Bryan County Hlth & Rehab Ctr
127 Carter St, Richmond Hill, GA 31324 · For profit - Corporation · 100 certified beds · (912) 756-6131 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high number of inspection citations overall (23) — 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 (2/5)
- 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) | 2 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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 24.9% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 9.1% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.5% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 7.6% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 22.7% | 11.3% | 6.5% | worse |
| 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 | 24.3% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.4% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.1% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 9.4% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.4% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 78.4% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 13.8% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 22.9% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.96 | 1.90 | 1.80 | typical |
§ 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.
49.2% 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 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 27.3% 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 44 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 0.15 therapist hours per resident per day in 2026Q1 — more than 13% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 49.2%CMS range 35.5–65.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.2–17.1 | 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 | 27.3% | 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 | 29.6% | 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 | 22.7% | 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 | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 3.1% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 4.6% | 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 | 7.9%CMS range 4.7–12.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.50 | 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 100 beds and averages 88.2 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.33 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 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 3.85 hrs/resident/day on weekends vs 4.14 on weekdays — 7% thinner on weekends. RN hours go from 0.35 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as 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.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · F2026-04-01 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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 observation, staff interviews, and review of the facility's policy titled Preparation of Pureed Foods for Residents with Dysphagia, the facility failed to ensure that pureed foods were prepared according to standardized recipes and professional food service standards for residents (R) requiring texture modified diets. This deficient practice had the potential to affect nine residents receiving pureed diets.Findings Include:Review of the undated policy titled Preparation of Pureed' foods for the Residents with Dysphagia, revealed under the Moist and Consistency section, to add appropriate liquids to achieve proper consistency: broth, milk, gravy or approved thickened liquids. It was revealed under the Nutritional Adequacy section to ensure meals meet residents' nutritional needs. Fortify foods when needed (e.g., adding protein powder, butter, or supplements).Observation and interview on 03/31/2026 at 10:49 AM revealed that Dietary Aide (DA) HH did not use a recipe while pureeing carrots and chicken dumplings. Carrots and water were used to prepare the pureed carrots. A can…
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 before2026-04-01 · 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 interviews, record review, and review of the facility's policy titled Food Storage, the facility failed to ensure that all foods were properly labeled, dated, and discarded, and failed to ensure the cleanliness of kitchen equipment used in the preparation of food for residents. Failure to follow this policy resulted in improper food storage and unsanitary food preparation practices. This deficient practice had the potential to place 83 residents (R) who received an oral diet at risk of contracting a foodborne illness.Findings include:A review of the facility's undated policy titled Food Storage, documented under Food Service Employees, Stock is rotated so that older items are used first. Products are dated to assure First In- First Out procedures are followed. Foods are inspected regularly for damage due to spoilage. Dented, bulging, leaking cans will be discarded, or returned to vendors for appropriate credit. The purpose is to prevent the transmission of disease carrying organisms.Observation tour of the kitchen on 03/30/2026, beginning at 10:15 AM,…
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 · F2026-04-01 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and the facility policy, Outside Dumpster Policy the facility failed to ensure the outdoor garbage and refuse area was maintained in a sanitary manner, creating the potential for harboring pests and insects. Findings include:A review of the facility's undated policy titled Outside Dumpster Policy revealed several key requirements. Under General Waste Disposal, dumpster lids must remain closed at all times after use, and trash bags must not be left on the ground or outside the dumpster. In Approved Waste Only, only designated general trash may be disposed of in outside dumpsters. Under Safety Guidelines, staff must report damaged dumpsters or unsafe conditions immediately to maintenance, and the dumpster area must be kept free of debris to prevent slips, trips, and falls.Observation and interview on 03/30/2026 at 10:58 AM of the trash dumpster area, accompanied by the Dietary Manager (DM), revealed that numerous wooden pallets were present behind the dumpsters. The top lids of two of the three dumpsters were open, and the side door of one…
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 before2026-04-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff and resident interviews, record review, and review of the policy titled Resident Dignity & Safe Feeding Policy, the facility failed to maintain dignity for four of 45 sampled residents (R7, R27, R67, and R83). This failure placed the residents at risk for a reduced quality of life in an environment meant to support their well being.Findings Include:Review of the facility's policy titled, Resident Dignity & Safe Feeding Policy, revised 7/23/2025 revealed that Prohibited Practices included Do not feed while standing, rush feeding, feed multiple residents at once, or ignore swallowing difficulty.1.Review of the Quarterly Minimum Data Set (MDS) for R7, dated 02/01/2026, revealed that Section C (Cognitive Patterns) documented that R7 had a Brief Interview for Mental Status (BIMS) score of 00 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that R7 was dependent on eating and with oral hygiene. Section I (Active Diagnoses) documented diagnoses of, but not all inclusive, Alzheimer's disease, feeding difficulties,…
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 · D2026-04-01 · 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, staff and resident interviews, record review, and review of the policy titled, Self Administration of Medications at Bedside Policy, [NAME] County Health and Rehabilitation Center, the facility failed to ensure that one of 46 sampled residents, Resident R23, did not have access to self administered medications. This failure had the potential to place Resident R23 at risk for adverse consequences. Findings include:Record review of policy titled, Self- Administration of Medications at Bedside Policy [NAME] County Health and Rehabilitation Center revised 05/03/2025 documented I. Policy Statement -Residents who are capable of safely managing their own medications may be permitted to self-administer medication at the bedside in accordance with physician orders, facility assessment, and applicable state and federal regulations. IV. Eligibility Criteria: Residents are not eligible if they: Have cognitive impairment affecting safety. Have a history of medication misuse. Are at risk for harm 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 · D2026-04-01 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration - General Guidelines, the facility failed to administer a medication at the correct time for one of eight sampled resident(R) (R6), whose medication was ordered to be given on an empty stomach, and failed to crush and administer medications separately for one of eight sampled R (R60). These failures occurred among eight residents with gastrostomy tubes observed during medication administration. This deficient practice had the potential to place R6 and R60 at risk for medical complications and abnormal laboratory results.Findings Include:Review of the facility's policy titled, Medication Administration-General Guidelines, effective date 4/1/2016 under Procedures revealed, A. Preparation. 7. Tablet crushing/Capsule opening: Crushing tables may require a physician's order, per facility policy.d. Medications should be crushed and administered individually if administered via tube. B.…
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 · D2026-04-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in the Facility, the facility failed to ensure that one of two medication rooms was free of expired medications. This deficient practice had the potential to place residents at risk of receiving expired medications.Findings Include: A review of the facility's policy titled Medication Storage in the Facility, effective 4/1/2026, documented under section Expiration Dating (Beyond-Use dating).a.Blister-pack cards and medication vials-12 months from the date of dispensing (where the manufacture's expiration date is longer than 12 months). C.Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose injectable vial, an ophthalmic medication,3. An item for which the manufacturer has specified as usable life after opening.D. When the original seal of a manufacturer's container or vial is initially broken, 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 · D2025-08-13 · 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
Based on record review and staff interviews, the facility failed to ensure a complete and accurate medical record was maintained for one of three sampled Residents (R1) reviewed for skin conditions. Specifically, R1's medical record did not contain documentation of all care planned skin assessments or consistent documentation of the completion of ordered skin treatments.Findings include:Review of R1's admission Record revealed, the resident had a medical history that included a diagnosis of acute kidney failure.Review of R1's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/21/2025 revealed, R1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment.Review of R1's Care Plan Report included a focus area, initiated 6/14/2023 and revised 3/12/2025, that indicated the resident was incontinent and at risk for complications, including skin irritation and rashes. A focus area, initiated 3/2/2023 and revised 4/6/2023, indicated the resident was at risk for decreased quality of life related to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-04-13 · 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 policy titled, Food Storage, the facility failed to ensure that all opened food was labeled and dated. The deficient practice had the potential to affect all residents who were on an oral diet. Findings include: Review of the facility policy titled Food Storage revealed under POLICY: It is the policy of the Food and Nutrition Department that food storage occur in a strictly defined manner as outlined in the procedures below, PURPOSE: To prevent the transmission of disease carrying organisms. ACTION: .2. Stock is rotated so that older items are used first. Products are dated to assure First-In, First-Out procedure is followed. Observation during a tour of the kitchen on 4/14/2025 at 9:45 am revealed the following: Pork sausages, chicken breasts, chicken nuggets, French fries, okra, crispy fried onions, located in the freezer, were not labeled or dated. In an interview on 4/14/2025 at 9:45 am with the [NAME] confirmed that there should be an open date and a use by date labeled on items that have been opened. In an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-13 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility policy titled, Standard Precautions the facility failed to ensure infection control practices were followed for two of eight residents (R) (R37 and R84) during wound care, the facility failed to ensure infection control practices were followed when disposing of used Personal Protective Equipment (PPE), and the facility also failed to ensure infection surveillance was conducted monthly. The deficient practices had the potential to affect all residents residing in the facility. Findings include: Review of the facility policy titled Standard Precautions dated October 2018 revealed under Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. 1. Record review revealed R37 was admitted to the facility with diagnoses of but not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · Dcited before2025-04-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and the review of the facility policies titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol and Residents Federal and State Rights, the facility failed to ensure four of eight residents (R) (R37, R84, R11, and R45) were provided privacy during wound care treatment. Specifically, the facility failed to ensure R37, R84, R11, and R45 full privacy was provided by ensuring window blinds were closed and the privacy curtains were fully engaged when conducting wound care treatments. Findings include: Review of the facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated April 2018 on page 5: Dressings, Dry/Clean under preparation. number 5. Explain procedure to the resident and provide privacy. Review of the facility's undated policy titled, Residents Federal and State Rights, revealed under Privacy and Confidentiality number 1. You have a right to personal privacy and confidentiality of your personal privacy which includes privacy in accommodations, medical treatment, written and telephone communications,…
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 · D2025-04-13 · 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, record review, staff interviews, and review of the facility policy titled, Environment Rounds/Repairs, the facility failed to ensure that the environment was safe, clean, comfortable, and homelike in two rooms on A hall (room [ROOM NUMBER] and room [ROOM NUMBER]) located on two of four halls. Specifically, plaster on the wall was missing and cracked in two areas on Hall C, and chipped floor tile, black marks on privacy curtains, and a dirty feeding pump pole were noted on hall A. Findings include: 1. Review of the facility policy titled Environmental Rounds/ Repair revealed under Policy Statement: name of facility is committed to maintaining a home-like environment and to repair issues in acceptable time frame. Under Procedures: Maintenance Director will make environmental rounds every week. Any noted areas that are in need of repair will be repaired as soon as possible.Facility also has a part-time painter employed who is available to repair sheet-rock issues and paint and/or retouch 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 · Dcited before2025-04-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility policies titled, Care Planning- Interdisciplinary Team and Care Plans, Comprehensive Person-Centered, the facility failed to ensure a care plan for oxygen use was developed for one of nine residents (R) (R52) using oxygen. The facility also failed to ensure a care plan was developed for one of three residents, R35 that had an indwelling catheter. The deficient practice had the potential to increase the probability of R52 and R35's needs not being met according to their care needs. Findings include: Review of the facility policy titled Care Planning- Interdisciplinary Team dated March 2022 revealed under Policy Statement: The interdisciplinary team is responsible for the development of resident care plans. Under Policy Interpretations and Implementation number 2. Comprehensive person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Review of the facility policy titled Care Plans, Comprehensive Person- Centered dated March 2022 revealed under Policy…
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 · D2025-04-13 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review. and staff interviews, the facility failed to follow the Physician Orders related to wound care for one of four residents observed during wound care (R11). The deficient practice had the potential for R11's wound to worsen. Findings include: Record review for R11 revealed resident was admitted to the facility with diagnoses of but not limited to cerebral infarction, unspecified, unspecified diabetes mellitus without complications. Review of the Physician's orders in the Electronic Medical Records (EMR) revealed the following order: Lt (left) Ankle Lateral: Cleanse with WC (wound cleanser) or NS (normal saline), pat dry, apply gentamicin 0.1% ointment (antibiotic), cover with dry protective dressing such as ABD (abdominal) pad then rolled gauze with tape daily and PRN (as needed) per dislodgement/soiling. Wound care observation for R11 on 4/9/2025 at 11:48 am performed by Licensed Practical Nurse (LPN) II revealed she sanitized her hands, donned (put on) gloves, sanitized plastic tray, placed a paper incontinence pad on top of the tray, 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 · D2025-04-13 · 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 observations, staff interviews, and record review, the facility failed to ensure an environment free from potential accident hazards by failing to properly secure an oxygen (O2) tank for one of 10 residents (R) (R28) receiving oxygen therapy. The deficient practice had the potential to harm R28 or other residents that could come in contact with the unsecured O2 tank. Findings include: A policy on accident hazards was requested, however the Director of Nursing (DON) revealed the facility did not have one. Review of R28's electronic medical record (EMR) revealed the resident was admitted with diagnoses of but not limited to acute respiratory distress and heart failure, unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of Physician order's for R28 revealed an order dated for Oxygen as needed at two liters per minute (LPM). Observations on 4/11/2025 at 9:00 am…
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 before2025-04-13 · 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, and review of the facility policy titled, Oxygen Administration, the facility failed to ensure one of nine residents (R) (R52) oxygen (O2) was administered as ordered by the physician. Specifically, the facility to failed to ensure R52's O2 rate was set on 2 liters per minute (LPM) instead of 4 LPM via nasal cannula (NC). Findings include: Review of the facility policy titled, Oxygen Administration, dated October 2010 revealed under Preparation, number 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Record review revealed R52 was admitted to the facility with diagnoses of Parkinson's disease, essential hypertension, anxiety disorder, and depression. Review of the physician orders for R52 located in the Electronic Medical Record (EMR) system under Orders revealed an order for oxygen (02) via nasal cannula at 2 liters per minute as needed for Shortness of Breath (SOB), wheezing or 02 Saturations (Sats) <92% (under 92 percent). Review of the care plan for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-09-15 · 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 staff interview and record review the facility failed to ensure that six residents ((R) R#66, R#67, R#74, R#126, R#176, R#276) of 8 residents reviewed had completed pneumococcal consent forms and received pneumococcal vaccines in a timely manner. Findings include: 1.Review of record revealed R#276 was admitted to the facility 9/2/22. The Pneumococcal consent form is incomplete, it is not circled do or do not consent. During an interview on 9/14/22 at 12:52 p.m. with the Infection Control Preventionist (ICP) it was stated that she is not sure rather R#276 wants the pneumococcal vaccine. ICP expressed that she has not followed up to clarify with R#276, and she has not checked GRITS to see if he has already had the pneumococcal vaccine. 2.Review of record revealed R#66 was admitted to the facility on [DATE]. Record revealed resident's responsible party (RP) consented to pneumococcal vaccine on 8/24/22. Review of record revealed resident has not received the pneumococcal vaccine as of 9/14/22. This was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-09-15 · 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 staff interviews, record review, and review of policy titled Facility COVID-19 Vaccination Plan, the facility failed to ensure that five residents ((R) R#66, R#74, R#126, R#176, R#276) of eight residents reviewed received COVID-19 vaccines in a timely manner. Findings include: Review of the facility policy titled Facility COVID-19 Vaccination Plan (Updated 10/21/21) revealed: Purpose: To offer science-based information and vaccination to all staff, residents, and family members wanting to receive vaccination. Plan: When new residents are admitted to the facility, residents will be offered information from the CDC about Sars-CoV-2 vaccine that is available to our facility through local health department and/or facility's pharmacy provider. Vaccination will be encouraged but not required. When resident is newly admitted , meeting will be held with family either virtually or in person. Same information from CDC about the Sars-CoV-2 vaccine that is available to our facility through local health department…
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 · D2022-09-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to accommodate one resident (providing equipment to encourage self toileting at night), (R) R#57) of 20 sampled residents. Findings include: Record review revealed R#57 admitted to the facility on [DATE] with diagnoses that included but not limited to fracture of unspecified part of neck of right femur. Further review of the medical record revealed an admission Minimum Data Set (MDS) assessment dated [DATE] that revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. R#57 also noted to have functional limitation in range of motion in the lower extremity with impairment to one side. Review of record also revealed that resident was admitted to the facility for therapy after undergoing a recent surgery for a fracture of part of the right femur which resulted from a fall prior to admission. During interview with R#57 on 9/13/22 at 12:11 p.m., it was reported that previously she was in another room…
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 · D2022-09-15 · 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 record review, resident and staff interviews, and policy titled, Admission, Transfer, and Discharge Policy & Procedure, the facility failed to notify the Physician or the responsible party of change in condition for one resident (R) R#18) of 4 residents transferred to the hospital. Findings include: Review of facility policy titled Admission, Transfer, and Discharge Policy & Procedure - (not dated) revealed the following: Notice Before Transfer - Before a resident is transferred, the facility will notify the resident, and if known, a family member or legal representative of the resident of the transfer or discharge. Record review of the medical record for R#18 revealed resident was sent out to the emergency room on 8/21/22. Review of the Nurse's Notes dated 8/21/22 at 10:30 a.m. revealed R#18 was sent to the emergency room for evaluation and treatment after having a behavioral episode with another resident. There was no documentation to support that the responsible party or the Physician had been notified. An interview was conducted on 9/14/22 at 2:51 p.m. with the Director…
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 before2022-09-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, staff interview, and review of the facility policy titled Using the Care Plan the facility failed to follow the care plan related to providing oxygen as ordered for one resident (R) (R#67) one of 15 sampled residents receiving oxygen. Findings Include: Review of the facility policy titled Using the Care Plan (revision date August 2006) revealed the following; Policy Statement: The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Review of medical record for R#67 revealed diagnoses that consisted of but not limited to chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, and chronic respiratory failure with hypoxia. Review of Care Plan dated 8/9/2022 revealed R#67 has/is at risk for ineffective breathing patterns related to COPD and is at risk for complications related to this with interventions to: Administer medications, respiratory treatment, and oxygen as ordered and 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 · Dcited before2022-09-15 · 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, record review, staff interviews, and review of the facility policy titled, Oxygen, Use of Policy and Procedure, the facility failed to have clear oxygen orders for one resident (R) R#67) of 15 residents receiving oxygen. Findings Include: Review of facility policy titled Oxygen, Use of Policy and Procedure, (not dated) revealed the following: Policy: Designated staff member will administer oxygen therapy only per physician's orders or as an emergency measure until and or as an emergency measure until and order can be obtained. The physician's orders will specify the rate of flow of oxygen. Review of records for R#67 revealed diagnoses of chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, and chronic respiratory failure with hypoxia. Review of Medication Administration Record (MAR) dated 9/1/2022-9/30/2022 revealed no oxygen orders. Review of hospice order dated 8/23/2022 for O2 (Oxygen) at 5 liters via nasal cannula continuous to maintain O2 saturation between 88-94%. Review of Physician Order dated 8/23/2022 O2 at 4 liter…
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 · D2022-09-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and facility's policy titled Medication Orders IB3: Stop Orders, the facility failed to document the intended rationale and duration of therapy for one resident ((R) R#57), that had an as needed order (PRN) for a PRN antianxiety medication beyond 14 days of five residents reviewed for medication usage. Findings include: Review of facility's policy titled Medication Orders IB3: Stop orders, effective date of November 28, 2017, Procedures Section E reads; PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Review of the clinical record for R# 57 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety disorder. The resident's most recent Significant Minimum Data Set…
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 |
|---|---|---|---|
| COOK, SHEILA | Individual | DIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/21/2013 |
| COOK, TERRY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/15/2013 |
| OLDFIELD, CHRISTOPHER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/14/2023 |
| STANFIELD, DANA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/19/1999 |
CMS files one row per role, so the 15 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — 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.
This home reported $581K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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 115621. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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.