Pruitthealth - Savannah
12825 White Bluff Road, Savannah, GA 31419 · For profit - Corporation · 140 certified beds · (912) 927-9416 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $4,963 in federal fines (most recent 2024-01-18)
- its independent health-inspection rating is low (2/5)
- about 28% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 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 held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 28.0% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.8% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.4% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.6% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.0% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.6% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.4% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 94.4% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.1% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.8% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 19.8% | 11.6% | 12.0% | worse |
§ 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.
57.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 223 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
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 91 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 0.31 therapist hours per resident per day in 2026Q1 — more than 50% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.6%CMS range 51.0–63.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.0%CMS range 9.2–15.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 57.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 44.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 57.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 97.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.7%CMS range 5.7–13.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 140 beds and averages 124.5 residents a day — about 89% occupied, or roughly 16 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 3.71 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.63 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.23 hrs/resident/day on weekends vs 3.91 on weekdays — 17% thinner on weekends. RN hours go from 0.76 to 0.33 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Dcited before2025-12-22 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one of 36 residents (R) (R2) reviewed for MDS completions. The facility census was 132. Findings include:Review of the RAI Manual, dated October 2025, indicated, There are three types of discharges: two are OBRA [Omnibus Budget Reconciliation Act] required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS [Prospective Payment System] Discharge. A Discharge assessment is required with all three types of discharges . Any of the following situations warrant a Discharge assessment . Resident is discharged from the facility to a private residence . Discharge Assessment - return not anticipated. Discharge assessments must be completed within 14 days of discharge. Record review for R2 revealed that the resident was admitted to the facility on [DATE] and was discharged from the facility on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-20 · tag F0628 — patternProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 Involuntary Transfer and Discharges, the facility failed to ensure written bed hold policy and transfers notices were provided to the resident or resident representative (RR) for seven of seven residents (R) (R7, R66, R76, R43, R26, R57 and R45) reviewed for emergent hospital transfer out of a total sample of 28 residents. This failure had the potential to affect the resident and/or their RR by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. This had the potential to affect all residents who resided at the facility in the event that they were transferred out of the facility. Findings include: Review of the facility's policy titled Involuntary Transfer and Discharges, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-20 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
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 Medication Administration - Insulin Injections and Medication Administration - General Guidelines, the facility failed to ensure insulin injection pens were used as recommended by the manufacturer and medications were administered according to physician's orders, resulting in a medication administration error rate of 13.64 percent with six errors for four residents (R) (R121, R43, R64, and R31) out of a possible 44 opportunities for error. This failure had the potential to affect the accurate dosing of insulin administered or the potential blood bioavailability of multi-dose medications administered per day to the residents. Findings include: Review of the facility policy titled Medication Administration - Insulin Injections, revised 7/18/2024, revealed: For Insulin Pens: 1. Remove the cover from the pen and swab with an alcohol swab. Screw on a new needle and remove cap. 2. Prime pen by dialing up 2 units on the pen and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-20 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to review and revise residents' care plans for one of 28 sampled residents (R) (R27). The facility did not ensure care conferences occurred at least quarterly, where R27's care plan would be reviewed and/or revised. This failure placed the resident at risk for unmet care needs. Findings include: Review of the facility's policy titled Care Plans, reviewed on 7/27/2023, revealed It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Review of R27's admission Record, located in the resident's electronic medical record (EMR) under the Resident tab, revealed the resident was admitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, documentation review, review of the facility documents titled Hot Water Sanitizing Upright Door Dish Machine, and Installation and Operating Manual for ECOLAB Models: ES-2000HT INTL, and review of the facility policy titled Dishwashing, the facility failed to ensure the dishwasher rinse temperature was at the proper temperature to sanitize the dishes. The facility further failed to ensure staff performed hand hygiene between handling the soiled dishes and handling the clean dishes. This had the potential to affect 120 of 126 residents in the facility who consumed food from the kitchen. The facility identified six residents who consumed nothing by mouth (NPO). Findings include: Review of the Instruction Manual for the dish machine titled Hot Water Sanitizing Upright Door Dish machine, and Installation and Operating Manual for ECOLAB Models: ES-2000HT INTL dated July 10, 2006, page 8 under operating instructions revealed the operator should verify the temperature of the rinse water is between 180- and 195-degrees Fahrenheit for the entire rinse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-18 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policy titled Infection Control - Linen and Laundry, the facility failed to ensure one Laundry Aide (LA)1 donned (put on) proper personal protective equipment (PPE) while sorting soiled resident clothing and bed linens. This deficient practice had the potential to affect the staff and/or all residents which could potentially lead to the development of infectious diseases. Findings include: Review of a policy provided by the facility titled Infection Control - Linen and Laundry, dated 10/30/2023 indicated .Soiled laundry will be handled as contaminated, and all partners will practice standard precautions when handling or exposed to soiled laundry. Standard precautions involve wearing the appropriate PPE when handling or exposed to soiled laundry.Personal protective equipment (e.g. gown, gloves, and mask) will be readily available for use and must be worn, as indicated, to protect employees from exposures.Laundry partners should wear protective gloves, procedure mask, rubber/plastic apron and eye protection while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and review of the facility policy titled Medication Storage in the Healthcare Centers, the facility failed to assess one of 12 sampled residents (R) (R109) reviewed for self-administration of medications. This failure had the potential for the resident not to self-administer the medication properly and for staff not to be aware if they were administered. Findings include: Review of the facility's policy titled Medication Storage in the Healthcare Centers, last reviewed on 7/28/2023, revealed Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication . is accessible only to licensed nursing personnel . Review of R109's quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/13/2023 and located under the RAI (Resident Assessment Instrument) tab of the electronic medical record (EMR), revealed R109 was admitted to the facility on [DATE] and scored 12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor 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 record review, staff interviews, and review of the facility policy titled Advanced Directives: Georgia, the facility failed to ensure one resident (R) (R44) of 36 residents reviewed for code status was accurately documented in the medical record to ensure her and/or her responsible party (RP) wishes were honored. Findings include: Review of the facility policy titled Advanced Directives: Georgia, with a revised date of [DATE], revealed that the resident had the right to change the code status and the change should be documented in the medical record. Review of R44's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with an order for a Full Code status. In addition, the Face Sheet of the EMR revealed Full Code in a red block. Review of her Plan of Care located under the Care Plan tab of the EMR with a problem start date of [DATE] revealed her Care Plan revealed attempt resuscitation under the area of advanced directives.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Physician Notification, the facility failed to ensure the physician was notified of a change of skin condition for one of 40 sampled residents (R) (R103). Specifically, the facility failed to notify the physician of a fungal rash that required treatment. This failure had the potential for R103 to not receive the necessary treatment needed to promote the healing of a skin condition. Findings include: Review of the facility's policy titled Physician Notification, revised on 9/15/2023, revealed, . the physician will be notified when the resident has a change in condition . Review of R103's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R103 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, rash and other skin eruption. Review of R103's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2023 and located under the RAI…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Advance Beneficiary Notices (ABNs),, the facility failed to issue a Notice of Medicare Non-Coverage Notices (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) to Medicare A recipients when therapy or skilled nursing services were ending for three of three sampled residents (R) (R112, R179, and R379) reviewed for NOMNC and SNFABN. This failure had the potential for residents and/or their representatives not being informed of potential available services and fees for those services or the advisement of the ability to appeal the Resident's discharge from Medicare Part A benefits. Findings include: Review of the facility policy titled, Advance Beneficiary Notices (ABNs), last revised 7/19/2016, revealed, . The company recognizes the patients/residents have the right to be informed in writing (in a readable and comprehensive manner) in a timely fashion, about their liability for payment of services prior to 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.
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- Potential for harm · D2024-01-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure two residents (R) (R1 and R60) of eight residents reviewed for abuse, were free from resident-to-resident abuse for two separate incidents. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/09/2020 indicated .It is the mission of [NAME] Health and its affiliated providers (collectively, the Organization) actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The Organization recognizes that every patient has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The purpose of our abuse prohibition procedures is to assure that our…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that an allegation of abuse was reported to the State Survey Agency (SSA) in a timely manner for one of eight residents (R) (R60) reviewed for abuse. This failure had the potential for other allegations of abuse to not be reported in a timely manner. Findings include: Review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, dated 10/09/2020 indicated .Federal regulations applicable to skilled nursing facilities.do not require that every bruise or scratch incurred by patients in the course of everyday activities be reported to the State. The regulations require that occurrences of abuse and mistreatment be reported, including injuries of unknown origin, in accordance with established State procedures. Review of R60's EMR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure that thorough investigations of resident-to-resident incidents that involved residents (R) (R279, R60, and R1) were completed. There was no evidence the facility interviewed other current residents or staff regarding the allegations of a physical resident-to-resident altercation with R279 and R60. There was no evidence the facility interviewed other current residents or staff regarding the physical resident-to-resident altercation with R279 and R1. The facility's investigation failed to include the names of the residents who were the victims. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect. Findings include: Review of a policy provided by the facility titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility policy titled Bed Holds and Room Reserves, the facility failed to ensure two residents (R) (R59 and R110), and/or their responsible party (RP), of four residents reviewed were given a written bed hold policy at the time the residents were transferred/discharged to the hospital. Findings include: Review of the facility's policy titled Bed Holds and Room Reserves, with a revised date of 11/22/2016 revealed it is the facility's policy to provide written information regarding the bed hold policy and allowed duration to the resident or the responsible representative prior to the resident transfer. The policy stated upon initiation of transfer, the charge nurse on duty is responsible to offer the patient the bed hold option. The bed hold acknowledgment form will be presented to the resident or resident representative and the written notice will be included in the transfer packet. If the resident representative is not present, a copy of the bed holds acknowledgment form will be sent by mail to the responsible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-18 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to follow the RAI's transmittal requirements, which indicates that within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System for one resident (R) (R94) of 40 sampled residents reviewed. Specifically, it has been over 120 days since the quarterly MDS was completed and the MDS had not been transmitted to the CMS System. Finding include: Review of the RAI 3.0 Manual section 5.2 Timeliness Criteria indicated, .Transmitting Data: Submission files are transmitted to the Quality Improvement and Enhancement System (QIES) Assessment Submission and Processing (ASAP) system using the CMS wide area network. Providers must transmit all sections of the MDS 3.0 .Transmission requirements apply to all MDS 3.0 records used to meet both federal .requirements Assessment Transmission: .All other MDS assessments must be submitted…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record reviews, review of facility policy titled MDS Assessment Accuracy, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (R) (R89) of 40 sampled residents, had an accurate Minimum Data Set (MDS) assessment related to anticoagulant use. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the resident. Findings include: Review of the facility's policy titled MDS Assessment Accuracy, dated 12/06/2022 revealed: It is the policy of this healthcare center that each Minimum Data Set (MDS) reflects the acuity and the medical status of each resident .6. All MDS Assessments must be completed following the guidance set forth in the RAI manual as directed by the Centers for Medicare and Medicaid Services (CMS). Review of the RAI Manual, dated 10/01/2019, indicated, It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items 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.
- Potential for harm · D2024-01-18 · tag F0655 — isolatedCreate 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 staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure a baseline care plan was provided for one of nine sampled residents (Resident (R) 329). Specifically, the facility failed to develop a baseline care plan for pressure ulcers. This failure had the potential to cause staff to not receive the necessary instructions needed to provide effective care and meet the needs of residents. Findings include: Review of the facility's policy titled, Care Plans, revised on 7/27/2023, revealed . It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan . Baseline Care Plan- Must include the minimum healthcare information necessary to properly care for each patient/resident immediately upon their admission, which would address patient/resident specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure one of one (Resident (R)52) who went to dialysis three times per week, had care plan interventions including to monitor R52's left upper extremity fistula for bleeding or bruising, monitoring of blood pressure, and venipuncture to the left arm. The Care Plan further failed to include R52's liberalized renal diet with Complex Carbohydrates, High Fiber, and Optimal Protein (CCHO) and double portions of protein and whether to provide a to-go breakfast before R52 left the facility for dialysis. Findings include: Review of the facility's policy titled Care Plans dated 7/27/2023 revealed, .3. The comprehensive person-centered care plan is developed to include .a .resident's medical, nursing .needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial needs that are identified in the comprehensive assessment. 4 . The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-01-18 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of a policy provided by the facility titled Care Plan, the facility failed to ensure four residents (Residents (R) R280, R60, R52, R51) and/or their representative was invited to participate in their quarterly care plan meetings out of a total sample of 40 residents. This failure had the potential to affect the residents' care needs. Findings include: Review of a policy provided by the facility titled Care Plan, dated 7/27/2023 indicated . The patient/resident and or the patient/resident's representative will participate to the extent practicable in the care planning process. An explanation must be included in a patient/resident's medical record if the participation of the patient/resident and their patient/resident representative is determined not practicable for the development of the patient/resident's care plan. Comprehensive care plans should be reviewed not less than quarterly according to OBRA [Omnibus Reconciliation Act] MDS [Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled, Care Plans, Documentation of Skin and Wound Care, and Physician Orders, the facility failed to ensure pressure ulcer care was provided according to professional standards for one of four sampled residents (Resident (R) 329) out of a total sample of 40 residents. Specifically, the facility failed to transcribe physician treatment orders in the electronic medical record (EMR), conduct pressure ulcer assessments per the facility policy, develop a baseline care plan for pressure ulcers, and document treatments administered in the EMR. This failure had the potential to cause the resident not to receive the necessary care needed to promote healing of pressure ulcers. Findings include: Review of the facility's policy titled, Care Plans, revised on 7/27/2023, revealed . It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 resident and staff interviews, record reviews, and facility documentation reviews, the facility failed to ensure showers were provided for one of seven sampled residents (Resident (R) 103) out of a total sample of 40 residents. Specifically, the facility failed to ensure R103 received showers per the developed shower schedule. This failure had the potential to cause residents' personal hygiene needs to not be met. Findings include: Review of R103'sFace Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R103 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, muscle weakness, and a stage IV pressure ulcer on the right heel. Review of R103'sMinimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2023 and located under the RAI (Resident Assessment Instrument) tab of the EMR, revealed R103 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. It was also recorded R103…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews, record review, and review of the facility's policies titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, and Documentation of Skin and Wound Care, the facility failed to implement dental orders for one (Resident (R)89) to treat pain and a potential dental abscess. The facility further failed to conduct an assessment and provide treatment for a change in skin condition for R103. Specifically, the facility failed to conduct an assessment and obtain a treatment for an identified fungal rash. This failure had the potential for the resident to not receive the necessary care needed to promote healing of a skin condition. Findings include: Review of a policy provided by the facility titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health dated 12/06/2022 indicated .The clinical records shall show documentation of all consultation by the specialty service…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 reviews, and review of the facility's policies titled Physician Orders, and Documentation of Skin and Wound Care, the facility failed to ensure that nursing staff followed the recommendations of the Wound Nurse Practitioner (WNP2) and document verbal and telephone orders in R113's medical record after making rounds with the WNP2 or after reviewing the WNP2's documented progress notes regarding the treatment plan for the areas for one of three residents (R) R113 reviewed for pressure ulcers. In addition, the facility failed to ensure that nursing staff provided care to R103's right heel as ordered by the wound consultant. Additionally, the facility nursing staff failed to assess R329's sacral and right hip pressure ulcers from admission on [DATE] until 1/17/2024 and failed to obtain orders for treatment. Findings include: Review of the facility's policy titled Physician Orders, dated 9/15/2017 revealed, .Verbal and Telephone Orders: 1. All verbal and telephone…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview, the facility failed to provide respiratory care per standards of practice for one of two sampled residents (Resident (R) 7). Specifically, the facility failed to ensure respiratory equipment was stored properly for R7. The failure to store respiratory equipment consistent with professional standards had the potential to cause contamination and damage to the respiratory equipment. Findings include: Review of R7's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed R7 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Review of R7's Physician Order, dated 9/06/2023 and located in the EMR under the Orders tab, revealed an order for levalbuterol HCL (a medication used to prevent difficulty breathing, shortness of breath, and wheezing) inhalation solution 1.25 mg (milligram)/3ml (milliliter) amount 1 vial: inhalation every eight hours and a Physician Order, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to communicate with the dialysis center prior to the resident arriving at the dialysis center and failed to obtain communication documentation from the dialysis center after the resident completed dialysis and returned to the facility for one of one resident (Resident (R) 52) who attended dialysis three times per week. The failure of the facility to communicate with the dialysis center prior to and after dialysis could affect the care of the resident as well as prevent continuity of care. Findings include: Review of R52's Physician Orders, dated 10/24/2023 through 1/17/2024 and located under the Resident tab of the electronic medical record (EMR), revealed R52 was admitted on [DATE] with a diagnosis of End Stage Renal Disease (ESRD). R52's Physician Orders indicated R52 went to dialysis three times per week and had a left upper arm fistula for dialysis access. Review of R52's EMR Resident tab, Progress Notes tab, and Misc. (Miscellaneous) tab…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0808 — failed to follow doctor-ordered diets — isolatedEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
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, staff interviews, record review, and review of the facility's policy titled Diet Order System, the facility failed to ensure that one of one resident (Resident (R) 52) received her diet as ordered by the attending physician. This failure had the potential for the resident to receive inadequate nutrition. Findings include: Review of the facility's policy titled Diet Order System, dated 9/29/2022, revealed, It is the policy . that each resident has the correct diet order . Procedure: 1. Nursing will review physician orders and send written communication to the Dietary Department regarding the diet order or diet change in a timely manner. 2. When the diet order/change is received, the Dietary Department will adjust the diet in the electronic tray card system to reflect the correct diet order . 5. The diet order/change communication form will be kept in a file for at least six months . Review of R52's Physician Orders, dated 10/24/2023 through 1/17/2024 under the Resident tab of the electronic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and staff interview, the facility failed to ensure that opened items were resealed and labeled with a date in the walk-in freezer. and reach-in refridgerator. One of one kitchen. Observation of kitchen on 10/17/2023 at 11:00 a.m. with the dietary manager, one open carton of milk in reach-in refrigerator opened with no date. Observation of walk-in freezer on 10/17/2023 at 11:04 a.m with the dietary manager., the following items were opened and exposed to air; pizza dough, hamburger patties, fish patties and corn on cob. None of these items were sealed and dated with an opened or use by date. Interview with Dietary Manager EE on 10/17/2022 at 11:07 a.m., the staff member stated that all items that are opened in the dietary department are required to be resealed and dated. Interview with Facility Administrator AA on 10/17/2023 at 12:30 p.m., she stated that she had spoken with staff member EE and was aware that there were items that had not been labeled and stored properly in the kitchen and the situation had been corrected because all food that is opened should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-07-07 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and policy review, the facility failed to conduct outbreak testing for Coronavirus (COVID-19) for all staff and residents in accordance with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) requirements, after one staff member tested positive for COVID-19 on 6/26/22. The facility did not maintain testing logs, line listing forms for the residents or staff, or a log of community transmission levels. The census was 101. Findings Include: A review of facility policy dated 2014 titled Coronavirus- COVID-19 Infection Prevention and Control Practices revealed the following: 1.Once COVID-19 has been identified, outbreak prevention and control measures are to be implemented immediately. The location will also follow the directions from the DPH (department of public health). 2. Implement contact and droplet precautions for all patients/residents with suspected or confirmed flu-like symptoms and for suspected or confirmed COVID-19. 3.Facility Administrator and Director of Health Services are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-07 · tag F0885 — failed to notify residents/families about COVID-19 — isolatedReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of facility policy titled COVID-19 Infection Prevention and Control Practices, the facility failed to notify the residents, families, and their representatives by 5:00 PM the next calendar day following the occurrence of a resident or staff that tested positive for COVID-19 on 6/26/22. The census was 105. Findings include: A review of policy titled COVID-19 Infection Prevention and Control Practices dated 2014, the communication section revealed PruittHealth alert message regarding Coronavirus (COVID-19) will be deployed to all family member and partners. Interview with the Administrator on 7/7/22 at 2:00 p.m., the Administrator described her process for the notification of residents, families, and their resident representatives of residents that test positive for COVID. The Administrator stated that he notifies the Area [NAME] President who then notifies the [NAME] President of Policy Management, and she creates a message which identifies how many staff and/or residents were positive for COVID-19. The message information is sent out per…
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.
- No harm found · C2024-01-18 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interview, and a review of the facility's policy titled State Minimum Staffing for Healthcare Centers, the facility failed to ensure that the daily nurse staffing document included the name of the facility, the facility's census, and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice had the potential to affect all 125 of the 125 residents and visitors of the facility. Findings include: Review of the facility's policy titled, State Minimum Staffing for Healthcare Centers, dated 7/15/2016 revealed, . 1. Each facility will complete the Daily Nursing Hours for Healthcare Centers Form Information on the form will include a. the Facility name . c. resident census d. The total number of each category directly responsible for resident care per shift (Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nurse Aides (CNA) f. The total number of hours worked for each category per shift . Observation on 1/15/2024 at 11:59 am and on 1/16/2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$4,963 in federal fines across 1 penalty.
- $4,963 — penalty dated 2024-01-18
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 PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MURRAY, CHRIS | Individual | W-2 MANAGING EMPLOYEE | since 04/05/2021 |
| PRUITT, NEIL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 09/24/2007 |
| PRUITT, NANCY | Individual | CORPORATE OFFICER | since 09/24/2007 |
| PRUITTHEALTH INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 09/24/2007 |
CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.3M paid to related parties — landlords or management companies under common ownership — equal to about 28% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115339. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-20, 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.