Woods at Sparta of Journey LLC, The
60 Providence Street, Sparta, GA 31087 · For profit - Corporation · 71 certified beds · (706) 444-5153 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,325 in federal fines (most recent 2024-08-11)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (1/5)
- about 21% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 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.
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 | 26.6% | 15.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.2% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 3.0% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 25.4% | 11.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 8.4% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.6% | 15.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 29.4% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 17.5% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 41.7% | 19.9% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 21.5% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 16.1% | 11.6% | 12.0% | worse |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.03 therapist hours per resident per day in 2026Q1 — more than 1% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 12% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 71 beds and averages 40.2 residents a day — about 57% occupied, or roughly 31 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.00 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.79 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 2.35 hrs/resident/day on weekends vs 3.26 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.41 to 0.08 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
21 citations, most serious first. The 12 most serious are shown; the remaining 9 are one tap away and print in full.
- Actual harm · G2024-08-11 · 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
Based on record review, staff and resident interviews, review of the facility policy titled, Incidents and Accidents, facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, and Operational Manual, the facility failed to ensure three of 19 sampled residents (R) (R14, R15, R30) were free of accidents and hazards. Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an electrical stimulation (e-stim) treatment (a device that sends electrical impulses through electrodes attached to the skin to help with physical therapy and fitness) treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Additionally, the facility failed to ensure resident's (R) (R14), (R15), and (R30) safety by having power strips maintained on the floor and bedside table while being utilized with medical equipment. Findings include: A review of the facility's undated policy titled Incidents and Accidents, revealed it is the policy of the facility for staff to report, investigate, and review any accidents or incidents that…
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 · G2024-08-11 · tag F0940 — failed to train staff — isolatedDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and a review of the facility's Facility Assessment, the facility failed to ensure the physical therapy staff were informed or educated prior to applying an electronic medical device for electrical stimulation treatment (also known as e-stim, which is a treatment method often used in physical therapy and pain management to deliver mild electrical currents through the patient's skin to either target the muscles to stimulate quicker recovery or the nerves to reduce pain) for one of one resident (R) (R 14). Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an e-stim treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Findings include: A review of the Facility Assessment, dated 8/8/2024, revealed Purpose Statement: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.…
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 before2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure sanitary conditions in the kitchen. This deficient practice had the potential to place the 37 residents who received food or nutrition from the kitchen at increased risk of foodborne illness. Findings include:Review of the facility's policy titled Food Safety Requirements, reviewed 7/2025, revealed the Definition section included, Contamination means the unintended presence of potentially harmful substances, including, but not limited to, microorganisms, chemicals, or physical objects.Observation on 12/9/2025 at 9:30 am with the Dietary Manager (DM) in the kitchen revealed one window-unit air conditioner (AC) located above a countertop with a dish rack containing silverware and another containing cups. Observation revealed the AC unit had a buildup of grey, fuzzy substance and black, flaky substance on the vents. The AC unit was turned on and blowing across the racks of dishes. The DM confirmed the findings. Observation on 12/9/2025 at 12:50 pm…
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 before2025-12-11 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility failed to ensure that one resident (R) (R35) with a qualifying diagnosis, from a sample of 28 residents, was referred to the appropriate state-designated authority for Level II PASRR (Preadmission Screening and Resident Review). This deficient practice had the potential to place R35 at risk of not having her mental and psychological care needs met. Findings include:Review of the admission Record for R35 revealed diagnoses including, but not limited to, major depressive disorder, dated 10/15/2018, anxiety disorder, dated 10/15/2018, and Post Traumatic Stress Disorder (PTSD), dated 8/22/2024. Further review revealed no diagnosis of dementia or Alzheimer's disease. Review of the Annual Minimum Data Set (MDS) assessment for R35, dated 8/7/2025, revealed that Section A (Identification Information) documented that the resident was not currently considered by the state-level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Section C (Cognitive Patterns) documented 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 · Fcited before2024-08-11 · 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 interviews, and review of the facility policies titled Manual Warewashing-3 Compartment Sink and Food Receiving and Storage, the dietary staff failed to prevent wet nesting with stacks of steam table pans to prevent bacteria growth, failed to store food items off the floor in the dry storage area, and failed to demonstrate the proper usage of the three compartment sink to prevent cross-contamination. The deficient practices had the potential to place 40 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings include: 1. A review of the facility's undated policy titled Manual Warewashing-3 Compartment Sink revealed the sanitizing procedures for three-compartment sink included to allow pots/utensils to air dry and store pots upside down or covered. Observation on 8/9/2024 at 8:50 am revealed four stacks of steam table pan on a shelf under the steam team. A stack with four square pans were pulled apart which revealed the inside of the top pan was wet with water. Continued observation revealed a stack 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 · F2024-08-11 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and staff interviews, the facility failed to properly maintain one of two dumpsters to prevent leakage onto the ground. The facility census was 40 residents. Findings include: Observation on 8/9/2024 at 9:00 am of the dumpster area revealed that the facility had two medium-sized dumpsters located on asphalt behind the building. The dumpster closest to the building was missing the plug located towards the bottom of the dumpster. Continued observation of this dumpster revealed a liquid substance actively dripping from the unplugged hole. During an interview on 8/9/2024 at 9:00 am, the Dietary Manager (DM) confirmed that no plug was in place at the bottom of the dumpster. The DM also confirmed that the unplugged hole was actively dripping a liquid substance onto the asphalt ground. Observation on 8/10/2024 at 9:00 am of the dumpster closest to the building revealed that the plug at the bottom was still not in place. In an interview on 8/10/ 2024 at 9:00 am, the DM confirmed that the dumpster continued to have no bottom plug in place. Observation on 8/11/2024 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.
- Potential for harm · F2024-08-11 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility's policies titled Infection Prevention and Control Program and Laundry Services, the facility failed to maintain an effective infection control program by failing to ensure infection control policies were followed during the handling, storage, and processing of linens. In addition, the laundry staff failed to ensure the washing machine was clean and free from chemical deposits, dust, and lint. These failures had the potential to spread infection due to cross-contamination to 40 residents residing in the facility. Findings include: A review of the facility's policy titled Infection Prevention and Control Program, reviewed and revised 1/9/2024, revealed the facility had established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. The Policy Explanation and Compliance Guidelines section included: 12.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · 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
Based on staff interview, record review, and a review of the facility policy titled Notification of Changes, the facility failed to timely notify the health agent of a significant change related to a burn for one of 18 sampled Residents (R) (R14). This deficient practice places the resident at risk for complications such as infection and further deterioration of the burn wound. Findings Include: A review of the facility's undated policy titled Notification of Changes, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. b. Potential to require physician interventions. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative if known. Record review of the quarterly Minimum Data Set (MDS) for R14 dated 6/12/2024 revealed a Brief Interview of Mental Status (BIMS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and a review of the facility policies titled Maintenance Inspection and Preventative Maintenance Program, the facility failed to ensure a safe, clean, comfortable home-like environment in four of 29 resident rooms (Rooms 111, 113, 102, and 302) and one common area (the Resident Dining Room). The deficient practices placed residents at risk of living in an unsanitary and unsafe living environment and the potential for diminished quality of life. Findings include: A review of the facility's undated policy titled Maintenance Inspection, revealed the Policy of The facility would be maintained to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. A review of the facility's undated policy titled Preventative Maintenance Program revealed the Policy of A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure pre-employment screenings, specifically reference checks, were conducted prior to employment for eight of 60 employees. This deficient practice had the potential to place residents residing in the facility at risk of abuse, neglect, and exploitation from staff. The census was 40 residents. Findings include: A review of the facility policy titled Abuse, Neglect, and Exploitation, dated 8/1/2024, revealed the Policy was It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. The section titled Screening documented A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · tag F0644 — isolatedCoordinate 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 staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure two of four residents (R) (R34 and R35) reviewed with a serious mental disorder (MD) were referred for a Level II PASARR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R34 and R35. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 1/9/2024, revealed the Policy was This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. 1. A review of the electronic medical record (EMR) revealed that R34 was admitted to the facility…
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 before2024-08-11 · 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 staff interviews, record review, and review of the facility policy titled Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure one of four residents (R) (R19) reviewed with a serious mental disorder (MD) was referred for a Level II PASRR assessment on admission or within 30 days of a new diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R19. Findings include: A review of the facility policy titled Resident Assessment-Coordination with PASARR Program, dated 1/9/2024, revealed the Policy was This facility coordinates assessments with the PASARR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance Guidelines section included .6. The Social Services Director shall 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.
Show the remaining 9 citations
- Potential for harm · Dcited before2024-08-11 · 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
Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop or implement a comprehensive, person-centered care plan for two of 19 sampled residents (R) (R14 and R15). Specifically, the facility failed to develop a care plan for pain management for R14 and implement a care plan for oxygen therapy for R15. The deficient practice had the potential to place R14 and R15 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans revealed the Policy stated, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment 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.
- Potential for harm · D2024-08-11 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the facility policy titled Comprehensive Care Plans, the facility failed to revise the care plan for one resident (R) (R3) who had a change in code status. The sample size was 19. Findings include: A review of the facility's undated policy titled Comprehensive Care Plans, revealed the comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. A review of R3's MDS assessments revealed the quarterly MDS assessment was completed on [DATE]. A review of the physician orders dated [DATE] revealed that R3's code status was Do Not Resuscitate (DNR). A review of the Physician Orders for Life-Sustaining Treatment (POLST) document dated [DATE] revealed that R3 had a change in code status from DNR to Allow for Natural Death. A review of R3's care plan revealed the resident was care planned for Full Code status, which indicated the staff was to honor the resident's wish…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · 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 interviews, record review, and a review of the facility policies titled, Oxygen Administration and Nebulizer Therapy, the facility failed to provide respiratory care consistent with professional standards of practice for two of five residents (R) reviewed for respiratory services (R15 and R30). Specifically, the facility failed to ensure oxygen (O2) was administered as ordered for R15 and failed to properly store the nebulizer mouthpiece, when not in use, for R30. The deficient practices had the potential to cause respiratory distress for R15 and respiratory infection for R30. Findings include: A review of the facility's undated policy titled Oxygen Administration revealed the Policy Explanation and Compliance Guidelines section included: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. 5. Other infection control measures include: e. Keep delivery devices covered in a plastic bag when not in use. A review of the facility's undated policy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · 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
Based on record review, staff interview, and review of the facility policy titled Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one of six residents (R) reviewed for unnecessary medications (R3). Findings include: A review of the facility's undated policy titled Use of Psychotropic Medication revealed as needed (PRN) psychotropic drugs should be used only when necessary and for a limited duration. If the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, they would document the rationale in the resident's medical record and indicate the duration of the PRN order. A review of R3's physician orders dated 5/30/2024 revealed an order for 0.5 milligrams (mg) of Ativan (a psychotropic medication used to treat anxiety) by mouth every four hours as needed for anxiety. The order had an indefinite end date. A review of the Medication Administration Record (MAR) revealed R3 was administered Ativan 0.5 mg by mouth 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 · D2024-08-11 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, review of facility menus, and review of the facility policy titled Therapeutic Diet Orders, the facility failed to follow established menus posted to ensure the appropriate nutrition was provided to residents. In addition, the facility also failed to notify the Registered Dietitian (RD) of meal/menu substitutions. This deficient practice affected three residents receiving a mechanical soft ground diet and six residents receiving a puree diet, from 40 residents consuming an oral diet. Findings include: A review of the facility policy titled Therapeutic Diet Orders revealed that the facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. A review of the main resident menu and the Diet Spread Sheet revealed the posted lunch meal for all diet consistencies was fried chicken, black eye peas, collard greens, cornbread, and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-11 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, review of the posted menu, review of the recipe for puree fried chicken, and review of the facility policy titled Food Preparation Guidelines, the dietary staff failed to follow the recipe for fried chicken as printed, compromising the nutrient value. This deficient practice affected six residents who received puree consistency and three residents who received mechanical soft ground consistency from 40 residents receiving an oral diet. Findings include: A review of the resident menu revealed lunch meal to be served included fried chicken, blackeye peas, collard greens, cornbread, and cake. A review of the recipe for Chicken Fried Pureed Thick revealed the ingredients listed were fried chicken, low sodium chicken base, hot water, and food thickener. A review of the facility policy titled Food Preparation Guidelines revealed the cook or designee shall prepare menu items following the facility's written menus and standardized recipes. Foods shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes but is not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-07-27 · 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 interviews, record review, and review of the facility policy titled Labeling and Dating Guidelines, the facility failed to discard expired foods in the dry goods storage room and refrigerator. In addition, the facility failed to clean and secure overhead vents in the kitchen. These failures had the potential to promote foodborne illnesses associated with bacterial growth and cross contamination for 45 of 46 residents consuming an oral diet. Findings include: Review of the facility policy titled Labeling and Dating Guidelines not dated revealed: Upon receipt, all items must have a received date and an expiration date. Upon opening, all items must have an open date and a use by date. Observation on 7/25/2023 at 8:50 a.m. of the kitchen refrigerator revealed: An open box of cubed potatoes that was not labeled with content, no expiration date, no open date or use by date on bag. A bottle of ranch dressing with an open sticker of 6/17/2023 that indicated to use within 30 days after opening. A jar of [NAME] sauce with an open sticker dated 7/1/2023 without 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.
- Potential for harm · Dcited before2023-07-27 · 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 — the official record, unedited, may be distressing
Based on observation, staff interview, and record review, the facility failed to complete an oxygen (O2) therapy care plan for one of 21 Residents (R) (R#2) receiving O2 therapy. This failure had the potential for residents to not receive treatment and/or care according to their needs. Findings include: Observation on 07/25/2023 at 10:30 a.m. of R#2 wearing a nasal cannula for oxygen therapy. His oxygen concentrator was properly dated 7/24/2023 by his bedside at an O2 level of 2.5 liters per minute (LPM). A review of the physician orders dated 7/5/2023 revealed an order for O2 at two-four LPM as needed for low 02 Saturation 89% below every 24 hours. A review of the care plan revised on 7/17/2023 did not include a focus area or interventions for oxygen therapy. Interview on 7/27/2023 at 10:15 a.m. with Registered Nurse (RN) CC verified the physician's orders for O2 at two-four LPM to be administered to the resident. RN CC confirmed that the O2 therapy should be on the care plan. She verified that there was no O2 therapy care plan in place and added it while being interviewed.
- Potential for harm · D2023-07-27 · 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
Based on observations, staff, and resident interviews the facility failed to provide ADL care related to showers for one of 21 Residents (R) (#40) reviewed for showers. This failure had the potential to decrease the quality of life related to the unmet needs of the resident. Findings include: Requested the policy for Activities of Daily Living (ADL) care from the Administrator and Director of Nursing (DON); however, the facility did not provide a policy for ADL care. A review of the bathing schedule revealed resident is scheduled for Monday/Wednesday/Friday on the Day shift 7 a.m. - 7 p.m. shift. A review of the Bathing log revealed no baths/showers for the Month of July; all scheduled days were blank. Observation and interview on 07/25/2023 at 10:39 a.m. revealed R#40 Brief Interview Mental Status (BIMS) 13 had long facial hair on the mustache area and chin, and his long facial hair was noted to be touching the top of his chest. He stated that receiving his bath has been his biggest complaint. He expresses that his beard is so long due to the facility not providing him a shower or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$13,325 in federal fines across 2 penalties.
- $6,500 — penalty dated 2024-08-11
- $6,825 — penalty dated 2024-08-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
About 89% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $540K paid to related parties — landlords or management companies under common ownership — equal to about 21% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in GA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115397. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.