policy review, it was determined the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) Program was in place. Specifically, the facility's QAPI Program failed to identify, implement, or monitor corrective interventions to ensure residents had a functioning call system. The facility census was 72 residents. (Cross refer to F919.) Findings included: A review of an undated facility policy, titled, QAPI Committee, revealed, The primary goals of the QAPI Committee are: To monitor and evaluate the appropriateness and quality of services provided within the framework of the QAPI Program. To provide a means whereby negative outcomes relative to resident care and facility services can be identified and resolved through an interdisciplinary approach, and positive outcomes can be reinforced through education and monitoring. Observations during the initial tour from 8:28 AM until 2:52 PM on 07/05/2022 revealed the facility's call system was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-08 · tag F0919 — failed to provide a working call system — patternMake 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 and interviews, the facility failed to maintain a functioning call bell system for 12 of 21 sampled resident . During the initial tour of facility on 07/05/2022, a concern was identified with the resident call bell system. There were 12 resident rooms identified with a non-functioning call bell (Rooms 4, 6, 7, 9, 11, 14, 16, 20, 21, 33, 35, and 39). Resident rooms 4, 9, 16, 20, 35 and 39 were noted with a round call disk that had temporarily been put in place to use for the call bell and were also found to be non-functional. Findings include: An observation of room [ROOM NUMBER] on 07/05/2022 at 8:28 AM revealed the call bell was non-functional. An observation of room [ROOM NUMBER] on 07/05/2022 at 9:25 AM revealed the call bell and call disk were non-functional. An observation on 07/05/2022 of room [ROOM NUMBER] at 9:30 AM revealed the call bell and call disks were observed to be non-functioning. An observation on 07/05/2022 of room [ROOM NUMBER] at 9:35 AM, revealed the call bell and call…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-08 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure the discharge planning process was documented in the medical record for one (Resident [R] #223) of two sampled residents reviewed for discharge planning. Findings include: A review of the facility's policy titled, admission and Discharge Process, dated 03/2016, revealed, The Discharge Management process is managed by the interdisciplinary team. Further review of the policy revealed Refer to the following policy and procedure manuals for Discharge related policies: Electronic Documentation - Progress Notes - Discharge Home Instructions - Recapitulation of Stay. A review of R #223's admission Record, revealed the facility admitted the resident on 01/14/2021 with diagnoses of cerebral infarction, circulatory surgical after care, chronic kidney disease, and chronic obstructive pulmonary disease. A review of R#223's Significant Change Minimum Data Set (MDS) dated [DATE] revealed R#223 was severely cognitively impaired, with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-08 · 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, interviews, record review, and facility policy review, the facility failed to ensure that one [Resident (R) #15] of 21 residents whose care plans were reviewed had a person- centered care plan to address contractures. Findings include: A review of a facility policy titled, RAI [Resident Assessment Instrument; a standardized, minimal assessment and screening tool to assess key domains of function, mental and physical health, social support, and service use]/Care Planning Management, revised 7/2022, revealed Goals will be resident specific, measurable, and realistic. Interventions will be action verb directed and specific to each resident. A review of an admission Record for R#15 revealed the facility admitted the resident on 10/21/2021 with diagnoses that included cerebral palsy, persistent vegetative state, and contractures of the muscles of the right and left lower legs and right and left upper arms. A review of R#15's admission Minimum Data Set (MDS), dated [DATE], revealed a Staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-08 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and facility policy review, the facility failed to revise the care plans for one [Residents (R) #223] of 21 sampled residents reviewed for care planning. Specifically, R#223's care plans were not revised to include a change in code status and discharge care planning. Findings include: A review of the facility's policy titled, RAI/Care Planning Management, dated July 2022, revealed Conferences are also held quarterly and annually with each review. In addition, care plan reviews are conducted when a resident has a change in condition. Care plans are to be updated in an acute situation when identified, such as falls with injury, new skin alterations, worsening skin conditions, behaviors, resident events, weight loss, infections, uncontrolled pain, allegations of abuse and other concerns that involve resident care/condition. A review of R#223's admission Record, revealed the facility admitted the resident on 01/14/2021 with diagnoses of cerebral infarction, circulatory surgical after care, chronic kidney disease, and chronic obstructive pulmonary…
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 before2022-07-08 · 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 record review, interviews, and facility policy review, the facility failed to investigate to determine the causal factors of a fall for one (Resident [R]#49) of 3 sampled residents reviewed for falls. Findings include: A review of the facility policy, titled, Falls Standard, (undated), revealed, Procedure Post-Fall, 7. Nursing to complete: Fall Risk Assessment form. Incident report, to include vital signs, with lying and standing blood pressure. Incident report and accident/event management protocol to be completed per nurse. Start investigation process to determine root cause of the fall. FSI- Fall Scene Investigation Report (used to identify the root cause analysis ). A review of (R)#49's admission Record revealed the facility admitted the resident with diagnoses which included dementia with behaviors, generalized muscle weakness, and lack of coordination. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated R#49 had severely impaired cognition with a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-08 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 record review and interviews, the facility failed to maintain accurate medical records for two [Residents (R) #52 and #223] of 21 residents whose medical records were reviewed regarding code status to denote if a resident desired life-saving measures, to include cardiopulmonary resuscitation (CPR). Findings include: A policy regarding complete and accurate medical records was requested on [DATE] at 9:11 AM but was not received by the end of the survey. 1. A review of R#223's admission Record revealed the resident had diagnoses of cerebral infarction (stroke), circulatory surgical aftercare, chronic kidney disease, and chronic obstructive pulmonary disease. A review of R#223's Discharge Minimum Data Set (MDS). dated [DATE], revealed R#223 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of three out of 15. Per the MDS, R#223 required extensive staff assistance for activities of daily living (ADLs). A review of R#223's Physician's Telephone Orders, 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.
“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.
Part of a chain
This home belongs to BEACON HEALTH MANAGEMENT — 11 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.5 | -0.5 vs chain |
| Health inspection | 2 of 5 | 1.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 1.6 | -0.6 vs chain |
| Quality measures | 2 of 5 | 2.1 | -0.1 vs chain |
The other 10 homes this chain runs (chain average 1.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RWC HEALTHCARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| PWW HEALTHCARE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| GREEN, DWIGHT | Individual | W-2 MANAGING EMPLOYEE | — | since 12/28/2021 |
| BEACON HEALTH MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2016 |
| WERTHEIM, BRUCE | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2016 |
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 89% 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 $402K 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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115575. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, 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.