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Abercorn Rehabilitation Center

11800 Abercorn Street, Savannah, GA 31419 · For profit - Corporation · 100 certified beds · (912) 925-4402 Medicare & Medicaid certified

Call the home — (912) 925-4402 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Jan 20251 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$10,868 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $10,868 in federal fines (most recent 2025-01-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (58%) 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 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
11806 Mercy Blvd · (912) 921-8926 · Call to confirm hours
Pharmacy
12012 Abercorn St · (912) 925-5568 · Call to confirm hours
Grocery
Publix0.1 mi
11701 Abercorn St · (912) 925-4112 · Call to confirm hours
Park
10875 Abercorn St · Typically dawn to dusk
Place of worship
12033 Abercorn Ext · (912) 376-9262

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 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
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 increased4.1%15.3%15.4%better
Long-stay residents who lose too much weight3.8%5.6%5.4%better
Long-stay residents with a catheter left in their bladder2.2%0.9%0.9%worse
Long-stay residents with a urinary tract infection1.1%2.5%2.0%better
Long-stay residents with depressive symptoms5.9%11.3%6.5%typical
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.4%3.2%3.3%better
Long-stay residents whose ability to walk worsened7.2%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.4%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.0%95.3%typical
Long-stay residents with pressure ulcers4.7%5.6%4.7%typical
Long-stay residents with worsening bladder/bowel control3.8%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table12.1%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication0.9%2.6%1.4%better
Short-stay residents given the seasonal flu vaccine69.5%78.4%79.4%worse
Short-stay residents rehospitalized after admission24.1%25.0%22.6%typical
Short-stay residents with an outpatient ER visit23.6%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.312.151.67better
Long-stay outpatient ER visits per 1,000 resident days0.811.901.80better

§ 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.

38.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 130 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

38.4%U.S. median 51.5%
Got home and stayed home
14.1%U.S. median 10.7%
Went back to hospital
57.1%U.S. median 56.6%
Met the expected recovery
0.46U.S. median 0.31
Therapy hours / resident / day
0.24hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 57.1% 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 63 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 0.46 therapist hours per resident per day in 2026Q1 — more than 77% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 13% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF38.4%CMS range 30.7–47.551.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.1%CMS range 10.6–18.910.7%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 discharge57.1%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 discharge66.7%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 discharge55.6%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 identified99.2%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 setting97.5%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 stay0.0%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 worsened2.5%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 hospitalization7.4%CMS range 4.5–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.151.02Oct 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

0.23
RN hours/ resident / day
1.11
LPN hours/ resident / day
2.07
Aide hours/ resident / day
3.41
Total nurse hours/ resident / day
0.18
RN hoursweekends
58.2%
Total nursing turnover
80.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 87.5 residents a day — about 88% occupied, or roughly 12 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.41 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.23 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.07 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 3.00 hrs/resident/day on weekends vs 3.58 on weekdays — 16% thinner on weekends. RN hours go from 0.26 to 0.18 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above 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

6
deficiencies at the latest standard inspection (2026-02-26)
9
at the previous standard inspection (2025-01-24)

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.

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · Gcited before2025-01-24 · 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 observations, record review, and interviews, the facility failed to provide adequate supervision to prevent accidents during incontinence care for one (Resident (R) 295) of four sampled residents reviewed for accidents. The failure resulted in a fall with injury, two fractured knees, and a fractured hip, requiring transfer to the hospital for evaluation. Findings include: Review of R295's Clinical Census located under the Census tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE], with diagnoses which included anxiety, muscle weakness, and hemiplegia and hemiparesis following cerebrovascular disease affecting left dominant side. R295 was discharged to the hospital on [DATE]. Review of R295's Care Plan located under the Care Plan tab of the EMR revealed the resident had an ADL self-care deficit related to debility and impaired mobility that was initiated on 08/16/22 with an intervention that two staff were required to assist with bed mobility. Review of R295's Progress…

    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 · Past Non-Compliance
  • Potential for harm · F2026-02-26 · 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 interviews, and review of the facility's policies titled Food Storage Principles, the facility failed to ensure opened food items in the walk-in cooler/freezer were labeled and dated. In addition, the facility failed to discard one food item by the expiration date. This had the potential to affect 80 residents receiving oral diets from the kitchen. Findings Include:Review of the Food Storage policy, revised 11/14/2025, documented under procedure 1. Train employees regarding proper food storage procedures. 5. Label opened food items with 'Date Opened.' Observation and interview with the Dietary Manager (DM) on 02/24/2026 at 9:05 am, revealed inside the freezer there was a bag of what appeared to be meat that was labeled with a prepared date of 2/8 without a use by date, a bag of meat that was not labeled or dated, and an item labeled Chix with a prepared date of 1/28/2026. The Dietary Manager confirmed that all of the items should be labeled with an open date, and a use by date.Observation and interview with the DM on 2/24/2026 at 9:45 am, revealed inside…

    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 · E2026-02-26 · tag F0880 — failed to prevent and control infections — pattern
    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 and review of the facility policy titled Hand Washing/Hygiene, the facility failed to ensure that staff were washing or sanitizing their hands while passing out lunch trays to the residents. The deficient practice had the potential to place residents at risk for infections from cross contamination.Findings include: Review of the Hand Washing/Hygiene Policy, revised 8/2023, documented Procedure. 3. The Centers for Medicare and Medicaid State Operations Manual indicates that hand hygiene should be performed: (d), before and after assisting a resident with meals. Observation of dining on 02/25/2026 at 12:10 PM, revealed the residents were brought into the dining area and sat at the tables without washing their hands. The residents were not offered wet wipes, hand sanitizer, or soap and water by facility staff. The staff were also observed not washing or sanitizing their hands in between serving trays, staff did not satanize hands before opening straws or passing out drinks. Observation of dining on 02/26/2026 at 12:20 PM revealed that staff 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-26 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, resident and staff interviews, and record review, the facility failed to develop a person-centered, comprehensive care plan for one resident (R) (R102) of 43 sampled residents. Specifically, the facility did not develop a care plan for R102 for oxygen (O2) therapy. The deficit practice had the potential to place R102, at risk for medical complications, unmet needs, and a diminished quality of life.Findings Include:A request for a Care Plan policy was made on 02/26/2026 at 2:30 PM and 3:00 PM and was not provided by the facility prior to survey conclusion. Review of R102's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic atrial fibrillation, and chronic kidney disease, stage 2.Review of R102 's Clinical Physician Orders revealed an order dated 09/15/2025 for O2 at 2 liters per minute (LPM) continuously via a nasal cannula (NC) Review of R102's Comprehensive Care Plan, reviewed 02/24/2026 revealed no documented care plan for oxygen use.Observations on 02/25/2026 at 9:44 AM and 10:09 AM revealed R102 receiving O2 by an O2…

    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 before2026-02-26 · 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 observations and interviews, the facility failed to ensure that two bathrooms (one shared bathroom between room [ROOM NUMBER] and 14, and one private bathroom room [ROOM NUMBER]) had water temperatures under 120 degrees Fahrenheit and two resident rooms (Room TB 045A and Room TB 053A) were free of chemicals from a total of 54 rooms. The deficient practice increased the risk to residents for burns and other injuries. Findings include: 1. Observation on 02/24/2026 at 11:42 AM in Room TB 045-A revealed that there was one pressurized aerosol container stored on the bedside table in the resident's room. Observation on 02/24/2026 at 1:04 PM of Room TB 053-A revealed that there were two pressurized aerosol containers and two liquid disinfectant solution containers stored on the bedside table in the resident's room. Second Observation on 02/25/2026 at 12:18 PM of Room TB 045-A bedside table revealed that the one pressurized aerosol container was still located on the bedside table in the resident's room. Second…

    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 before2026-02-26 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure that oxygen (O2) was administered according to physician orders for one of six residents (R) (R102) reviewed for oxygen administration. This failure had the potential to place R102 at risk of respiratory complications and unmet needs.Findings include:Review of the facility policy titled Oxygen Administration, revised 08/2023, documented a resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs. Pulse oximetry monitoring and clinical examination determine the adequacy of oxygen therapy. The resident's disease, physical condition, and age will help determine the most appropriate method of administration.Review of R102's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic atrial fibrillation, and chronic kidney disease, stage 2.Review of R102 's Clinical Physician Orders revealed an order dated 09/15/2025, for O2 at 2 liters per minute (LPM) continuously via a nasal cannula (NC.)…

    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 · D2026-02-26 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, staff interviews, and facility policy titled, Medications Storage Room, the facility failed to ensure one of four medication carts and two of three medication rooms were free of expired medications. This deficient practice had the potential to place residents at risk of receiving expired medications.Findings include:A review of the facility's policy titled Medication Storage Room, updated 06/28/2024, documented under section Medications: . that discontinued or expired medications are not present, and medications packages are properly labeled, including expiration date.Observation and interview with LPN Unit Manager KK on 02/25/2026 at 2:09 PM revealed that in a red bin in the Transitional Care Unit (TCU) hallway medication room were two 1000 milliliter intravenous bags of 0.45 percent sodium chloride with the outer protective covering removed. The bags were not labeled or dated. An interview with LPN Unit Manager KK confirmed that the bags were not labeled, and she did not know how long they were out of the outer covering.Observation and interview with LPN Unit…

    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 · E2025-01-24 · tag F0554 — pattern
    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, record review, interviews, and policy review, the facility failed to ensure four (Resident (R) 93, R23, R95, and R34) of 90 facility residents observed during initial screening had medications available for self-administration and stored at the bedside only when assessed to do so safely and with a physician's order. These failures placed all four residents at risk for medication errors, overdose, or misappropriation of medications. Findings include: Review of the facility's policy titled, Self-Administration of Medications, dated 06/28/24, revealed, The resident has the right to self-administer medications if the interdisciplinary team [IDT] has determined that this practice is clinically appropriate . A resident may only self-administer medications after the IDT has determined which medications may be self-administered . Based on the interdisciplinary team's assessment, a decision is made as to whether the resident is a candidate for self-administration. This will be recorded on 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure resident rooms were clean, creating a homelike environment for three (Residents (R) 63, R59, and R46) of eight residents reviewed for homelike environment. This failure had the potential to negatively impact residents' environment and overall well-being. Findings include: 1. Review of R63's Profile, located in the electronic medical Record (EMR) under the Profile tab, revealed R63 was initially admitted on [DATE] and readmitted on [DATE]. Review of R63's Medical Diagnosis, located in the EMR under the Diagnosis tab revealed R63 had a diagnosis of dementia. Review of R63's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/01/24 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicating R63 was cognitively intact. Review of R63's Care Plan located in the EMR under the Care Plan tab revealed interventions to address cognitive impairment,…

    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 · D2025-01-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy review, the facility failed to report an allegation of resident-to-resident sexual abuse within two hours after the allegation for two residents (Resident (R) 36 and R294) of seven sampled residents. The deficient practice could result in residents being abused. Findings include: Review of R36's Clinical Census located under the Census tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Review of R36's Medical Diagnoses located under the Med Diag tab in the EMR revealed the resident had diagnoses including dementia and cognitive communication deficit. Review of R36's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/29/24, located under the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident had severe cognitive impairment. Review of R36's Care plan located under the Care plan tab of the EMR, revealed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 facility policy, the facility failed to develop and implement a baseline care plan that included instructions needed to provide effective and person-centered care within 48 hours of admission for one (Resident (R) 94) of six sampled residents. Failure to develop and implement a baseline care plan could place residents at risk for unmet care needs. Findings include: Review of R94's Clinical Census located under the Census tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE]. Review of R94's Medical Diagnoses located under the Med Diag tab in the EMR revealed the resident had diagnoses that included amputation of right great toe, non-pressure chronic ulcer of left foot and heel, type 2 diabetes, hypertension, and fracture of left great toe. Review of R94's Administration Record dated January 2025, located under the Orders tab in the EMR, revealed R94 was prescribed levofloxacin and linezolid (antibiotics) for osteomyelitis (an infection),…

    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
Show the remaining 9 citations
  • Potential for harm · Dcited before2025-01-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 observation, interview, record review, and facility policy review, the facility failed to provide staff assistance with activities of daily living for one (Residents (R) 63) of two residents reviewed for activities of daily living out of a total sample of 31 residents. This failure had the potential to lead to a decline in activities of daily living. Findings include: Review of R63's Profile, located in the electronic medical record (EMR) under the Profile tab revealed R63 was initially admitted on [DATE] and readmitted [DATE]. Review of R63's Medical Diagnosis, located in the EMR under the Diagnosis tab revealed R63 had a diagnosis of dementia. Review of R63's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/01/24 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 indicating R63 was cognitively intact. The MDS also indicated R63 required partial assistance to complete bathing, dressing, using the toilet, 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and record review, the facility failed to ensure one (Resident (R)1) in the sample of 31, received wound care per the physician's orders. The facility's deficient practice increased R1's risk of infection which delayed healing and caused discomfort. Findings include: Review of R1's undated admission Record located in the electronic medical record (EMR) under the Profile tab revealed admission date of 02/15/22 with a diagnosis of encephalopathy. Review of R1's Physician's Orders located in the EMR under Orders tab dated 08/03/24 revealed, .clean nostril lesion, apply xeroform, cover with band aide daily Review of R1's Treatment Administration Record (TAR) located in the EMR under Orders tab dated 08/03/24 revealed, .clean nostril lesion - Start Date- 08/03/2024. Review of R1's TAR, located in the EMR under the Orders tab from 08/03/2024 through 01/24/2025, revealed no staff initials were documented on eleven days: 08/04/2024, 08/12/2024, 09/03/2024, 09/07/2024, 10/05/2024, 10/05/2024, 11/14/2024, 11/28/2024, 12/24/2024, 01/08/2024, 10/08/2024. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, staff and resident interviews, record review, and facility policy review, the facility failed to provide respiratory care in accordance with professional standards for two (Residents (R) 53 and R63) of three residents reviewed for respiratory care out of a total sample of 22 residents. This failure had the potential to lead to respiratory complications and infections. Findings include: Review of the facility's policy titled, Caring and Handling of Respiratory Equipment, revised 08/23, revealed, . 5. Equipment should be changed based on the following schedule: a. Change within every seven days or when obviously contaminated: Cannula and humidifier, Simple mask, Partial rebreathing mask, Non-rebreathing mask, Tracheostomy collar, Face tent, T-piece, Handheld nebulizers, Large bore tubing, Ventilator breathing circuits with conventional humidifiers .10. Empty intermittently used nebulizers after use and rinse with warm water and allow to air dry. After drying, place in a plastic bag, which is…

    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 · D2025-01-24 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review, and interviews, the facility failed to ensure residents were provided with food that was palatable and at a safe and appetizing temperature for three of three residents (Resident (R) 2, R15, and R65) of 31 sample residents. This failure had the potential to affect resident food satisfaction leading to potentially decreased oral intake and weight loss. Findings include: Review of the facility's policy titled, Food Service Policy, revised 08/23, revealed The center provides and each resident receives food that is .palatable, attractive, and at the proper temperature . Review of R2's quarterly Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 12/24/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 was cognitively intact. During an interview on 01/21/25 at 10:07 AM, R2 stated the food was cold all the time, especially at breakfast. She stated they did not always have time to warm it up. Review of R15's quarterly MDS located…

    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 · D2023-05-25 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and a review of the facility's policy titled, Advanced Directives, the facility failed to obtain a Physician's order for one of five residents (R) (#296) reviewed for full code status. Findings include: A review of the policy titled Advance Directives, last reviewed on [DATE], revealed that a resident has the right to accept or refuse medical or surgical treatment, at the individual's option, formulate an advanced directive. Record review of the Electronic Medical Record (EMR) for R#296 revealed that the resident had a signed Physician Order for Life-Sustaining Treatment (POLST) that acknowledged that the resident and her family wanted a full code, which means that Cardiopulmonary Resuscitation (CPR) is to be performed in case that R #296 heart had stopped. It was signed by R#296 son and the physician on [DATE]. Record review of the admission Minimum Data Set (MDS) for R#296 dated [DATE] revealed that the resident has a Brief Interview for Mental Status (BIMS) score was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, and record review, the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for two of 32 sampled residents (R) (#9 and R#57) following a new diagnosis of schizophrenia for R#9, and a new diagnosis of schizoaffective disorder for R#57. Findings include: Record review revealed R#9 was admitted with a diagnosis of but not limited to schizophrenia, major depressive disorder, and anxiety disorder-a new diagnosis of schizophrenia on 9/26/2018. Record review revealed R#57 was admitted to the facility with a diagnosis of but not limited to major depressive disorder-a new diagnosis of schizoaffective disorder on 5/9/2022. Interview on 5/24/2023 at 1:52 p.m. with Regional Clinical Director revealed that the facility does not have a licensed Social Services Director. She stated that there is no one with access to the system. She stated they are in the process of applying for a level II PASRR. Interview on 5/24/2023 at 3:33 p.m. with the Administrator revealed that the former Director of Nursing (DON) was…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-25 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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 3. Record review of the care plan for R#86 dated 5/22/2023 revealed that the resident is at risk of falls, with interventions that include a bed in the low position, fall mats at the bedside, and wedges placed for positioning. Record review of the most recent minimum data set (MDS) for R#86, dated 2/24/2023, revealed that the resident has a Basic Interview for Mental Status (BIMS) score of 12, indicating a mild cognition difficulty. She needs extensive assistance with total dependence for bed mobility and transfers in section G. Review of the facility's falls list; R # 86 had a fall on 5/19/2023. Interview on 5/25/2023 at 8:35 a.m., the resident was interviewed, with a family member at the bedside. She and the aunt both revealed that she had not had a fall. Observations on 5/23/2023 at 12:55 p.m. of the resident lying in the bed, without a wedge, no fall mats were in place, and the bed was in a high position. Observation on 5/25/2023 at 8:35 a.m. of R#86, revealed the bed was in a low position, there were no…

    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 before2023-05-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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

    Based on observations, resident and staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to showers according to the schedule for one of 32 residents. (R) (#26). This failure had the potential to cause a diminish in residents' quality of life. Findings include: Record review for the most recent quarterly Minimum Data Set (MDS) for R#26, dated 3/26/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and physical help with bathing and partial/ moderate assistance with getting dressed was required. Interview on 5/23/2023 at 10:26 a.m. with R#26 reported that they are supposed to get showers on Tuesdays and Thursdays, but it has been a week since he/she had a shower. A review of the bath schedule for 5/23/2023 revealed that R#26 was on the list for a shower. Observation on 5/24/2023 at 10:05 a.m. the resident was sitting in bed with a hospital gown on. He stated that he did not have a shower last night. Observation on 5/25/2023, at 9:43 a.m. R#26 was…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-25 · 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, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). Two medication errors with 28 opportunities for two residents (R) (#43 and #19) were observed during a medication pass. The medication error rate was 7,14%. This failure had the potential to result in medication not being given in accordance with the physician's orders and has the potential to affect the residents' clinical conditions. Findings include: 1. During a medication pass on 5/24/2023 at 9:07 a.m., Licensed Practical Nurse (LPN) AA was observed giving R#19 his morning medications. The medications included Systane eye drops, one drop in each eye. After preparing all the resident's morning medications, LPN BB went into the resident's room to administer the R#19s medication for that time of the day. She was observed giving the eye drop into R#19 eyes by pulling up on the upper eyelid and touching the eye with the eye drop container tip. During an interview on 5/24/2023 at 9:41 a.m., LPN AA verified that she worked with pediatrics before she…

    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

$10,868 in federal fines across 1 penalty.

  • $10,868 — penalty dated 2025-01-24

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.

Part of a chain

This home belongs to SOVEREIGN HEALTHCARE HOLDINGS — 43 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 →

RatingThis homeChain avg
Overall 1 of 53.7-2.7 vs chain
Health inspection 2 of 53.2-1.2 vs chain
Staffing 1 of 53.1-2.1 vs chain
Quality measures 4 of 54.5-0.5 vs chain
The other 42 homes this chain runs (chain average 3.7★, per CMS)
1 of 5Sunnybrook Rehabilitation CenterRaleigh, NC 2 of 5Lake Worth Rehabilitation CenterLake Worth, FL 2 of 5Monroe Rehabilitation CenterMonroe, NC 2 of 5Pinellas Point Nursing And Rehab CenterSaint Petersburg, FL 2 of 5Riviera Palms Rehabilitation CenterPalmetto, FL 2 of 5Rocky Mount Rehabilitation CenterRocky Mount, NC 3 of 5Bayshore Pointe Nursing And Rehab CenterTampa, FL 3 of 5Lanier Rehabilitation CenterJacksonville, FL 3 of 5Lincolnton Rehabilitation CenterLincolnton, NC 3 of 5Medicana Nursing And Rehab CenterLake Worth, FL 3 of 5Port Orange Nursing And Rehab CenterPort Orange, FL 3 of 5Raleigh Rehabilitation CenterRaleigh, NC 3 of 5Tiffany Hall Nursing And Rehab CenterPort Saint Lucie, FL 3 of 5Treyburn Rehabilitation CenterDurham, NC 4 of 5Atlantic Shores Nursing And Rehab CenterMelbourne, FL 4 of 5Bonifay Nursing And Rehab CenterBonifay, FL 4 of 5Boulevard Rehabilitation CenterBoynton Beach, FL 4 of 5Braden River Rehabilitation Center LLCBradenton, FL 4 of 5Hunters Creek Nursing And Rehab CenterOrlando, FL 4 of 5Metro West Nursing And Rehab CenterOrlando, FL 4 of 5Northdale Rehabilitation CenterTampa, FL 4 of 5Ocala Oaks Rehabilitation CenterOcala, FL 4 of 5Orange City Nursing And Rehab CenterDebary, FL 4 of 5Pettigrew Rehabilitation CenterDurham, NC 4 of 5Royal Oaks Nursing And Rehab CenterTitusville, FL 4 of 5Sarasota Point Rehabilitation CenterSarasota, FL 4 of 5Silas Creek Rehabilitation CenterWinston-Salem, NC 4 of 5Warner Robins Rehabilitation CenterWarner Robins, GA 4 of 5Zebulon Rehabilitation CenterZebulon, NC 5 of 5Arbor Trail Rehab And Skilled Nursing CenterInverness, FL 5 of 5Boynton Beach Rehabilitation CenterBoynton Beach, FL 5 of 5Crestview Rehabilitation Center, LLCCrestview, FL 5 of 5Cypress Pointe Rehabilitation CenterWilmington, NC 5 of 5Fort Walton Rehabilitation Center, LLCFort Walton Beach, FL 5 of 5Jacksonville Nursing And Rehab CenterJacksonville, FL 5 of 5Macclenny Nursing And Rehab CenterMacclenny, FL 5 of 5Marianna Health And RehabilitationMarianna, FL 5 of 5Moultrie Creek Nursing And Rehab CenterSaint Augustine, FL 5 of 5Palm City Nursing & Rehab CenterPalm City, FL 5 of 5Parkview Rehabilitation Center At Winter ParkWinter Park, FL

Showing 40 of 42; 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 / managerTypeRoleSince
SOVEREIGN CAROLINA HOLDINGS LLCOrganizationDIRECT OWNERSHIP INTERESTsince 03/06/2014
CRONQUIST 2015 FAMILY TROrganizationINDIRECT OWNERSHIP INTERESTsince 12/31/2015
JOHN J NOTERMANN BUSINESS TROrganizationINDIRECT OWNERSHIP INTERESTsince 11/12/2017
CRONQUIST, ROYCEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/01/2018
KELLY, MICHELLEIndividualCORPORATE OFFICER; ADP OF THE SNFsince 02/01/2018
MELTON, DONALDIndividualCORPORATE OFFICER; ADP OF THE SNFsince 05/01/2014
SOUTHERN HEALTHCARE MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/15/2025
KANAGALA, VAMSIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2025
MUKWINDIDZA, CHIDOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/24/2025
NOTERMANN, BRENDAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/15/2025

CMS files one row per role, so the 16 rows in the source record cover these 10 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.

4 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.

$9.1M
Net patient revenuemost recent cost report
-8.9%
Operating marginrevenue minus expenses
$453K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 65%Medicare 9%Other / private 26%

This home reported $453K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$297per resident / day
operating cost
$9,016per month
≈ monthly operating cost
$272per 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 115132. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-26, 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.

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