No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Senior Care Center - St Marys

805 Dilworth Street, Saint Marys, GA 31558 · For profit - Limited Liability company · 78 certified beds · (912) 882-4281 Medicare & Medicaid certified

Call the home — (912) 882-4281 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited May 2026Behavioral-health or dementia-care citation — no harm found (F0758)$4,072 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
  • a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $4,072 in federal fines (most recent 2024-03-14)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (62%) runs well above the national median (45%)

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.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
214 Professional Circle Ste A · (912) 510-8224 · Call to confirm hours
Pharmacy
Cvs1.8 mi
2700 Osborne Rd · (912) 882-4841 · Call to confirm hours
Grocery
100 W Church St · (912) 439-3055 · Call to confirm hours
Park
(912) 409-9726 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased33.1%15.3%15.4%worse
Long-stay residents who lose too much weight12.8%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.9%0.9%better
Long-stay residents with a urinary tract infection1.8%2.5%2.0%typical
Long-stay residents with depressive symptoms2.9%11.3%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.1%3.2%3.3%typical
Long-stay residents whose ability to walk worsened30.7%15.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.0%20.5%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers3.1%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control22.2%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table17.3%19.9%17.1%typical
Short-stay residents who newly got an antipsychotic medication0.0%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine91.0%78.4%79.4%better
Short-stay residents rehospitalized after admission29.7%25.0%22.6%worse
Short-stay residents with an outpatient ER visit14.2%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.672.151.67better
Long-stay outpatient ER visits per 1,000 resident days1.151.901.80better

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

52.5% 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 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.5%U.S. median 51.5%
Got home and stayed home
10.3%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
not reportedno hours filed
Therapy hours / resident / day

Met the expected recovery: 58.1% 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 43 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.5%CMS range 39.9–63.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.3%CMS range 7.4–14.310.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge53.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting89.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot 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 stay3.7%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.5–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.51
RN hours/ resident / day
0.77
LPN hours/ resident / day
1.63
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.23
RN hoursweekends
62.5%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 78 beds and averages 63.8 residents a day — about 82% occupied, or roughly 14 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.63 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 2.24 hrs/resident/day on weekends vs 3.18 on weekdays — 30% thinner on weekends — a notable drop. RN hours go from 0.62 to 0.23 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above 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

2
deficiencies at the latest standard inspection (2025-11-21)
11
at the previous standard inspection (2024-03-14)

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.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 10 most serious are shown; the remaining 11 are one tap away and print in full.

  • Potential for harm · Fcited before2026-05-13 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policies titled, Foodborne Illnesses, and Food Ordering, Receiving, and Storage, the facility failed to ensure food for residents was stored, prepared, and served in a sanitary manner in the kitchen. Specifically, the facility failed to label and date food in the freezer, the refrigerator/walk-in cooler, and the dry storage pantry, with a received by date, open date, expiration, and/or use-by date, failed to discard food by the expiration or use-by date, and failed to ensure meat was thawed properly and in a sanitary manner. This deficient practice could have affected 62 of 65 residents receiving an oral diet.Findings included:Review of the Facility's policy titled, Foodborne Illnesses, with revised date October 18, 2017, documented. Procedure: 2. Foods will be used before the expiration date, use by date, best by date, and sell by date, as indicated on the food item. Foods not used prior to the expiration date, us by date, best by date, or…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policy titled Abuse Prevention and Reporting, the facility failed to ensure three of 15 residents (R) (R1, R2, and R3) were protected from verbal and/or physical abuse by staff. This deficient practice had the potential to affect the quality of life for all residents reviewed.Findings included:Review of the facility's policy titled Abuse Prevention and Reporting, revised June 20, 2025, documented Definitions: Abuse: Any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Verbal Abuse: Any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents regardless of age, ability to comprehend, or…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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, resident and staff interviews, record reviews, and review of the facility's policies titled Restorative Nursing Program and Therapy Evaluations, the facility failed to ensure that restorative nursing services were consistently provided following the completion of therapy for four of eleven residents (R ) (R12, R13, R14, and R15) reviewed for restorative nursing services. Specifically, the facility failed to provide required restorative interventions, including transfer assistance for R12; ambulation/walking programs for R13 and R14; and Range of Motion (ROM) exercises for the upper or lower body for R12, R13, and R14. This deficient practice has the potential to diminish residents' quality of life.Findings included:Review of the facility's policy titled Therapy Evaluations, revised May 13, 2020, documented the following procedures: 5. The evaluation will include recommendations for treatment and follow up as clinically indicated. 12. Therapy will foster an interdisciplinary approach 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-05-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to provide protective oversight and supervision to prevent elopement and ensure resident safety. This deficient practice resulted in one of four sampled residents (R) (R1 and R10) exiting the facility and remaining unaccounted for by staff for over one hour, and in R10 experiencing a fall with major injury in the shower, resulting in a subarachnoid hemorrhage. Findings included:A review of the facility's policy titled, Occurrences, with a revised date of January 11, 2024, revealed under Policy Statement: .To prevent occurrences, each patient/resident will be observed and assessed for risks. Definitions: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to: Any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-13 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, review of facility documents titled, PBJ (payroll-based journal) Staffing Data Report, and review of the policy titled, State Minimum Staffing for Healthcare Centers, The facility failed to ensure adequate nursing staff to meet residents' needs in a timely manner. This failure delayed the provision of care, increased the risk of elopement and falls resulting in major injury, and could have decreased the quality of life of 61 residents residing in the facility. Findings included:Review of the facility's policy titled, State Minimum Staffing for Healthcare Centers, last reviewed November 2, 2025, documented Policy Statement: The facility will maintain the minimum staffing hours in accordance with federal law and the respective state's rules and regulations. Staff shall be sufficient to meet the healthcare needs of each patient/resident as identified in the patient/resident's plan of care.Review of the Facility Assessment for the period May 12, 2026 - May 11,…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-11-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Accident Reporting and Investigation Program, the facility failed to ensure hot water temperatures were in the acceptable range (110 degrees F (Fahrenheit) or less) in the bathroom sink for 13 of 38 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). The deficient practice had potential for residents to receive a scalding injury due to the water temperature.Findings include:Review of the facility policy titled, Accident Reporting and Investigation Program revised November 2009 revealed under Definitions: An accident is any occurrence that interrupts or interferes with the orderly progress of a job or task, usually occurring suddenly and unexpectedly, and results in harm to people. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-21 · tag F0554 — isolated
    Allow 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 interviews, record review, and review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to ensure one of 29 sampled residents (R) (R57) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to other residents and visitors in the facility.Findings include:A review of the facility policy titled Self-Administration of Medications by Patients/Residents dated 1/6/2025 stated under Policy Statement: Each patient/resident who desires to self-administer medication is permitted to do so if the health care center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients /residents of the healthcare center. Medication self- administration also applies to family members who wish to administer medication. Under Procedures: .3. If the Licensed nurse determines the patient /resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-14 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interview, and review of the facility policy titled, Food and Supply Storage, the facility failed to ensure all pans and dishes were allowed to be air dried before stacked and failed to ensure all food in the freezer was sealed closed. These failures had the potential to affect 63 of 65 residents who consumed an oral diet. Findings include: Review of the facility's policy titled, Food and Supply Storage, dated 1/2024 revealed, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Frozen storage: Wrap food tightly to prevent cross contamination. Use food grade plastic bags for food storage. During an observation on 3/11/2024 at 9:58 AM, the following observations in the kitchen were made with and verified by the Supervisor Food/Nutrition (SFN): 1. The freezer contained one bag of chicken and one bag of hamburgers that were not closed shut. 2. There were 12 plastic plate covers being used for lunch that were 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-03-14 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Certified Nursing Assistants (CNAs) documentation. This had the potential to affect all residents of the facility. Findings include: Review of the facility policy titled, Quality Assurance/Performance Improvement (undated) revealed, .The facility will implement the Plan-do-Study-Act (PDSA) cycles as its QAPI methodology for testing actions and implementing and evaluating change. The facility will conduct and include Root Cause Analysis in their PDSA methodology. PIPs are evaluated to address gaps/and or effectiveness in systems and processes. Corrective actions may be taken when evaluating effectiveness. Changes identified in PIP action steps may require the development of additional measures for monitoring (audits/checklists), in effort to evaluate PIP effectiveness in achieving…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-03-14 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, document review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy titled, Antibiotic Ordering, the facility failed to maintain an infection prevention and control program (IPCP) that included a functional Antibiotic Stewardship Program that followed the McGeer Criteria for antibiotics. This had the potential to affect all 65 resident of the facility, specifically being prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility policy titled, Antibiotic Ordering dated 9/01/2023 revealed . 10. The Infection Control Preventionist (lCP) will monitor resident antibiotic use to determine appropriateness.11. The ICP will utilize evidence-based, standard definitions for identifying infections as the criteria in determining antibiotic appropriateness.12. The ICP will review antibiotic surveillance findings during the monthly lnfection Prevention and Control Team (IPCT) meetings. The IPCT will develop antibiotic stewardship action plans, if indicated. 13. The ICP will…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · D2024-03-14 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, staff interviews, and review of facility policy titled, Resident Call Lights, the facility failed to ensure one of 30 Residents (R) 22 had their call light in reach during multiple observations. This had the potential for the resident to have unmet care needs. Findings include: Review of the facilities' undated policy titled, Resident Call Lights revealed the purpose was to respond to resident's needs. Further review of the policy revealed resident call lights will be kept within the resident's reach when the resident is in the room. Review of R22's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R22 was admitted to the facility with a diagnosis of cardiac pacemaker. Review of R22's admission Minimum Data Set (MDS) assessment located in the EMR under the MDS tab with an admission Reference Data (ARD) of 2/22/2024 revealed R22 had impaired vision and a Brief Interview of Mental Status (BIMS) of seven out of 15 which indicated severely impaired cognition. Reveal of the MDS further revealed R22 needed…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 Resident Assessment Instrument (RAI) Manual, the facility failed to ensure that two residents (Resident (R) 47 and R14) out of 30 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/2023, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Inter-Disciplinary Team] completing the assessment . 1.Review of R47's electronic medical record (EMR) undated, admission Record, located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included: stroke affecting the right side, and aphasia (loss of ability to speak). Review of R47's annual MDS located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated the assessment inaccurately indicated R47 took 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide 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

    Based on observations, record review, staff interviews, and review of Rehab Department Procedures, the facility failed to ensure an order for a resident's palm protector was followed for one of two residents (Resident (R) 47) reviewed for range of motion (ROM). The deficient practice had the potential to inhibit optimal independence for R47 by not applying splints as ordered for contractures. Findings include: Review of a document provided by the facility titled, Rehab Department Procedures (undated), revealed Original orders are placed in a folder in Medical Records office to be signed by the physician. After originals are signed, they are placed in patient's medical hard chart. Review of R47's electronic medical record (EMR) admission Record located under the Profile tab, indicated R47 was admitted to the facility with diagnoses that included stroke affecting the right side and aphasia (difficulty in speaking). Review of R47's annual Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 1/18/2024 indicated R47 had a Brief Interview…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, and review of the facility policy titled, Pain & Assessment Control, the facility staff failed to perform a pain assessment prior to administering a narcotic as needed (PRN) pain medication and failed to assess the effectiveness after the medication was administered for one of ten Residents (R) 2. The deficient practice had the potential to prevent the accurate determination of the effectiveness of the pain medication regimen. Findings include: Review of the facility policy Pain & Assessment Control dated 09/22/22 revealed, . The patient's pain is treated promptly accordingly to physician's orders. The patient is reassessed to determine pain relief. a. The patient is evaluated at appropriate intervals after he/she is medicated using the appropriate pain scale. b. All patients receiving medications for pain control are reassessed . Review of R2's undated Face Sheet provided by the facility revealed R2 was admitted to the facility with a diagnosis of acute pain. Review of R2's annual Minimum Data Set (MDS) with an Assessment Reference Date…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, staff interview, review of the Dialysis Agreement, and review of the facility policy titled, Dialysis, the facility failed to have collaboration of care between the facility and the dialysis center for one of three (Residents (R) 45) receiving dialysis treatments. This had the potential for R45 to have unmet care needs. Findings include: Review of the facility policy titled, Dialysis dated 7/10/2023 revealed, . The facility and the dialysis clinic will coordinate and communicate resident needs pertinent to dialysis care and services . Review of the dialysis agreement between the facility and the dialysis center dated 6/05/2007 revealed, . Center shall provide to Facility (sic) information on aspects of the management of the resident's care . Facility shall ensure that all appropriate medical, social, administrative, and other information accompany all Designated (sic) Residents (sic) at the time of the transfer to the Center. This information, shall include, but is not limited to, where appropriate, the following: . (d) Appropriate medical records, including…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    Based on record review and staff interviews, the facility failed to ensure a psychotropic medication was discontinued when ordered by the physician for one of five residents (Resident (R) 55) reviewed for unnecessary medications. The resident continued to receive the medication for two months after it was discontinued. Findings include: The policy for pharmacy recommendations was requested but not provided by the time of the exit of the survey. Review of R55's Face Sheet in the electronic medical record (EMR) under the Face Sheet tab revealed R55 was admitted to the facility with diagnoses that included Alzheimer's disease, hypertension, non-traumatic brain dysfunction and anxiety. Review of R55's admission Minimum Data Set (MDS) located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 10/03/2023 revealed a Brief Interview of Mental Status (BIMS) was not done due to impaired cognition. Review of the high-risk drug class of the MDS revealed antipsychotics were used on a routine basis. Review of R55's undated Consultant Pharmacist Recommendations in the hard…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-14 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, staff interviews, review of Lippincott procedures, and review of facility policy titled, Medication Administration-General, the facility failed to ensure there was less than a five percent (%) medication error rate. Two errors were observed out of 27 opportunities for one Resident (R)6 out of the six residents observed during medication administration resulting in a mediation error rate of 7%. Findings include: Review of the facility policy tilted, Medication Administration-General policy with a revised date of 12/01/2019, revealed the purpose of the policy was to provide resident medication efficacy and safety by following established principles of medication administration. Procedural Guidelines Medication Administration that medications will be administered per the Lippincott Manual of Nursing Practice. Review of the Lippincott procedures - Enteral tube drug instillation, long-term care manual, with a revised date of December 11, 2023, provided by the facility revealed don't mlx different medications intended for administration together…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, and staff interviews, the facility failed to maintain infection control during incontinence care during a dressing change for one of five (Residents (R)8) observed for incontinence care. Findings include: Review of R8's undated Face Sheet provided by the facility revealed R8 was readmitted to the facility with the diagnosis of stage three pressure ulcer. During an observation of wound care on 4/14/2024 at 11:23 AM with Registered Nurse (RN)1 revealed as RN1 removed the old dressing to the sacral area and R8 began to have a bowel movement. Certified Nursing Assistant (CNA)2 began to perform incontinence care with a disposable wipe. CNA2 proceeded to wipe from the anal area up towards the sacral pressure ulcer to remove the bowel movement. During an interview, on 3/14/2024 at 1:40 PM with the Director of Nursing (DON) revealed The CNA should never wipe bowel movement up in the direction of a resident's wound as it could potentially contaminate the wound. During an interview with CNA2 on 3/14/2024 at 1:51 PM the CNA was asked when she performed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-06-30 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record review, and review of facility policy titled Infection Prevention and Control Program Overview the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation, and control of infection to prevent the onset and spread of infection. The facility census was 53. Findings include: Review of facility's undated policy titled Infection Prevention and Control Program Overview 5. The facility will ensure the following elements are incorporated within the IPCP management activities. Elements may include, but are not limited to: IPCP Coordination, Communication, and Oversight Written Policies and Procedures Surveillance and Data Analysis Antibiotic Stewardship Community Acquired and Healthcare Associated Infections Outbreak Control Vaccinations and Screening Employee Health and Safety 6. The facility will designate a licensed nurse, who meets the infection control training requirements, to be the facility's Infection Control Preventionist (ICP). The ICP's role and…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-06-30 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, and review of facility documents, the facility failed to establish an Antibiotic Stewardship Program that included antibiotic use protocols and a monitoring system to track and trend antibiotic use. The facility census was 53 residents. Findings include: Interview with Infection Control Preventionist (ICP)/ Director of Nursing (DON) on 6/30/22 at 1:24 p.m. revealed she has completed the CDC Nursing Home Infection Preventionist Training Course. DON stated the facility uses the McGeers Criteria to determine if there was an infection and if it was community or facility acquired. She stated she have not used this criterion because she has not been monitoring. Continued interview with the DON revealed there has not been anyone tracking the antibiotics since the last IP left in December 2021. DON stated the IP role was handed down to her after the previous ICP stopped working at the facility. However, she has not been able to do anything with it as far as tracking the antibiotics and maintaining the Antibiotic Stewardship program. She stated she has other duties…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-06-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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 and staff interview, the facility failed to ensure that PRN [as needed] orders for antipsychotic drugs were limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) #10) reviewed for medication management. Findings include: R#10 was admitted to the facility on [DATE] with admit diagnoses of Alzheimer's disease. Review of R#10 Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of the physician orders for R#10 for June 2022 revealed an order for Seroquel 25mg by mouth prn for agitation. The original order dated was 2/16/22. Review of the care plans for R#10 revealed a care plan for the following: Psychotic drug use-receives an antidepressant daily to aid with sleep. 3/4/22 placed on an antipsychotic due to episodes of agitation. Interview on 6/30/22 at 1:01 p.m. with the Director of Nursing (DON) who…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$4,072 in federal fines across 1 penalty.

  • $4,072 — penalty dated 2024-03-14

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

Who owns this facility

Owner / managerTypeRoleSince
BARKER, JEFFERYIndividualCORPORATE DIRECTORsince 05/01/2018
CHITTY, STEPHENIndividualCORPORATE DIRECTORsince 05/01/2016
HAMPTON, KAYIndividualCORPORATE DIRECTORsince 05/01/2016
HARRIS, ROOSEVELTIndividualCORPORATE DIRECTORsince 01/01/2024
HEPBURN, VALERIEIndividualCORPORATE DIRECTORsince 05/01/2015
HEYS, ANGELAIndividualCORPORATE DIRECTORsince 01/01/2024
HODGES, MICHAELIndividualCORPORATE DIRECTORsince 05/01/2015
LOOMIS, JAMESIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2020
SUDDATH, WILLIAMIndividualCORPORATE DIRECTORsince 01/01/2023
TINDALL, CATINAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 05/01/2023
TURNER, ROBERTIndividualCORPORATE DIRECTORsince 05/01/2015
WILSON, SHIRLEYIndividualCORPORATE DIRECTORsince 05/01/2019
CARTER, DENNYIndividualCORPORATE OFFICERsince 01/01/2024
JORDAN, CHRISTYIndividualCORPORATE OFFICERsince 03/03/2024
PRUITTHEALTH ST MARY'SOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 09/01/2024
SOUTHEAST GEORGIA HEALTH SYSTEM, INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 05/01/2015
GRANT, RHONDIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/14/2025
LACANILAO, ANGELITOIndividualADP OF THE SNFsince 04/14/2025

CMS files one row per role, so the 21 rows in the source record cover these 18 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.

$6.3M
Net patient revenuemost recent cost report
-23.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 64%Medicare 5%Other / private 31%

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

$346per resident / day
operating cost
$10,519per month
≈ monthly operating cost
$281per day
avg. revenue, all payers

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

What families pay in GA

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115684. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

What to do next