Harborview Health Systems Thomaston
310 Avenue F, Thomaston, GA 30286 · For profit - Limited Liability company · 119 certified beds · (706) 647-6676 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (35% vs 45% nationally) — better care continuity
- 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 (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
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 | 2 of 5 |
| Long-stay residentspeople who live here | 2 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 improved from 1 to 3 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 | 10.9% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 13.0% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.2% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 5.2% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 36.4% | 11.3% | 6.5% | check this† — see note marked dagger 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 | 2.1% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 20.4% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.1% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 99.1% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.4% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.6% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 23.0% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 4.0% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 98.4% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.7% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 7.9% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.60 | 2.15 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.66 | 1.90 | 1.80 | typical |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.4% 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 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 39 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 0.13 therapist hours per resident per day in 2026Q1 — more than 10% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 33% 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 | 48.4%CMS range 36.8–63.3 | 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 | 9.9%CMS range 6.7–14.6 | 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 | 46.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 41.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 30.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 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 | 0.0% | 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 | 7.3% | 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 | 6.2%CMS range 3.4–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 119 beds and averages 106.4 residents a day — about 89% occupied, or roughly 13 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 3.19 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.68 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 2.69 hrs/resident/day on weekends vs 3.38 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.37 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 35% is below the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.
- Potential for harm · Fcited before2025-07-02 · 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's policy titled Food Receiving and Storage, the facility failed to ensure that opened food items were dated and failed to discard food items after the best if used by date in the walk-in refrigerator. This deficient practice had the potential to place the 101 residents receiving an oral diet from the kitchen at risk of foodborne illness.Findings include:Review of the facility's policy titled Food Receiving and Storage revealed the Policy Statement section stated, Food shall be stored in a manner that complies with safe food handling practices. The Policy Interpretation and Implementation section included, 1. Food Services, or other designated staff, will always maintain clean food storage areas. 2. When food is delivered to the facility, it will be inspected for safe transport and quality before being accepted. 6. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).Observation on 6/30/2025 at 9:45 am of the walk-in freezer revealed several food items were not labeled…
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 · E2025-07-02 · tag F0761 — failed to label and store drugs safely — patternEnsure 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, record review, staff interviews and review of the facility's policies titled Medication Administration and Medication Storage, the facility failed to place open dates on one container of glucometer strips on each of the 100 and 300 Hall medication carts, and failed to remove one expired inhaler from the 100 Hall medication cart. The facility's census was 105. The facility's census was 105. Findings include: Review of the facility's policy titled Medication Administration, reviewed 6/1/2024, documented Policy: Medications are administered In accordance with professional standards of practice . Policy Explanation and Compliance Guidance: 13. Identify expiration date. If expired, notify the manager.Review of the facility's policy titled Medication Storage, reviewed 3/1/2025, documented Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations . Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-02 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each 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 observations, record reviews, residents and staff interviews, and review of the facility policy titled Resident Rights, the facility failed to accommodate the needs of one of 42 sampled residents (R) (R8). This deficient practice had the potential to place R8 at risk of not attaining or maintaining her highest practicable physical, mental, and psychosocial well-being. Findings include: Review of the policy titled Resident Rights, revised 2/1/2025, included the facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility.The facility will also provide the residents with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. 5. Self-determination. The resident has the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-03 · tag F0921 — failed to keep a safe, functional, sanitary building — patternMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled, Cleaning Cycle, the facility failed to provide a safe, clean, and comfortable environment in three of six units of the facility (Unit 400, Unit 500, and Unit 600). Specifically, the facility failed to maintain an environment free of a strong odor of urine in resident rooms, bathrooms, and unit hallways. This deficient practice had the potential to place residents at risk of living in an unsanitary living environment and a potential for diminished quality of life. Findings include: A review of the facility's policy titled, Cleaning Cycle, dated revised 3/1/2024, stated, The frequency of cleaning and disinfection of the facility environment may vary according to the: a. Type of surface to be cleaned. b. The number of individuals in the area. c. Amount of activity in the area. d. Risk to residents. e. Amount of soiling. In addition, the policy stated, The Environmental Services Manager is responsible to ensure that cycle cleaning…
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 · D2024-10-03 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record reviews, and review of the facility policy titled Medication Administration, the facility failed to provide medications according to physician orders and in accordance with professional standards for one of three sampled residents (R) (R14) observed during the medication pass. This failure has the potential to place R14 at risk of inadequate medication effectiveness due to improper administration of medication. Findings include: A review of the facility's policy and procedure titled, Medication Administration, dated 6/1/2024, indicated: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 12) Compare medication source (bubble pack, vial, etc.) with MAR [Medication Administration Record] to verify resident name, medication name, form, dose, route, and time . b. Administer within 60…
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 before2024-10-03 · 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 observation, resident and staff interview, record review, and review of the facility policy titled Activities of Daily Living (ADLs), the facility failed to ensure that one of 15 sampled residents (R) (R8) received necessary assistance with incontinent care. This deficient practice placed R8 at risk for unmet needs and a diminished quality of life. Findings include: Review of the facility's policy titled Activities of Daily Living (ADLs), last revised 3/1/2023, revealed .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; .3. Toileting; .Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility will maintain individual objectives of the care plan and periodic review and evaluation. 1. Review of R8's clinical record revealed diagnoses included diabetes…
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 · D2024-10-03 · tag F0745 — failed to provide medically-related social services — isolatedProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 Social Services, the facility failed to ensure that medically related social services were provided to one of 15 sampled residents (R) (R9) who exhibited behavioral issues. This deficient practice had the potential for R9 not to receive the appropriate treatment and services, preventing R9 from maintaining their highest level of functioning and enhancing their well-being. Findings include: Review of the facility's policy titled Social Services, last revised on 3/1/2024, noted, Policy: The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Definitions: 'Medically-related social services' are services provided by the facility's staff to assist residents in attainment or maintenance of a resident's highest practicable well-being. Policy Explanation and Compliance Guidelines: .3. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-01 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 a review of the facility policy titled, Food Receiving and Storage, and Pot and Pan Washing and Sanitation; Manual Warewashing and Sanitation, revealed the facility failed to ensure opened food was dated, labeled, and sealed, ensure storage was free of dented cans, and drying containers were not stacked wet. This had the potential to affect 105 of 107 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: A review of the facility's undated policy titled Food Receiving and Storage, revealed 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). A review of the facility's undated policy titled Pot and Pan Washing and Sanitation; Manual Warewashing and Sanitation, revealed 5. Air-dry pots and pans on the drain board . During an initial tour of the kitchen on 08/29/2023 at 9:05 a.m., with the Administrator present, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policy titled, Call Lights: Accessibility and Timely Response, the facility failed to accommodate the need of a special call system for one Resident (R) (#27) of 32 residents reviewed for call light accommodation needs. Specifically, R27 was unable to push the call bell light to call for assistance if desired. Findings include: Review of the facility's policy titled, Call Lights: Accessibility and Timely Response dated, 1/1/2023 revealed the following: .Each resident will be evaluated for unique preferences and needs to determine any special accommodations that may be needed for the resident to utilize the call system . Review of R27 Face Sheet undated, located in the electronic medical record (EMR) under the Profile tab, indicated R27 was admitted with diagnoses including but not limited to cerebrovascular disease with hemiplegia and hemiparesis and contractures. Review of R27's significant change Minimum Data Set (MDS) located in R27's EMR under the MDS tab, with an Assessment Reference Date (ARD) 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 · Dcited before2023-09-01 · 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
Based on observation, interviews, and record review, the facility failed to ensure that one of one Residents (R) (#9) with the diagnosis of Post Traumatic Stress Disorder (PTSD) received assistance with eating, getting dressed, and getting out of bed for the highest level of care in accordance with his care plan preferences from sampled 32 residents. Findings include: Observation on 08/29/2023 at 10:55 a.m. revealed R#9 in bed with head of bed (HOB) 45 degrees. The resident was wearing a hospital gown, call light on side rail within reach. Resident was unshaven with breakfast food remanent on face, chest area, and gown. Food remanent appeared to be chocolate crumbs on bedspread. Reacher/grabber equipment on the floor across the room. Observation on 08/29/2023 at 1:28 p.m. revealed resident in bed attempting to feed himself lunch. The head of the bed (HOB) was elevated 90 degrees. The resident had a clean shirt on but had food spillage on the shirt, and no clothing protector in place. The resident's beverages had a plastic covering preventing the resident from drinking. 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 17 citations
- Potential for harm · D2023-09-01 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of the facility's activities calendar, the facility failed to provide stimulating activities for one of one Resident (R) (#9) with a diagnosis of post traumatic stress disorder (PTSD) reviewed from a sampled of 32 residents. This failure has the potential for R#9 to experience signs and symptoms of PTSD. Finding include: Observation on 08/29/2023 at 10:55 a.m. revealed R#9 in bed with head of bed elevated 45 degrees. The resident was wearing a hospital gown, call light on side rail within reach. The resident was unshaven with breakfast food remanent on face, chest area, and gown. Food remanent what appeared to be chocolate crumbs on bedspread. A review of the facility's activities calendar indicated there was an activity in progress in the dining room area. However, there was no activity occurring in the resident's room. During an observation on 08/31/2023 at 10:15 a.m. a staff member was going up and down the hall inviting residents, present in the hallway, to attend activities. However, no staff member entered R#9's room…
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 · D2023-09-01 · 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, staff interview, and review of facility policy titled, Medication Storage the facility failed to ensure that one of four medications carts were locked to prevent resident access to medications. This failure had the potential for any cognitively impaired residents to gain access to medications that could cause them harm. Findings include: Review of facility policy titled Medication Storage dated 3/01/2013 read in part . During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Observation on 8/30/2023 at 8:16 a.m. revealed an unlocked medication cart next to room [ROOM NUMBER]. The cart was out the sight of the nurse. The medication cart was unlocked. A staff member was in the resident's room setting up a breakfast tray. No medications were on the cart, only hand sanitizer and applesauce; however, the drawers to the cart were easily accessible to anyone walking down the hall. Observation…
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 · D2023-09-01 · 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 and interview, the facility failed to maintain the cleanliness of the BiPap (Bilevel Positive Airway Pressure) mask when not in use for one of one Resident (R) (#16) reviewed for BiPap cleanliness of 32 sample residents. This deficient practice increases the risk of infection for a resident requiring BiPap therapy. Findings include: Record review of the undated Face Sheet located in the Electronic Medical Record (EMR) for R#16 under the Profile tab, indicated R16 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia (lack of oxygen), congested heart failure and pneumonia. Record review of the Physician Orders for R#16 located in the EMR under the Orders tab, revealed orders dated 08/01/2023 for BiPap d18 Respiration Pressure 6, Expiratory rate of 14 and FIO2 (fraction of inspired oxygen) 32% wear every night. Observations were conducted on 08/31/2023 at 9:12 a.m., at 10:35 a.m., and at 2:00 p…
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 · D2023-09-01 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and record review, and a review of the facility's policy titled, Medication Administration, the facility failed to ensure timely evaluation of pain medication effectiveness and accurate documentation of pain medication administration consistent with the professional standards of practice for three of 32 Residents (R) (#6, #16 and #74) reviewed for pain. Findings Included: 1. Record review of undated Face Sheet located in the Electronic Medical Record (EMR) for R#6 under the Profile tab, indicated a diagnoses including but not limited to multiple sclerosis and pain. Record review of the most recent quarterly Minimum Data Set (MDS) for R#6 located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 08/12/2023, revealed a score for the Brief Interview for Mental Status (BIMS) 13 out of 15 which indicated R6 was cognitively intact. R#6 was also coded as requiring limited assistance of one staff member for transfers and dressing and supervision for set up help only for personal hygiene. Record review of EMR for R#6 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-01 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, record review, and review of facility policy titled, Medication Administration, the facility failed to ensure a medication error rate below five percent. During medication administration four medication errors for Residents (R) (#67 and #102) were made from 29 opportunities during medication administration. The medication error rate was 13.79 percent. Findings include: A review of the facility policy titled Medication Administration with an implementation date of 01/01/23 read in part .Administer medication as ordered in accordance with manufacturer's specifications. 1. Observation on 08/31/2023 at 7:53 a.m. revealed Licensed Practical Nurse LPN 7 preparing medication for R#102. The following medications were prepared: breo Inhaler 200 micrograms (mcg), Depakote 250milligrams (mg) one tablet (tab) antiepileptic, gabapentin100mg one-tab (anticonvulsant), multivitamins one tab supplement; metoprolol 25 mg extended release one tab antihypertensive; clear laxative one cap full in 240 cc (cubic centimeters/milliliter) water laxative; and senna 8.6…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-07-22 · 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, interview, manufacturer's guidelines, policy review, and document review, the facility failed to ensure: 1. the trash can was functional at the hand washing sink; 2. that all food items in the coolers or refrigerator were labeled to include the date the item was placed in the cooler; 3. the fan used to dry the floor after it was mopped did not have a dusty fan grate and blowing on the stove where food was being prepared; 4. Mighty Shakes were thawed no more than the manufacturer's recommendations; and 5. employee's lunch box and other food items were not store in the residents' pantry refrigerator and freezers. This deficient practice had the potential to affect 105 of 110 residents receiving an oral diet. Findings include: Review of the facility's policy titled, Food Receiving and Storage, dated October 2017, revealed, Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation.1. Food Services, or other designated staff, will maintain clean food storage areas at all…
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 before2022-07-22 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to assist with activities of daily living (ADL), specifically bathing, for nine (Resident (R) 97, R57, R36, R82, R35, R67, R103, R15, and R99) of 34 residents reviewed for ADL care out of a total sample of 37 residents. This failure had the potential to affect the residents' comfort, body image and increases the risk for infections. Findings include: Review of a policy provided by the facility titled Resident Showers, dated 01/01/22, indicated . It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy. 1. Review of R97's electronic medical record (EMR) undated admission Record, located under…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0559 — isolatedHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
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 interview, record review, and policy review, the facility failed to provide evidence that one of one resident (Resident (R) 35) reviewed for room transfers in a total sample of 37 residents was notified of the reason for the transfer and when the transfer would occur prior to being transferred to another room in the facility. Finding include: Review of the facility's policy titled, Room Change/Roommate Assignment: dated 05/2017 indicated, .Policy Interpretation and Implementation .2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives (sponsors)) will be given a _____ hour/day advance notice of such change. 3. Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. 4. Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · 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 observation, interview, record review, and policy review, the facility failed to notify the resident's attending physician when a facility nurse removed the resident's indwelling urinary catheter, did not reinsert the indwelling urinary catheter, and failed to obtain an order to discontinue the use of the indwelling urinary catheter for one of one resident (Resident (R) 82) reviewed for an indwelling urinary catheter in a total sample of 37 residents. Findings include: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated May 2017, indicated Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician .changes in the resident's medical/mental condition and/or status (e.g., changes in level of care .). Policy Interpretation and Implementation 1. The nurse will notify the resident's Attending Physician or physician on call when there has been .e. need to alter the resident's medical treatment significantly; .A significant change 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 · D2022-07-22 · 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, record review, and interview, the facility failed to ensure a safe, clean comfortable and homelike environment as evidenced by damaged walls and doors for four resident rooms (102, 107, 108, and 111). The census was 110. Findings include: On 07/18/22, during the initial facility tour, observed room [ROOM NUMBER], the hall entry door had approximately three inches of split wood on the lower right-hand corner of the faceboard. On 07/18/22, during the initial facility tour, observed room [ROOM NUMBER], which had approximately three inches of split wood on the side of the hallway entry door near the hinges. On 07/18/22, during the initial facility tour, observed room [ROOM NUMBER], which had approximately three inches of split wood on the side of the hallway entry door near the hinges. On 07/18/22, during the initial facility tour, observed room [ROOM NUMBER], which had damage to the wall near the head of bed B. The paint was down to the plaster, and there was an approximately twelve-inch…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on document review, interview, and policy review, the facility failed to provide evidence that an allegation of misappropriation of resident's property had been thoroughly investigated for one of four residents (Resident (R) 210) reviewed for abuse allegations out of a total sample of 37 residents. Findings include: Review of the facility's policy titled, Abuse and Neglect- Clinical Protocol, dated December 2016, revealed .3. Other forms of abuse include: .b. Misappropriation of resident property . and the facility's policy titled, Abuse Investigation and Reporting, dated December 2016, revealed . Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: .c. Interview the person reporting the incident; d. Interview the resident .; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members and visitors; i. Interview other resident to whom the accused employee provides care or services . Review of a Facility Reported Incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure one of four residents and/or their representatives (Residents (R)16) reviewed for discharge to the hospital out of a total of 37 sampled residents were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer or appeal information. This failure has the potential to affect any resident or Resident Representative (RR) in having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer if the resident or RR desired. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, revised August 2018, showed: .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · 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 record review, review of facility policy, and staff interviews, the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and plans for one of 37 sampled residents (Resident (R) R260) reviewed for care plans. Findings include: Review of a policy provided by the facility titled Care Plans, Comprehensive Person-Centered, dated 12/16, indicated . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of a Face Sheet, found in R260's electronic medical record (EMR) under Profile, indicated R260 was admitted on [DATE], with the use of a gastrostomy tube (G-tube through which nutrition/hydration/medication is provided directly into the stomach). Review of a document provided by the facility titled Care Plan, dated 07/08/21, indicated R260 required tube feeding to meet her nutritional and hydration…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
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 facility policy review, the facility failed to assess in a timely manner nutritional status after a significant weight loss for one (Resident (R) 91) of two residents reviewed for nutrition in a total sample of 37 residents. Findings include: Review of a policy provided by the facility titled Weight Assessment and Intervention, dated as revised March 2022, indicated Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss= (usual weight- actual weight)/(usual weight) x 100]: a. 1 month - 5% weight loss is significant: greater than 5% is severe.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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 policy, the facility failed to verify the residual (the amount of fluid left in the resident's stomach) and failed to ensure water flushes were being administered via the resident's G-tube for one (Resident (R) 260) of two residents reviewed for gastrostomy tube (G-tube) out of a total sample of 37 residents. This deficient practice had the potential to place R260 at risk for inadequate nutritional intake and potential dehydration. Findings include: Review of a policy provided by the facility titled Enteral Nutrition, dated 11/18, indicated Adequate nutritional support through enteral nutrition is provided to residents as ordered.The nurse confirms that orders for enteral nutrition are complete. Complete orders include.The enteral nutrition product.Instructions for flushing (solution, volume, frequency, timing and 24-hour volume) .The provider will consider the need for supplemental orders, including. Checks for gastric residual volume (GRV).…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · 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 interview, record review, and policy review, the facility failed to ensure that a resident's physician ordered medication was available in the facility and could be dispensed at the designated time for one resident (Resident (R) 103) of seven residents observed during the medication administration task. The deficient practice had the potential to result in muscle discomfort, since R103 had a diagnosis of Multiple Sclerosis, and the missing medication was a muscle relaxant. Findings include: Review of R103's electronic medical record (EMR) admission Record, under the Profile tab, revealed R103 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis and generalized muscle weakness. Review of R103's EMR annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/28/22 revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15 which indicated that R103 was moderately cognitively impaired. During medication administration observation on 07/19/22 at 3:38 PM, while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-07-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer two of five residents reviewed for flu/pneumonia vaccinations (Resident (R) 3 and R50) and/or their representatives, the opportunity for the residents to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or PCV 20, in accordance with nationally recognized standards out of a total sample of 37 residents. Findings include: Review of the CDC website titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, effective 01/28/22, indicated . CDC recommends pneumococcal vaccination for all adults 65 years or older . For adults 65 years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give 1 dose of PCV [Pneumococcal Conjugate Vaccine] 15 or PCV20 . If PCV15 is used, this should be followed by a dose of PPSV [Pneumococcal Polysaccharide Vaccine] 23 at least one year later. The minimum…
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
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| HARBORVIEW HEALTH SYSTEMS INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| ENGLANDER, DAVID | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 50% | since 07/01/2016 |
| LEIBOWITZ, CHAIM | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 50% | since 07/01/2016 |
| LEE, NELVA | Individual | W-2 MANAGING EMPLOYEE | — | since 07/01/2016 |
CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $517K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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, FY2023). 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 115329. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-02, 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 →
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