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Cambridge Post Acute Care Center

2020 McGee Road, Snellville, GA 30078 · For profit - Limited Liability company · 144 certified beds · (770) 978-7250 Medicare & Medicaid certified

Call the home — (770) 978-7250 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
$24,162 in federal fines
Insights

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

In its favor
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $24,162 in federal fines (most recent 2023-12-11)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2140 McGee Rd SW · (678) 626-0394 · Call to confirm hours
Pharmacy
2912 W Main St · (770) 225-1408 · Call to confirm hours
Grocery
2912 Main St W · (770) 225-0949 · Call to confirm hours
Park
2115 McGee Rd SW · (770) 978-5271 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 3 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

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

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 increased17.4%15.3%15.4%worse
Long-stay residents who lose too much weight6.2%5.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%0.9%0.9%better
Long-stay residents with a urinary tract infection0.9%2.5%2.0%better
Long-stay residents with depressive symptoms68.0%11.3%6.5%check this — see note marked dagger below the table
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 worsened14.9%15.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication16.2%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine99.2%95.0%95.3%typical
Long-stay residents with pressure ulcers5.6%5.6%4.7%worse
Long-stay residents with worsening bladder/bowel control22.0%15.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table27.3%19.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication5.4%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine86.2%78.4%79.4%typical
Short-stay residents rehospitalized after admission27.6%25.0%22.6%worse
Short-stay residents with an outpatient ER visit10.9%11.6%12.0%typical
Long-stay hospitalizations per 1,000 resident days1.552.151.67typical
Long-stay outpatient ER visits per 1,000 resident days1.561.901.80better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

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

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

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

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

49.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 155 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

49.0%U.S. median 51.5%
Got home and stayed home
10.0%U.S. median 10.7%
Went back to hospital
42.8%U.S. median 56.6%
Met the expected recovery
0.36U.S. median 0.31
Therapy hours / resident / day
0.14hours / resident / day
Physical therapy
0.16hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 42.8% 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 131 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 0.36 therapist hours per resident per day in 2026Q1 — more than 62% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF49.0%CMS range 39.9–58.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.0%CMS range 7.6–13.610.7%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 discharge42.8%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 discharge54.2%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 discharge36.6%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 identified99.5%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 setting29.2%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 discharge17.6%98.7%Oct 2024–Sep 2025CMS 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 stay2.4%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 worsened6.2%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 hospitalization10.4%CMS range 7.3–14.27.1%Oct 2023–Sep 2024worse than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.44
RN hours/ resident / day
0.85
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.52
Total nurse hours/ resident / day
0.22
RN hoursweekends
31.1%
Total nursing turnover
43.8%
RN turnover

How full it usually is: this home is certified for 144 beds and averages 138.4 residents a day — about 96% occupied, or roughly 6 beds typically open. It runs essentially full — expect a waiting list. 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.94 hrs/resident/day on weekends vs 3.76 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.53 to 0.22 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2026-04-10)
5
at the previous standard inspection (2025-02-10)

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.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

  • Potential for harm · D2026-04-10 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and facility policy review, the facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments were completed to ensure communication with the dialysis facility for one of two residents (Resident (R) 10) reviewed for dialysis of 32 sample residents. This failure had the potential to lead to uncommunicated and unassessed changes or complications for R10 and other residents receiving dialysis.Findings include:Review of the undated facility's policy titled, DIALYSIS, revealed Post Dialysis Monitoring: 1. Licensed nurse to obtain . Blood Pressure . Pulse . Presence/Absence of Bruit/Thrill as indicated . Licensed nurse will monitor for Signs/Symptoms of fluid overload/deficit . Dizziness . Neck vein distention . Remove pressure dressing from the shunt/fistula site upon return from Dialysis as indicated . Review of R10's admission Record located under the Profile tab of the electronic medical record (EMR) revealed she 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 · Dcited before2026-04-10 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and facility policy review, the facility failed to follow infection control guidelines during wound treatment for one of two residents (Resident (R) 10) reviewed for pressure ulcers and failed to follow infection prevention measures when an indwelling urinary catheter bag was placed on the floor for one of two residents (R10) reviewed for catheters of 32 sample residents. These failures had the potential to cause infections in the wound and the urinary tract for R10.Findings include:Review of the facility's policy titled, Dressings Non-Sterile, dated June 2025, revealed The purpose of this procedure are to provide guidelines for sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria . 20. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area.Review of the facility's policy titled, Catheter Care, Urinary, dated June 2025, revealed 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled Resident Rights, the facility failed treat one of 9 sampled residents (R) (R9) in a dignified manner. Findings included:During an observation on 2/4/2026 at 1:15 pm, R9 was observed at the nurses' station in her self propelling in her wheelchair. The resident was verbalizing that she had to use the bathroom. As R9 proceeded to self-propel her wheelchair towards the A Hall, Certificed Nursing Assistant (CNA) AA approached R9 from behind her wheelchair, stopping the wheelchair and requesting to help move R9 in another direction. At that time, R9 pointed down the hall and stated, No. I am going that way. CNA AA told R9, No, you don't need to go down there. R9's tone elevated, and she began to hit the arm of her wheelchair, stating, No, no, no, no. I want to go that way, pointing towards A Hall. Staff AA grabbed the handles of R9's wheelchair and backed her up against the wall across from the nurses' station and locked…

    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 · D2025-09-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Care of Central Venous Catheters including provide Peripherally Inserted Central Catheters (PICC Lines), the facility failed to provide appropriate treatment and services to one of 10 sampled residents (R) (RB). Specifically, PICC line dressing protocol was not followed, a chest x-ray was not ordered or performed and the PICC line was used without confirmation of placement, and dressing changes were not done according to facility policy and physician's orders.Findings include:Review of facility's policy titled, Care of Central Venous Catheters including Peripherally Inserted Central Catheters (PICC Lines) revealed under Policy Interpretation and Implementation: . 8. Change central line catheter site dressing every week transparent dressing (or as ordered by physician). Change central line catheter site dressing Q48 (every 48 hours) hours with gauze dressing (or as ordered by physician)Review of 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of the facility's policy titled, Medication Delivery Expectations-Nurses, the facility failed to keep one of six residents (R) (RB) free from significant medication error.Findings include:Review of the facility's policy titled Medication Delivery Expectations-Nurses last revised June 2025 documented under Protocol: .8. Notify the physician if medication will be given late or obtain an alternative order or different start time, if appropriate.Review of the electronic medical record (EMR) revealed RB was admitted with diagnoses of but not limited to intraspinal abscess and granuloma, infection following a procedure, candidiasis, chronic obstructive pulmonary disease (COPD), asthma, depression, and muscle weakness.Review of RB's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficits.Review of the care plans for RB revealed the care plan 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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, Infection Control and Dressings, Non-Sterile, the facility failed to follow infection control practices related to Enhanced Barrier Precautions and consistent hand hygiene when providing wound care for two of 16 residents (R) (R4 and R15) receiving wound treatment. The deficient practice had the potential of transmission of communicable diseases and infections.Findings include: Review of the facility's policy titled, Infection Control dated June 2025 revealed in Section Enhanced Barrier Precautions (EBP): .4.b. All residents with any of the following conditions should use enhanced barrier precautions.2) Wounds and/or indwelling medical devices (e.g., central line, urinary catheter.) regardless of MDRO (multi drug resistant organisms) colonization status who reside on a unit.c. During high-contact resident care activities:1) Dressing 2) Bathing/showering 3) Transferring 4) Providing hygiene 5) Changing linens 6)…

    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 · Ecited before2025-02-10 · 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, staff interview, and review of the facility's policy titled Giving a Bed bath, the facility failed to ensure residents' basins, urinals, and bedpans were labeled and covered for 11 of 69 shared rooms (D2, D5, D18, D16, C9, C15, B16, B5, A15, A5, and A11). These failures had the potential to expose patients to infections due to cross-contamination. Findings include: A review of the facility policy, Giving a Bed bath, dated April 2022 under the section titled Steps in the Procedure revealed, 23. Clean washbasins, be sure the resident's name is written on the wash basin, place in a clean plastic bag and store it in the resident's bathroom, closet or nightstand and return any other supplies to designated storage areas. Observation of rooms on halls A, B, C, and D with the Infection Control Preventionist (ICP) on 2/9/2024 from 4:40 pm through 5:05 pm revealed the following: Room D2, bathroom, shared by two residents, revealed two basins in a clear plastic bag. Neither of the basins was labeled with a resident name. Room D5, a bathroom shared by two residents,…

    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 · D2025-02-10 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medication Program, the facility failed to ensure that three of 56 residents (R) (R45, R113, and R432) did not have unauthorized and unsecured medications at the bedside. This failure created the potential for medication errors and unauthorized access to medications by other residents. Findings include: Review of the facility's undated policy titled, Self-Administration of Medication Program, revealed under the Policy statement, It is the policy of the facility to allow the resident and or legal representative of that resident the right to self-administer medication when it has been deemed by the interdisciplinary team (IDT) that it is clinically appropriate. Under the section titled Procedure revealed, (5) If a resident request to self-administer drugs, it is the responsibility of the IDT to determine it is safe for the resident to self-administer drugs, before the resident may…

    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 · Dcited before2025-02-10 · 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 Based on staff interview, record review, and review of the facility's policy titled, Care Plan-Comprehensive, the facility failed to develop a comprehensive person-centered care plan for two out of 56 residents (R) (R35 and R6). Specifically, the facility failed to develop a comprehensive person-centered care plan for R35 related to Methicillin-resistant Staphylococcus aures (MRSA) and R6 related to oxygen therapy. Findings include: A review of the facility's policy titled Care Plan-Comprehensive, dated January 2023 under the section titled Policy Interpretation and Implementation revealed, 1. An interdisciplinary team, in coordination with the resident, his/her family or representative, would develop and maintain a Comprehensive Care Plan for each resident. 2. The Comprehensive Care Plan has been designed to: (a) Incorporate identified problem areas; (b) Incorporate risk factors associated with the identified problems .4. Care plans are revised as changes in the resident's condition dictate. Reviews are made at…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-10 · 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 and resident interviews, record review, and review of the facility's policy titled, Oxygen Safety, the facility failed to ensure one resident (R) (R6) was administered oxygen therapy in accordance with the physician order and to ensure that the oxygen concentrators' filters remained clean for three residents (R98, R64, and R105) out of 19 residents receiving respiratory treatments. This deficient practice had the potential to put residents at risk for increased respiratory infections, medical complications and potentially life-threatening complications. Findings include: Review of the facility's policy titled, Oxygen Safety, dated April 2022 under the section titled Oxygen Administration revealed, 1. Oxygen therapy is administered to the resident only upon the written order of a licensed physician. 1. Review of the clinical records revealed R6 admitted to the facility with diagnoses that included but not limited to asthma, dependence of supplemental oxygen, and malignant neoplasm of unspecified bronchus or lung. Review of R6's clinical records revealed a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 17 citations
  • Potential for harm · D2025-02-10 · 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 observations, staff interviews, record review, and review of the facility's policy titled Administering Medications, the facility failed to ensure the medication error rate was less than five percent. There were two errors with 26 opportunities for one of five residents R (R35) for a medication error rate of 7.69 percent. These failures had the potential to place R35 at risk of medical complications and decreased therapeutic effects of medications. Findings include: Review of the facility policy titled Administering Medications, revised April 2019, revealed the Policy Heading section stated, Medications are to be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation section included . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review of R35's Electronic Medical Record (EMR) under admission Record revealed diagnoses including, but not limited…

    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 · F2024-07-09 · tag F0625 — widespread
    Notify 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews, and review of the policy titled Bed Hold Policy, the facility failed to provide written information about the facility's bed-hold policy to the resident or resident representative when the facility transfers a resident to the hospital for three of three residents (R) (R3, R14, R17) reviewed for Bed Hold. This failure had the potential to contribute to possible denial of re-admission following hospitalization for residents discharged emergently to the hospital. Findings included: A review of the Bed-Hold Policy revised January 2011 revealed it is necessary for the facility to explain the policies concerning reserving beds for residents that must be in the hospital for an undetermined number of days. 1. An approved Medicaid resident is allowed to receive seven days of bed hold and eight days for therapeutic leave per year (paid by the State) while confined to a hospital or on leave from this Healthcare facility. The patient's liability will continue to be paid to…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-09 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Antibiotic Stewardship, the facility failed to assess and determine clinical indications for use of antibiotics utilizing the McGreer Criteria, failed to implement systematic protocols to monitor, decrease use, and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics for two of three sampled residents (R) (R16 and R17). Findings included. Review of the policy titled Antibiotic Stewardship, dated April 2022, revealed the policy is the center will develop an Antibiotic Stewardship program to monitor antibiotics and determine true infections as part of the Infection Prevention and Control Program. Procedure: Program Overview: Number 1. The center will establish a multidisciplinary Antibiotic Stewardship Program that defines optimal antibiotic use and provides guidance for optimal antibiotics prescribed. Number 4. The members of the antibiotic stewardship committee should develop, endorse or adopt…

    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 · F2024-07-09 · tag F0882 — widespread
    Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and review of the policy titled Infection Control -Infection Preventionist, the facility failed to ensure that the person in the role of the Infection Control Preventionist (ICP) adequately assessed, developed, implemented, monitored, and managed the Infection Control and Prevention (IPCP) program, to prevent and control the spread of infections. This failure created the potential for an ineffective infection control program that placed residents at risk for the potential transmission of infections and communicable diseases. The facility census was 136. Findings included. Review of the undated policy titled Infection Control-Infection Preventionist, indicated it is the policy of the facility to employ an appropriate qualified professional to establish and maintain an infection control and prevention program designed to prevent the development and transmission of communicable diseases and infections. Procedure: Number 1. The facility will designate a qualified individual as the Infection Preventionist whose primary role is to coordinate and 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-07-09 · tag F0921 — failed to keep a safe, functional, sanitary building — widespread
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and review of the policy titled Maintenance Service, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. Specifically, the facility failed to address and remove bulking wallpaper and water-stained ceiling tiles from room C14. In addition, the facility failed to maintain the aesthetic appeal of the exterior of the facility and a clean and safe porch area at the entrance of the facility. The census was 136. Findings included: Review of the policy titled Maintenance Service dated April 2022 documented Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: Number 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Number 2. The following functions are performed by maintenance, but not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. b.…

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

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-09 · tag F0656 — failed to write and follow a full care plan — pattern
    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 Based on record review, interview, and review of the policy titled Care Plan-Goals and Objectives, the facility failed to develop a comprehensive person-centered plan of care which included a focus, goal, and interventions related to communication for four of four residents (R) (R4, R18, R26, and R27) reviewed for communication needs. Specifically, the facility failed to develop a care plan related to hearing loss for R4 and failed to develop a care plan for R18, R26, and R17 related to language barrier for non-English speaking residents. Findings included. Review of the policy titled Care Plan-Goals and Objectives dated January 2024, documented the policy is care plans shall incorporate resident-centered/trauma informed goals and objectives that lead to the resident's goals for admission and desired outcomes. Policy Interpretation and Implementation: Number 1. Goals and objectives are defined as the desired outcome for a specific resident problem. Number 2. Goals and objectives are: a. Resident-centered 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-09 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, and a review of the policy titled Certification Medication Aide Program, the facility failed to ensure that services provided by Certified Medication Technicians (CMTs) met professional standards of quality. Specifically, the facility failed to provide evidence that three of five CMTs (CMT MM, CMT LL, and CMT FF) were competent with skills and knowledge to provide insulin administration, before being allowed to administer insulin to residents. This failure had the potential to result in adverse outcomes for residents related to medication administration. Findings included: A review of the policy titled Certification Medication Aide Program, dated May 1, 2022, documented the policy is the intent of this facility to utilize individuals certified as medication aide who are listed on the Georgia Medication Aide Registry in the role of administering technical aspects with certain medications to nursing home residents. Procedure: Step 2. The nursing home shall conduct a comprehensive clinical skills competency review of each certified medication aide…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure medications were administered as ordered for two of three residents (R) (R17 and R25) reviewed for medication administration. Specifically, R17 missed 20 doses of her inhaler (Xopenex) and Atorvastatin 13 times, as ordered; and R25 missed seven doses of Pregabalin (Lyrica-can be used for nerve pain). The deficient practice had the potential for adverse consequences and events due to not receiving ordered and scheduled medications timely. Findings included: A review of the undated policy titled Pharmacy Services, revealed the facility will provide Pharmacy Services in accordance with state and federal regulations. Procedure: Number 5. The facility will provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological to meet the needs of each resident. Review of the policy titled Medication Delivery…

    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 · Ecited before2024-07-09 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    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, interviews, and review of the policy titled, Diabetes Care-Insulin Administration and Administration of Drugs, the facility failed to ensure staff administered insulin as ordered for three of five residents (R) (R15, R11, R5) reviewed for insulin administration. Specifically, there were multiple discrepancies in the blood sugar (BS) documentation and insulin sliding scale orders, as well as multiple days and times with no documentation that insulin was administered. This failure placed the residents at risk of hypoglycemia, hyperglycemia, and a diminished quality of life. Findings included. Review of the policy titled Diabetes Care-Insulin Administration, dated April 2022, revealed the policy is that special precautions should be followed in the administration of insulin. Policy Interpretation and Implementation: Number 2. Insulin dosage should be drawn only by personnel licensed to administer such drug and must be administered by the person drawing the injection. Number 3. The type of…

    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 · Ecited before2024-07-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of the policy titled Enhanced Barrier Precautions, the facility failed to ensure enhanced barrier precautions (EBP) and transmission-based precautions (TBP) were implemented for two residents (R) (R19 and R20) of four residents reviewed for infection control. Specifically, the facility failed to have personal protective equipment (PPE) supplies readily available and accessible for use by staff when providing high-contact care. This failure had the potential to expose residents to infections due to cross-contamination. Findings include: Review of the policy titled Enhanced Barrier Precautions revised March 30, 2024, documented Enhanced Barrier Precautions (EBP) are infection control interventions designed to reduce transmission of resistant organisms. Procedure: Number 1. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities…

    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 · D2024-07-09 · tag F0657 — failed to keep the care plan current — isolated
    Develop 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 record review, interviews, and review of the policy titled Care Plan-Goals and Objectives, the facility failed to ensure the person-centered comprehensive care plan was revised related to interventions for a sacral pressure ulcer for one resident (R)(R19) of three residents reviewed for pressure ulcers. This failure placed the resident at risk for unmet care needs. Findings included: A review of the policy titled Care Plan-Goals and Objectives dated January 2024, documented that the policy is care plans shall incorporate resident-centered/trauma-informed goals and objectives that lead to the resident's goals for admission and desired outcomes. Policy Interpretation and Implementation: Number 3. Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information. Number 4. Goals and objectives are reviewed/revised: a. when there has been a significant change in the resident's condition c. at least quarterly A review of the clinical record revealed that R19…

    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 · D2024-07-09 · 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 observations, interviews, and review of the policy titled Pharmacy Services, the facility failed to ensure expired insulin vials were removed from two of five medication carts. This failure placed the residents at risk of being administered ineffective medications. The census was 136. Findings included. Review of the undated policy titled Pharmacy Services, revealed it is the policy of the facility to provide Pharmacy Services in accordance with State and Federal regulations. Procedure: Number 10. Drugs and biologicals used in the facility will be labeled in accordance with currently accepted professional principals, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. 1. Observation and interview on 7/5/2024 at 4:35 am, the B-Hall medication cart was inspected with Licensed Practical Nurse (LPN) JJ and revealed one opened and used vial of Lantus (long-acting) insulin with an open date of 6/1/2024. LPN JJ was asked when Lantus insulin expires, and she replied, after 28 days. LPN JJ confirmed that the insulin vial had…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, the facility failed to provide education, offer, or provide the pneumonia vaccination for one of five sampled residents (R) (R18) reviewed for pneumonia vaccinations. This deficient practice had the potential to increase the spread of pneumonia among unvaccinated residents. Findings included. Review of the policy titled, Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, dated 8/2022 revealed it is the policy of the facility to ensure that the residents receive Influenza, Pneumococcal, and SARS-CoV-2 immunizations, in accordance with state and federal regulations, and national guidelines. Pneumococcal Immunization: Number 1. Pneumococcal immunization status will be determined and documented for each resident upon admission. Number 5. The resident's medical record includes documentation that indicates, at a minimum, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-09 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of policy titled Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, the facility failed to ensure one of five sampled residents (R) (R19) reviewed for Covid-19 immunizations, was provided education regarding the benefits, risks, potential side effects associated with the vaccine, was offered the Covid-19 vaccine, or declined the vaccine. This failure had the potential to place the resident at risk of acquiring and/or transmitting Covid-19. Findings included. Review of the facility policy titled, Infection Control-Influenza, Pneumococcal and SARS-CoV-2 Immunizations for Residents, dated 8/2022 revealed it is the policy of the facility to ensure that the residents receive Influenza, Pneumococcal, and SARS-CoV-2 immunizations, in accordance with state and federal regulations, and national guidelines. SARS-CoV-2. Number 1. Before offering the SARs-CoV-2 immunization, each resident and/or resident representative receives education…

    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 · D2022-12-08 · tag F0641 — isolated
    Ensure each resident receives an accurate 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 record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for weight loss for one resident (R) of 39 residents, R#54. Specifically, the facility failed to accurately code Section K of the MDS assessment for R#54 which reflected that the resident was on a prescribed weight loss program. Findings Include: Record review revealed R#54 was admitted to the facility on [DATE] with diagnoses that included but not limited to fluid overload, morbid (severe) obesity, dependence on renal dialysis, end stage renal disease (ESRD), anemia in chronic kidney disease and heart failure. Review of Registered Dietician (RD) Nutritional assessment dated [DATE], revealed R#54 was on a Renal, Regular texture, thins; Large Portions diet with plan/recommendations to provide additional nutrients and preventing further weight loss, Review of a care plan revised on 11/11/2022, revealed R#54 was at risk for altered nutrition and/or weight fluctuations related to diagnoses…

    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 · D2022-12-08 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure that one resident (R) of 39 residents, (R#30), was assessed for level two Preadmission Screening/Resident Review (PASRR). This deficient practice had the potential to affect the appropriate level of care and services provided for R#30. Findings include: Review of the electronic medical record (EMR) for R#30 revealed an initial admit date of 6/18/2020, with a recent admission date 2/15/2021. His initial admitting diagnoses included but not limited to toxic encephalopathy, morbid obesity, aphasia, adult failure to thrive, cardiomyopathy, gout, and unspecified diastolic congestive heart failure. Review of a diagnosis report dated 12/8/2022, indicated a diagnosis of major depressive disorder with onset date of 7/21/2020 and bipolar disorder with onset date of 2/15/2021. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated for Sections A (PASRR) (A1500) that R#30 had not currently been considered by the state level II PASRR…

    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 · D2022-12-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, staff interview, and review of the facility policy titled Medication and Treatment Orders the facility failed to ensure that licensed nursing staff accurately documented the medication administration record for one resident (R) of three residents (R#25) reviewed for intravenous (IV) fluids/medications. Specifically, the facility failed to document that R#25 received the IV fluids as per the active physician's order (PO). Findings include: Review of the facility policy titled Medication and Treatment Orders dated 10/19/2017 revealed: Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the electronic medical record (EMR) revealed that R#25 was admitted to the facility on [DATE], with diagnoses that included but not limited to urinary tract infection, falls, osteoarthritis, diabetes, failure to thrive, and dementia. Review of R#25's admission Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition:…

    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

“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

$24,162 in federal fines across 5 penalties.

  • $11,538 — penalty dated 2023-12-11
  • $3,147 — penalty dated 2023-11-20
  • $2,797 — penalty dated 2023-11-13
  • $2,447 — penalty dated 2023-11-06
  • $4,233 — penalty dated 2023-10-10

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 WELLINGTON HEALTH CARE SERVICES — 14 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 2 of 51.9+0.1 vs chain
Health inspection 2 of 52.0≈ chain avg
Staffing 2 of 52.0≈ chain avg
Quality measures 2 of 52.1-0.1 vs chain
The other 13 homes this chain runs (chain average 1.9★, per CMS)

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 / managerTypeRoleShareSince
WELLINGTON HEALTHCARE SERVICES LPOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; LIMITED PARTNERSHIP INTEREST100%since 07/31/2007
ANDWELL INVESTMENTS, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 01/10/2012
ANDREWS, JAMESIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLNO PERCENTAGE PROVIDEDsince 01/10/2012
BAILEY, TERESAIndividualW-2 MANAGING EMPLOYEEsince 07/01/2023
KELMAN, MOSHEIndividualCORPORATE OFFICERsince 07/01/2023
ELKINS ROAD ASSOCIATES LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 07/31/2007

CMS files one row per role, so the 10 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$14.2M
Net patient revenuemost recent cost report
+0.2%
Operating marginrevenue minus expenses
$698K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 11%Other / private 89%

This home reported $698K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

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

Cost & finances

$299per resident / day
operating cost
$9,090per month
≈ monthly operating cost
$300per 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 115771. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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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