Parkside Post Acute And Rehabilitation
3000 Lenora Church Drive, Snellville, GA 30078 · For profit - Limited Liability company · 167 certified beds · (770) 972-2040 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- lower-than-typical staff turnover (27% vs 45% nationally) — better care continuity
- it has 2 actual-harm citations
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,512 in federal fines (most recent 2024-03-24)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
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 | 16.8% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 9.4% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 3.4% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.7% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 11.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.3% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 19.3% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.7% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.9% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.3% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.5% | 15.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 27.4% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.6% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 88.9% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 25.1% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.1% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.85 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.14 | 1.90 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. 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.
43.9% 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.
Met the expected recovery: 54.4% 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 114 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 27% 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 | 43.9%CMS range 37.1–53.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.9%CMS range 8.6–14.8 | 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 | 54.4% | 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 | 60.5% | 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 | 39.5% | 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 | 98.9% | 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 | 100.0% | 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 | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.1% | 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 | 5.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.0%CMS range 4.7–10.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.20 | 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 167 beds and averages 147.4 residents a day — about 88% occupied, or roughly 20 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 3.52 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 3.16 hrs/resident/day on weekends vs 3.67 on weekdays — 14% thinner on weekends. RN hours go from 0.58 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 27% 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
Deficiencies are more than at the previous inspection — worsening. 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.
23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.
- Actual harm · Gcited before2024-03-24 · 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 record review, interviews, and review of policies titled Notification of Resident's Change in Condition, and Laboratory Testing, the facility failed to notify the physician and responsible party (RP) for a change in condition for one of 44 sampled residents (R) (R660). Specifically, facility staff failed to report critical urinalysis lab results for R660, who experienced actual harm on 12/16/2023, resulting in the resident being hospitalized for 11 days with urosepsis (sepsis caused by urinary tract infection) and acute renal failure. Findings include: Review of the policy titled Notification of Resident's Change in Condition revised 9/1/2019 indicated the policy statement as the facility will promptly notify the resident, his or her attending physician, and responsible party of changes in the patient's medical/mental condition and/or status (changes in level of care, billing/payments, resident rights, etc.). Practice Guidelines: Quality of Care - notification of changes - required notifications 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.
- Actual harm · Gcited before2024-03-24 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 provide appropriate treatment and care for one resident (R) (R660) with a severe urinary tract infection (UTI). Abnormal urinalysis (UA) and culture and sensitivity (C&S) results were reported to the facility on [DATE] and the facility failed to seek medication for treatment. Actual Harm occurred on 12/16/2023 when R660 was admitted to the hospital for 11 days with a urinary tract infection and acute renal failure. The sample size was 44. Findings include: Review of the electronic medical record (EMR) revealed R660 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (MS), muscle weakness, and lack of coordination. She was discharged on 12/16/2023. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed R660 was occasionally incontinent of urine and no urinary tract infections 30 days prior to the assessment. Review of the EMR revealed a Progress Note dated 12/9/2023 documented resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-08-07 · 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 observations, staff and resident interviews, record review, and review of the facility's policies titled, Food Storage: Cold Foods and Labeling and Dating, the facility failed to ensure frozen food wrappers were intact and that food items were not expired. This deficient practice had the potential to cause cross contamination of unwrapped meat and foodborne illness affecting 135 of 142 residents receiving meals prepared in the kitchen.Findings include:Review of the facility's policy titled Food Storage: Cold Foods revised February 2023 revealed under Procedures: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.Review of the undated facility policy titled Labeling and Dating revealed under Importance of Labeling and Dating: Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Under Guidelines for Labeling and Dating: Direct…
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 · E2025-08-07 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters, the facility failed to maintain a clean, homelike environment by not ensuring that the PTAC unit filters were free of debris in 2 of 48 rooms (A9, A8 located in A Hall) and failed to ensure PTAC unit grills were free of debris in 1 of 48 rooms (A8 located in A Hall) . The deficient practice had the potential to affect resident comfort, air quality, and infection control.Findings include: Review of the facility policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters”, documented under section titled, Steps, 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to 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 · Ecited before2025-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review and review of facility's policy titled, Water Temperature Policy, the facility failed to keep the residents free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in 8 of 138 resident rooms (A2, A4, E31, E19, E16, E3, B10 and B12 located in A, B, and E Halls ) and in 1 of 3 showers (B Hall). The deficient practice had the potential to cause injury to residents residing in these rooms.Findings include: Review of the facility provided document titled Water Temperature Policy revealed under Policy Statement: Hot water temperature at all resident-use fixtures shall not exceed 110- degrees Fahrenheit per Georgia Administrative Code Rule 111-8-56.18. Physical Plant Standards. Review of the facility's TELS system (maintenance reporting system) and water temperature logs from 1/27/2025 to 8/4/2025 revealed temperatures consistently ranging from 107 degrees F to 108 degrees F in most areas, with the kitchen water temperature recorded at 120 degrees F. Review of resident skin assessments and shower…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-08-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain appropriate infection control practices by not using sterile procedure during tracheostomy care for one of 60 sampled residents (R) (R120), not storing respiratory equipment in an approved container for two of 60 sampled R's (R2 and R5), not protecting shared medical supplies from contamination during wound care for one of 60 sampled R's (R10), by storing personal items on clean linen carts, and by staff not adhering to contact precautions by entering a room with a sign for contact precautions without proper PPE (personal protective equipment). The deficient practices had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors.Findings include: A review of the facility's policy titled Infection Prevention and Control Program, dated June 2025 revealed under Policy Statement: Facility’s…
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 · D2025-08-07 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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's policy titled, Preadmission Screening and Annual Resident Review (PASARR) Policy, the facility failed to obtain a level II PASARR screening for one of 60 sampled residents (R) (R41). The deficient practice had the potential to prevent R41 of achieving the highest practicable mental, physical, and psychosocial well-being.Findings include:Review of the facility's policy titled Preadmission Screening and Annual Resident Review (PASARR) Policy revised 5/15/2025 revealed in the section titled Policy Statement: It is the policy of this facility to screen all potential admissions on an individualized basis. As part of the preadmission process, this facility participates in the Preadmission Screening and Resident Review (PASARR) screening process (Level ll (follow your state recommended guidelines or specific state criteria for PASARR) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-07 · 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 observations, record review, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to follow physician orders for two of 60 sampled residents (R). Specifically, the facility failed to follow physician orders related to colostomy care for R90 and administration of medications for R122. The deficient practice had the potential to compromise the residents' health and safety.Findings include: Review of the facility policy titled Administration of Medications dated June 2025 documented under Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Under section Procedure: .3. Medications must be administered in accordance with the orders, including any required time frame. 1. Review of R90's electronic medical record (EMR) revealed he was admitted to the facility with diagnoses including but not limited to hypertensive heart disease with heart failure, acute systolic (congestive) heart failure,…
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 before2025-08-07 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 facility policies titled Urinary Catheter Care, Anchoring and Changing, the facility failed to provide proper catheter care and positioning for one of 16 residents (R) (R71). Specifically, staff failed to provide correct cleaning and failed to ensure the catheter drainage bag was properly positioned. The deficient practice had the potential to cause pain, trauma to the urethra, catheter-associated urinary tract infections (CAUTIs), and impaired drainage.Findings include:Review of the facility policy titled Urinary Catheter Care, Anchoring and Changing revised March 2024 revealed under section 10: .10. For the male resident, .cleanse the meatus outward., and section 16 revealed: .16. Secure foley catheter drainage bag below level of bladder and above the floor. Catheter drainage bags will be covered when residents are in a public area.Review of the electronic medical record (EMR) revealed R71 was admitted to the facility with…
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 · D2025-08-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Oxygen Therapy Policy, the facility failed to obtain a physician's order for oxygen (O2) for one of 12 residents (R) (R165) and failed to ensure that O2 was administered as ordered for one of 12 Rs (R120) who use O2. This deficient practice had the potential to cause respiratory complications and inadequate oxygenation.Findings include: Review of the policy titled Oxygen Therapy Policy revised 4/1/2025 revealed under Standard of Practice: 1. Oxygen therapy is to be used with a written order by a physician. 1. Review of the electronic medical record (EMR) revealed R165 was admitted to the facility with diagnoses including but not limited to malignant neoplasm of the glottis, tracheostomy, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD). There was no completed Minimum Data Set (MDS) assessment for R165 at time of survey. The care plan for R165 did not include any…
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 before2025-08-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, staff interviews, and review of the facility policies titled, Storage of Medications and Biologicals and Administration of Medications, the facility failed to ensure the secure storage of medications by not locking medication carts when unattended for one of six medication carts. The deficient practice had the potential to allow residents, unauthorized staff, or visitors to access medications and biologicals, or to tamper with items stored on the cart.Findings include: Review of the facility's policy titled Storage of Medications and Biologicals reviewed April 2025, revealed under Policy Statement: The facility shall ensure medications and biologicals are stored appropriately and securely at any given time. Review of the facility's policy titled Administration of Medications reviewed June 2025 revealed under Procedure: .16. The medication cart should be locked at all times. 1. Observation and interview on 8/6/2025 at 11:19 am revealed a medication cart was left open and unattended in Hallway AI with no nurse in sight. When a staff member was asked who the cart…
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 · D2025-08-07 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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, resident and staff interviews, and review of the facility policy titled, Administration of Medications, the facility failed to document medication administration for 2 of 60 sampled residents (R) (R122 and R102. This deficient practice created an inaccurate record of care and services provided to the residents which had the potential to affect continuity of care.Findings include:1. Review of the facility policy titled Administration of Medications dated June 2025 documented under Procedure: .5. Each time you administer a medication, you need to be sure to have the right documentation. Under Procedure: .10. The individual administering the medication must initial the resident's electronic medication administration on the appropriate line entry after giving each medication and before administering the next ones, or document in wet ink the administration of medication.11. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering 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.
Show the remaining 11 citations
- Potential for harm · D2024-03-24 · 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 observations, record review, staff interview, and review of the policies titled Care Plan Policy and Smoking Policy for Residents, the facility failed to develop a care plan for three of 44 sampled residents (R) R108 for Post-Traumatic Stress Disorder (PTSD), R116 for dementia, and R126 for smoking. Findings include: Review of the facility's Care Plan Policy, reviewed 10/25/2022, revealed the policy is that each resident would have a plan of care to identify problems, needs, and strengths that would identify how the facility staff would provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standards of Practice: Number 2. A care plan to identify past trauma would be developed through input of the resident and/or resident representative to prevent re-traumatization to the resident. Number 10. Areas of concern or potential concern and residents' strengths would be addressed with measurable goals and specific person-centered approaches to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of the facility's Holiday Newsletter, policy titled Cleaning and Disinfecting Residents' Rooms, and the Material Safety Data Sheet (MSDS) for Rapid Multi Surface Disinfectant Cleaner, the facility failed to ensure the environment was free from potential accident hazards. Specifically, R2 had an electrical power strip lying in the bed with her, providing electrical to multiple devices. In addition, the facility failed to ensure a chemical spray bottle with cleaning solution was properly stored while not in use placing R82 at risk for exposure to the chemical. The sample size was 44. Findings include: Review of the facility's Holiday Newsletter Volume 5 Edition 12 dated December 2022, indicated extension cords are NEVER allowed in the facility. Extension cords are prohibited, except when used on a portable appliance, such as a vacuum cleaner. NFPA 70 440.8; IFC 605.4. Review of the policy titled Cleaning and Disinfecting Residents' Rooms reviewed…
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 before2022-04-01 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policies titled, Hand Washing/Hand Hygiene Policy and, Perineal (Skin) Care for Incontinent Resident, the facility failed to implement an effective Infection Control Program to prevent the development and transmission of communicable diseases and infection. Specifically, the nursing staff failed to offer and/or encourage hand hygiene for residents during meal delivery by four of four staff members observed delivering meals; housekeeping staff failed to perform hand hygiene between resident rooms and between glove changes on one of five halls (A Hall); and nursing staff failed to change gloves and perform hand hygiene when going from dirty to clean during incontinent care for one of two sampled residents (R#90) reviewed for incontinent care. The census was 153. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, updated…
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 before2022-04-01 · 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 record review, staff interviews, and review of the facility policy titled, Notification of Resident's Change in Condition, the facility failed to ensure the physician was immediately notified when resident (R) R#32, complained of pain following a fall for one of three residents reviewed for falls. Findings include: Review of the facility policy titled, Notification of Resident's Change in Condition, revised September 1, 2019, indicated, Standards: This facility will promptly notify the resident, his or her attending physician, and Responsible Party of changes in the patient's medical/mental condition and/or status. Action: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been: a. An accident or incident involving the patient. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#32's Brief Interview for Mental Status (BIMS) score was nine, indicating moderate cognitive impairment. Resident required supervision with one-person…
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 · D2022-04-01 · 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 observations, record review, and interviews, the facility failed to ensure showers were regularly provided as scheduled and facial hair was removed when needed for one resident (R) #58 of three sampled residents reviewed for activities of daily living (ADLs). Findings include: Review of the admission Record revealed R#58 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and essential hypertension. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#58 was moderately impaired in cognitive skills for daily decision-making per staff assessment for mental status. R#58 was dependent on two-plus person physical assistance for bathing and required extensive assistance of one person for personal hygiene, including shaving. Review of the care plan, revised 8/17/21, revealed a goal to have R#58's ADL needs met. The interventions indicated the resident was totally dependent on one staff member to provide a bath/shower and was totally dependent 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 · Dcited before2022-04-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure causative factors for falls were investigated and documented, interventions were developed and implemented to address the causative factors, and care planned interventions to prevent falls were consistently implemented for one resident (R) R#46, of three sampled residents reviewed for falls. Findings include: Review of the facility policy titled, Fall Prevention Protocol Policy, dated 9/1/18, revealed 4. After an incident of a fall: a. Complete the Post Fall Risk Assessment; b. Notify MD [medical doctor] and Resident Representative; c. Start neuro [neurological] check if there is a suspected head injury or for an unwitnessed fall as per facility protocol; d. Complete pain assessment after the fall; e. Fall placed on the 24-hour report; f. Refer to therapy or restorative nursing as deemed appropriate; g. Referrals, interventions, care plan updated completed in the clinical meeting; and h. Review fall…
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 · D2022-04-01 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 policies titled, Physician Order Review Process and Medication and Treatment Orders, the facility failed to ensure a psychiatric consultation was provided in accordance with the physician's order for one resident (R) R#7, of five residents reviewed for unnecessary medications. Findings include: Review of the facility policies titled, Physician Order Review Process dated 9/1/2018, and Medication and Treatment Orders dated 11/28/2017, revealed the policies did not specifically address the facility's process for following physician orders for psychiatric consults. Review of the admission Record revealed R#7 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting left dominant side, diabetes, hypertension (HTN), dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R#7 had a Brief…
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 · D2022-04-01 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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 observations, record review, staff interviews, and review of a facility policy titled, Controlled Substances, the facility failed to ensure controlled substances were accurately documented on a destruction form for 4 of 59 controlled substances reviewed. Findings include: A review of the facility's policy titled, Controlled Substances, revised [DATE], indicated Standards: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Number 14. Controlled medications remaining in the facility after the order has been discontinued or expired are retained in the facility in a securely locked area with restricted access until destroyed by two licensed clinicians or as otherwise directed by state regulation. Interview on [DATE] at 3:08 p.m. with the Director of Nursing (DON), stated Schedule II controlled medications were double locked in the DON's office. Per the DON, the pharmacist came…
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 · D2022-04-01 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 interview, and review of the facility policy titled, Pharmacy Services Overview, the facility failed to follow the consultant pharmacist's recommendations related to an as-needed (PRN) antianxiety medication order for one of five resident's (R) R#7, reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Pharmacy Services Overview, dated 9/1/2018 revealed, The facility shall contract with a licensed pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director: a. reviews each resident's medical chart during each monthly drug regimen review. b. The pharmacist consultant must report any irregularities to the attending physician and the facility's Medical Director and Director of Nursing, and these reports must be acted…
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 · D2022-04-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of facility policies, the facility failed to ensure psychotropic medications including antipsychotic and antianxiety medications were not ordered as needed (PRN) beyond 14 days, failed to document the rationale in the resident's medical record and indicate the duration for the PRN order for two of five sampled residents (R) R#102 and R#7; and failed to provide consistent documentation of target behaviors and potential side effects of psychotropic medications for two of five sampled residents (R) R#102 and R#7, reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Antipsychotic Medication Use, revised December 2020, revealed Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: a. schizophrenia; b. schizo-affective disorder; c. schizophreniform disorder; d. delusional disorder; e. mood disorders (e.g. [for example], bipolar disorder, depression with psychotic…
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 before2022-04-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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, staff interviews, and review of a facility policy, the facility failed to ensure medication carts were locked when not attended for one of six medication carts. The census was 153. Findings include: Review of the facility's policy titled, Storage of Medications and Biologicals, dated September 1, 2018, indicated, Standards: The facility shall ensure that the medications and biologicals are stored appropriately and securely at any given time. 5. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. All Medication, Treatment carts must be secured/locked when not attended by licensed staff. Observations on 3/29/2022 from 12:22 p.m. to 12:25 p.m. revealed an unlocked medication cart directly across from Room A1. The medication cart was unattended at this time. At 12:23 p.m., two maintenance employees walked by the cart at the same time, in opposite directions. At 12:24 p.m., a cognitively impaired resident in 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.
“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
$8,512 in federal fines across 2 penalties.
- $4,256 — penalty dated 2024-03-24
- $4,256 — penalty dated 2024-03-24
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 3 of 5 | 2.0 | +1.0 vs chain |
| Quality measures | 1 of 5 | 2.1 | -1.1 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| WHS APS HOLDING COMPANY II, LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2018 |
| ANDWELL INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| PARKWELL INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| STAFFWELL INVESTMENTS, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| WELLINGTON HEALTHCARE SERVICES- APS I, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| WHS APS HOLDING COMPANY I, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 09/01/2018 |
| ANDREWS, JAMES | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 08/30/2018 |
| STAFFORD, ANNETTE | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 08/30/2018 |
| WEST, LINDA | Individual | W-2 MANAGING EMPLOYEE | — | since 09/01/2018 |
| PARKER, SCOTT | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/30/2018 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $921K 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
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 115643. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-07, 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.