Brown Health and Rehabilitation
545 Cook Street, Royston, GA 30662 · Non profit - Other · 144 certified beds · (706) 245-1900 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
- about 23% of its spending goes to commonly-owned related companies
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 | 4 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 | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 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 | 18.1% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.9% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 16.5% | 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 | 4.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.6% | 15.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 34.3% | 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 | 3.4% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.2% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.0% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 6.1% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.6% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 27.6% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.8% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.01 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.69 | 1.90 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
47.6% 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 89 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 24.1% 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 29 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 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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 | 47.6%CMS range 37.2–56.1 | 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 | 9.5%CMS range 6.7–13.2 | 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 | 24.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 13.8% | 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 | 13.8% | 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 | 94.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 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 | 7.0%CMS range 4.1–11.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 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 144 beds and averages 89.8 residents a day — about 62% occupied, or roughly 54 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.42 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.35 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 2.89 hrs/resident/day on weekends vs 3.44 on weekdays — 16% thinner on weekends. RN hours go from 0.49 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%. 1 administrator has left in the past year.
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.
17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.
- Potential for harm · D2025-09-11 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from sexual abuse by another resident by not reporting to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R85) reviewed for abuse and neglect. The deficient practice had the potential of future unreported abuse.Findings include:Review of the facility policy titled Abuse Prohibition review date 4/7/2025 revealed under Policy: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is withing our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and, or their property. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews and review of the facility's policy titled, Infection Prevention Plan, the facility failed to ensure proper infection control procedures were followed for four residents (R) (R5, R11, R1 and R78), creating cross-contamination. This failure had the potential to contribute to the transmission of infectious diseases among residents and staff. Findings include:Review of the facility's policy titled, Infection Prevention Plan, dated 12/27/2024 revealed, under Scope Prevention of Infections - Policies, procedures, and aseptic practices are followed by personnel when performing procedures and disinfecting equipment.Observation on 9/10/2025 at 8:25 am, Certified Medication Aide (CMA) AA was performing a medication pass for R5 in Dining Room Three. CMA AA was observed with a paper towel placed on the medication cart as a barrier. She proceeded to administer medications to R11 and then R1 without changing the barrier, creating cross contamination. Interview on 9/10/25 at 9:00am with CMA AA, confirmed she used a barrier on her medication cart and did 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 · Ecited before2024-04-05 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policy titled, Standard Patient Room Cleaning, the facility failed to ensure prevention of spread of infection by using foam protectors in disrepair over bed rails that created an uncleanable surface for four of four Residents (R) (R19, R22, R10, and R13) reviewed for side rail use. This deficient practice had the potential for the foam covers on the side rails to harbor bacteria and spread infection to the residents. Findings include: Review of the facility's policy titled, Standard Patient Room Cleaning, dated January 2024, revealed 5. DISINFECT: . b. Patient zone: Using the same microfiber cloth and enhanced disinfectant, clean and disinfect surfaces in the patient's zone (i.e., over bed table, bed rails, bedside table, phone, call light cord). 1. Review of R22's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R22 was admitted with diagnoses including rheumatoid arthritis and chronic pain syndrome. Review of the Care Plan tab in R22's EMR revealed 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 · D2024-04-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating, the facility failed to complete a thorough investigation for two of two sampled Residents (R) (R48 and R82) reviewed for abuse. Specifically, there was no evidence the facility interviewed R48 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. Findings include: Review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating dated 12/29/2023 under the section titled, Guidelines indicated . Interviews will be conducted of pertinent parties. Written signed statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, person making the accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have witnessed the incident, and any other persons who may have…
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 · D2024-04-05 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete and electronically transmit a Discharge Minimum Data Set (MDS) assessment to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two of two residents (R) (R35 and R80) reviewed for discharge to home. Findings include: Review of the RAI Manual, dated 10/1/2019, indicated, There are three types of discharges: two are OBRA [Omnibus Budget Reconciliation Act] required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS [Prospective Payment System] Discharge. A Discharge assessment is required with all three types of discharges . Any of the following situations warrant a Discharge assessment . Resident is discharged from the facility to a private residence . Discharge Assessment - return not anticipated. 1. Review of an undated document provided by 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 · D2024-04-05 · 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 interviews, record review, and review of facility's policy titled, Patient's Plan of Care, the facility failed to update a Care Plan for one Resident (R) (R31) when a pacemaker monitoring device was provided to the facility and failed to ensure one (R1) was invited to participate in the quarterly care plan meeting. These failures had the potential for R31 not to receive necessary care and services for a pacemaker monitoring device and R1 not to be involved in decisions affecting care in the facility. The sample size was 41 residents. Findings include: Review of the facility policy titled, Patient's Plan of Care, dated 12/29/2023, revealed The patient's care plan should be reviewed . and revised based on changing goals, preferences, and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. The policy also documented, The center will provide the patient and/or patient's representative with advance notice of care planning conferences to enable patient/patient…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-04-05 · 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, record review, and review of the facility's policy titled, Using A Portable Lifting Machine, the facility failed to ensure a mechanical lift sling was inspected for damage and defects after laundering for one out of five residents (R) (R13) reviewed for falls. The deficient practice caused R13 to fall from a mechanical lift sling because of a broken strap while being transferred from his motorized wheelchair to the bed. Findings include: Review of the facility's policy titled, Using A Portable Lifting Machine, dated 12/29/2023, provided by the facility, revealed, Various manual and/or electric mechanical lifts may be used by this center. Manufacturer recommendations for use should be followed. Review of the manufacturer guidelines titled, Liko (Trademark) Soft Original High Back Sling, Mod. 26 Instructions for Use, dated 12/11/2013, provided by the facility, revealed Care and Maintenance of Liko Slings . Check the Sling after Washing. All points are inspected with regard…
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 · D2024-04-05 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure staff were informed or educated about the remote cardiac monitor's purpose for one of one Resident (R) (R 31) with a pacemaker monitor. The deficient practice had the potential to place R31 at risk of not receiving necessary care and monitoring for cardiac instability. Findings include: Review of the Facility Assessment, dated 3/6/2024, revealed Education is conducted on our L.E.A.D. platform which is assigned monthly by (Name of Company) and on an as needed basis for individuals and groups. L.E.A.D. assignments are conducted based on QAPI processes and annual education requirements for regulatory purposes. Other training needs are addressed through On-boarding and orientation-Annua/Skills Fair (completed in May 2023), Safety Boot Camp, Webinars, Staff Meetings, Huddles and (Name of Company). Notifications. (Name of Company) consultants conduct education during site visits and via Zoom meetings. Outside education is offered through GHCA, AHCA, Healthcare Coalitions and (Name of Company) training 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 · E2023-02-16 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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, record review, staff interviews, and review of the facility policy titled Skilled Inpatient Services - ADL Plan of care, the facility failed to follow the care plan for eight residents (R) (R#26, R#35, R#43, R#7, R#23, R#27) related to activities of daily living (ADL), R#19 related to falls, and R#24 related to elevated finger stick blood sugar levels. The sample size was 33. Findings include: Review of policy titled Skilled Inpatient Services ADL Plan of Care reviewed on 12/4/2021 revealed the intent is to develop and communicate patient needs for assistance with ADLs. The policy stated ADLs are assessed on admission for each resident, addressed on the baseline care plan, and communicated to the staff. Nursing is responsible for development of care plan and communication of level of assistance residents require. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder,…
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 · E2023-02-16 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
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, interviews, and review of the policy titled Skilled Inpatient Services -ADL Plan of Care, the facility failed to provide activities of daily living (ADL) care for six residents (R) (R#26, R#35, R#43, R#23, R#27, R#7). The sample size was 33. Findings included. Review of the policy titled Skilled Inpatient Services -ADL Plan of Care dated 12/4/2021, indicated the intent is to develop and communicate patient needs for assistance with ADLs. Guideline: Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder, major depressive disorder, need for assistance with personal care, muscle weakness, diabetes mellites type 2. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was 15, which 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.
Show the remaining 7 citations
- Potential for harm · Ecited before2023-02-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of facility policies, the facility failed to implement an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced infection control standards during wound care for two residents (R) (R#43 and R#71) and by not storing respiratory supplies properly for one resident (R#18). The census was 75. 1. Review of the policy titled Skilled Nursing Services Wound Care revised 10/11/2022 revealed the intent is to provide guidelines for clean technique in providing wound care. Start with a clean surface and a clean tray, using approved cleanser and observing appropriate wet times. Cover the tray with an impervious barrier. Prepare the supplies on the tray with the barrier. Upon entering room, place tray on a clean surface. If the resident is soiled, wound care should not be completed until the resident is clean. Review of the clinical record revealed R#43 was re-admitted to the facility on [DATE] with diagnoses 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 · D2023-02-16 · 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, record review, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by two Licensed Practical Nurses (LPN), administered insulin to R#18, using another resident's insulin pen on two different occasions. The sample size was 33. Findings include: Review of the policy titled, Pharmacy Services: Insulin Administration, copyright 2022, revealed policy guideline - nursing should double-check all insulin therapy before administering. Administration as follows: Patient name and drug order is checked and double-checked. Insulin pen: Never share insulin pens between patients. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, 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 · D2023-02-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to follow Physician Orders for one resident (R) (R#24) related to sliding scale insulin order to notify the physician for blood sugars greater than 401. The sample size was 33. Findings Include: Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Section N revealed resident received insulin injections seven days during the look back period. Review of the care plan dated 2/1/2023 revealed resident has diagnosis of diabetes mellitus with persistent elevation in fingerstick blood sugars (FSBS). Interventions to care include administer insulin…
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 · D2023-02-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, resident and staff interviews, the facility failed to implement restorative nursing care for three residents (R) (R#35, R#43, R#70) as recommended post discharge from inpatient Rehabilitation Services. The sample size was 33 residents. Findings include: 1. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit. Section G revealed resident was total dependent of two-persons for all activities of daily living (ADLs). She had functional limitations of upper and lower extremities on one side. Review of the care plan dated 1/1/2023 revealed the resident had limited mobility related hemiplegia and limited range of motion (ROM) to right side.…
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 before2023-02-16 · 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, record reviews, interviews, and review of the facility policy titled Fall Management, the facility failed to assure the safety of one resident (R#19) with a history of falls, by not placing resident in bed when she was asleep and leaning forward in wheelchair. The sample size is 33. Findings include: Review of the policy titled Fall Management reviewed 12/4/2021, indicates each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risks for falls. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's Disease, difficulty in walking, muscle weakness (generalized), need for assistance with personal care,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-02-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of facility polices, the facility failed to ensure respiratory care was provided in accordance with standards of nursing practice for two of 13 residents (R) receiving oxygen therapy. Specifically, the facility failed to change the oxygen nasal cannula for R#37 and failed to administer oxygen at prescribed flow rate for R#51. Findings include: Review of the facility policy titled, Skilled Inpatient Services: Use of Oxygen Therapy reviewed 12/4/2021, revealed the intent is to ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. The nasal cannula should be changed every month and as needed. 1. Review of the clinical record revealed R#37 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea (OSA). Review of the admission 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.
- Potential for harm · D2023-02-16 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident and staff interviews and review of facility policy titled Orientation, Training, and Competency, the facility failed to ensure staff was competent related to maintaining resident Bilevel Positive Airway Pressure (BiPAP) units used in the facility. The census was 75. Findings include: Review of the facility policy titled, Orientation, Training, and Competency reviewed 12/30/2022 revealed the intent of this center to establish an orientation plan, training schedule, and a defined set of competencies to promote well-trained associates for the position. Guideline: Competencies should be based on the center assessment Associates should complete competencies based on job duties and needs Education/training is provided routinely/covering various topics A record of learning for each associate will be maintained Organizational support may provide additional trainings through meetings, phone calls, emails, and webinars Review of CPAP [Continuous Positive Airway Pressure] Cleaning Instructions-How to properly clean your CPAP machine at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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 ETHICA HEALTH — 50 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 | 4 of 5 | 3.6 | +0.4 vs chain |
| Health inspection | 4 of 5 | 3.6 | +0.4 vs chain |
| Staffing | 2 of 5 | 3.1 | -1.1 vs chain |
| Quality measures | 2 of 5 | 2.8 | -0.8 vs chain |
The other 49 homes this chain runs (chain average 3.6★, per CMS)
Showing 40 of 49; lowest-rated first.
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 | Since |
|---|---|---|---|
| FRANKLIN COUNTY HOLDINGS, LLC | Organization | 5% OR GREATER MORTGAGE INTEREST; ADP OF THE SNF | since 03/31/2014 |
| CABLE, PAUL | Individual | CORPORATE DIRECTOR | since 03/14/2003 |
| DENNIS, KATHRYN | Individual | CORPORATE DIRECTOR | since 11/17/2015 |
| NICHOLS, JOSEPH | Individual | CORPORATE DIRECTOR | since 11/19/2024 |
| ROLLINS, RONNIE | Individual | CORPORATE DIRECTOR | since 03/14/2003 |
| WALL, JOSEPH | Individual | CORPORATE DIRECTOR | since 03/14/2003 |
| WARNOCK, RALPH | Individual | CORPORATE DIRECTOR | since 06/23/2020 |
| MOODY, TERESA | Individual | CORPORATE OFFICER | since 09/06/2023 |
| CLINICAL SERVICES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/01/2014 |
| GIPSON, TANA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/03/2021 |
| LAMBERT, RENO | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 09/01/2023 |
| SINHA, DEANNA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/09/2025 |
| SHEFFIELD, KIMBERLY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 04/14/2025 |
CMS files one row per role, so the 16 rows in the source record cover these 13 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.
2 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.
This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 23% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115090. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-11, 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.