Pruitthealth - Toccoa
633 Falls Road, Toccoa, GA 30577 · For profit - Corporation · 181 certified beds · (706) 886-8491 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jan 2023
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- about 24% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 4 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 fell from 2 to 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 | 3.8% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 5.8% | 5.6% | 5.4% | typical |
| 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 | 1.0% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 13.0% | 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 | 4.3% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 6.5% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 32.2% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 36.3% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 96.1% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.5% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.2% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.69 | 2.15 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.87 | 1.90 | 1.80 | 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.
67.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 75 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 46.9% 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 32 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 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% 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 | 67.8%CMS range 59.2–76.6 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.4%CMS range 8.0–16.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 46.9% | 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 | 43.8% | 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 | 28.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 1.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 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 | 5.5%CMS range 2.5–9.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 181 beds and averages 114.4 residents a day — about 63% occupied, or roughly 67 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 3.14 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.85 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 2.59 hrs/resident/day on weekends vs 3.36 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.54 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2025-08-28 · 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 observations, record review, and resident and staff interviews, the facility failed to ensure call lights were within reach for one of 31 sample residents (Residents (R) 58) reviewed for accommodation of needs and preferences. Specifically, the facility failed to ensure residents had access to their call lights to best assist the residents in maintaining and/or achieving their independent functioning, dignity, and well-being to the extent possible.Findings include:Review of R58's admission Record found in the Profile tab of the electronic medical record (EMR), revealed she was admitted with diagnoses including but not limited to dementia, cervical disc disorder with myelopathy, muscle weakness, and difficulty in walking.Review of R85's quarterly Minimum Data Set (MDS) located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 8/4/2025, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of nine out of 15, which indicated moderate cognitive impairment. R58 was observed on 8/25/2025 at 12:36 PM resting in bed with the call light…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-28 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview, document review, and facility policy review, the facility failed to report the results of the investigation of sexual abuse to the State Survey Agency (SSA) within five working days of the incident for one of one resident (Resident (R) 68) reviewed for abuse out of a total sample of 31 residents. Specifically, R71 removed her clothes and incontinence brief and climbed into R68's bed.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 2.A written report of the investigation .should be submitted to the appropriate agency within five working days of the occurrence.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, R71 was unclothed sitting at the end of R68's bed in their room. The file indicated that the SSA was initially notified on 7/31/2025 at 6:20 AM. However, the final report of the investigation was not sent to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-08-28 · 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 interviews, record review, document review and review of the facility's policy, the facility failed to complete a thorough investigation of an allegation of sexual abuse for two of 31 sampled residents (Resident (R) 68 and R71). The facility's failure to complete a thorough investigation placed residents at risk of being unprotected from abuse.Findings include:Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, dated 11/15/2024, indicated Procedure, 1. Documentation of the investigation should include. Signed statements from pertinent parties. Interview should be conducted of all individuals who have relevant information.Written signed statements from any involved parties should be obtained. patients involved, reliable patients who may have witnessed the incident.Review of the facility investigation, provided by the Administrator, into the allegation of sexual abuse, revealed that on 7/31/2025 at 5:25 AM, R71 was unclothed sitting at the end of R68's bed in their room. 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 · F2024-03-21 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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 observations, staff interviews, and review of the facility's policy titled How to Puree Foods, the facility failed to follow the recipes to ensure puree foods were prepared by methods to conserve nutritive value, flavor, and appearance. This deficiency had the potential to affect all twelve residents that received a puree diet. The facility census was 102 residents. Findings include: Review of the facility's policy titled How to Puree Foods under Preparation steps revealed: Number 1. Depending on the resident's dietary restrictions, follow the proper recipe to prepare the regular consistency food item. Number 2. Portion out the prepared food according to the number of pure 'ed portions needed, remember to include a little extra to make up for the loss of volume when pureeing. Number 5. If required, gradually add a small amount of liquid (2 -3 tablespoons) while continuing to process to form a very smooth puree (moist mashed potato consistency). Number 7. Taste and add seasonings while pureeing. The pureed food should be just as flavorful as the regular consistency food.…
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 · F2024-03-21 · 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 Patients/Residents' Personal Food, the facility failed to maintain sanitary resident nourishment refrigerators in the unit pantries, failed to store food items properly in the resident nourishment refrigerators and failed to dispose of expired food items in a timely manner in the resident nourishment pantries for two of three units (Blue Unit and Memory Care Unit). The facility had a census of 102 residents. Findings include: Review of the facility's policy titled Patient/Residents' Personal Food dated 5/12/2023 revealed, Number 7. Nursing/housekeeping partners will be responsible for the disposal of outdated foods maintained in the patient/resident's room and those stored in the nursing units' nourishment refrigerators/freezers. Observation on 3/21/2024 at 12:24 pm of the resident nourishment station on the blue unit revealed in the resident refrigerator one single 12 ounce (oz) can of coke zero in a gray plastic bag unlabeled/undated, one 17 oz can sparkling ice starburst drink unlabeled/undated,…
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 before2024-03-21 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled Infection Prevention-Hand Hygiene, and Medication Administration: General Guidelines, the facility failed to perform proper infection control processes as evidenced by two of six staff (Licensed Practical Nurse (LPN) JJ and LPN KK) observed not performing proper hand hygiene during meal tray pass, one of four staff (Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) DD observed for medication administration who failed to properly prepare insulin for one Resident (R) (R73), and two of four staff (CMA/CNA EE and CMA/CNA DD) that failed to properly handle medications during medication administration for two residents (R87 and R73). The facility census was 102 residents, and the sample size was 46 residents. Findings include: 1. Review of the policy titled Infection Prevention-Hand Hygiene dated 8/15/2023, under the Policy Statement revealed, [Name] partners will improve hand hygiene practices and reduce…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · 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, resident and staff interviews, the facility failed to ensure a safe/clean/comfortable/homelike environment in one of 14 resident rooms (room [ROOM NUMBER]) on the Magnolia Hall. Specifically, a metal plate was observed on the bathroom door in room [ROOM NUMBER] to have a hole with sharp, jagged edges. The deficient practice had the potential to cause injury to residents and staff. Findings include: Observations and interview on 3/19/2024 at 10:18 am of the bathroom door in room [ROOM NUMBER] revealed a metal plate attached to the door on the side facing the resident room with a hole with edges that were noted to be sharp and jagged. Interview with Resident (R) (R10) revealed when the room door opens, it would hit the bathroom door and that the doorknob of the room door created the hole. He stated he was uncertain of how long the door had been damaged. Observations on 3/20/2024 at 7:42 am in room [ROOM NUMBER] revealed the bathroom door had a metal plate attached to the door which had 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 before2024-03-21 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interview, and review of the facility's policy titled, Care Plan, the facility failed to follow the care plan for one of 46 sampled residents (R) (R37) related to providing assistance with showers and baths. Findings Include: Review of the facility's policy titled Care Plan dated 7/27/2023 revealed under admission Comprehensive Plan of Care, Number 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of Resident Face Sheet for R37 revealed diagnoses that included but not limited to Parkinson's disease, muscle weakness, difficulty in walking, unsteadiness on feet, muscle weakness, and other lack of coordination. Review of Quarterly Minimum Data Set (MDS) dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) the facility failed to ensure that one of 46 sampled residents (R) (R37) had the necessary assistance with ADLs. Findings include: Review of the facility's policy titled, Documentation: Charting Activities of Daily Living (ADLs) dated 1/11/2024 revealed that the responsibility of the person completing the documentation on the Certified Nuse Assistant (CNA) /ADL flowsheet is to code the maximum amount of support the patient/resident received over the entire shift irrespective of frequency. For utilizing Care Assist, ADLs should be documented at the point of care each time care is given. The software will determine the most dependent episode. Review of R37's Resident Face Sheet located in the Electronic Health Record (EHR) revealed diagnoses included but not limited to Parkinson's disease, muscle weakness, difficulty in walking, unsteadiness on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-03-21 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's titled Medication Storage in Healthcare Centers and Medication Administration: General Guidelines, the facility failed ensure the medication cart was locked when unattended for one out of five medication carts and failed to obtain orders from a physician to allow one out of 46 sampled Residents (R) (R55) the ability to self-administer medications prior to leaving medications at the bedside. Findings include: Review of the facility's policy titled Medication Storage in Healthcare Centers reviewed and revised on 3/1/2024, under the Policy Statement revealed, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those tot the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel. Respiratory Therapist may access medications used in the provision of respiratory services. Under the section titled Procedure Number 2 revealed…
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 16 citations
- Potential for harm · D2024-03-21 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and record review, the facility failed to ensure that the call light communication system was functioning adequately to allow the resident to call for assistance in one room (room [ROOM NUMBER]A) on one of five halls. The sample size was 46 residents. Findings include: Record Review of R71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Section A (Identification Information) revealed entry date of 12/15/2023; Section C (Cognitive Pattern) Brief Interview for Mental Status (BIMS) score of nine; Section I (Active Diagnosis) Debility, Cardiorespiratory Conditions. Observation and Interview on 3/20/2024 at 9:15 am, in room [ROOM NUMBER] A revealed, the call light was lying on the floor. The call light was inspected by the surveyor and was nonfunctional. Interview with Resident (R) R71, revealed, she was high risk for falls and had to resort to yelling or using her roommate's call light for assistance. Further Interview on 3/20/2024 at 9:55 am 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 · E2023-01-26 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. There were no Registered Nurses in the facility for at least eight consecutive hours on 12/18/22 and 1/21/23. The facility census was 98. Findings include: Review of past 30 days of daily staffing grids revealed there was no RN on duty for the minimum eight consecutive hours per day on 12/18/2022 and 1/21/2023. Interview on 1/25/2023 at 1:30p.m., the Director of Health Services (DHS) confirmed there was no RN coverage for eight consecutive hours on Saturday 1/21/2023. She stated there was no RN on duty during the 24-hour period. During further interview, the DHS revealed the scheduled RN was given her shift off by the Assistant Director of Health Services (ADHS), not realizing there was no other RN scheduled to work. She stated it is her expectation that a RN be on duty for at least eight hours per day. Interview on 1/25/2023 at 1:40p.m., the Administrator confirmed there was no RN coverage on Saturday…
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 before2023-01-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and review of the policies titled Medication Storage in the Healthcare Centers and Controlled Substances for Healthcare Centers, the facility failed to ensure that two of six medication carts and one of two treatment carts on one of two units (unit one) were locked and secured when unattended and out of the view of the nurse. In addition, facility failed to ensure that narcotics were counted and documented at the beginning and end of each shift on one of six medication carts (Unit one). The census was 98. Findings include: 1. Review of the policy titled Medication Storage in the Healthcare Centers revised 9/15/17, revealed the policy is medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Procedure number 2. Only licensed nurses and the pharmacy personnel are allowed access to the medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized…
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 before2023-01-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, facility documentation, and policy review, the facility failed to maintain an effective Infection Control Program (ICP) to prevent the spread of infections by not ensuring staff donned required Personal Protective Equipment (PPE) prior to entering COVID-19 positive room for one resident (R) (R#19) and failed to ensure staff washed/sanitized their hands during the provision of wound care for one resident (R) (R#144). In addition, the facility failed to properly store continuous positive airway pressure (CPAP) mask for R#344. The sample size was 38. Finding include: 1. Review of the policy titled COVID-19 Isolation and Cohorting Process revised 1/9/23 procedure: III. 9. Entering or exiting confirmed positive (level 1) or suspected of COVID-19 infection (level 2) room. 2) Personal Protective Equipment (PPE) will be used in each transmission-based precautions (TBP) room and changed accordingly: a) N95 mask; b) Eye protection; c) PPE donned properly. Review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · 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 and staff interviews, the facility failed to ensure that it was maintained in a clean, comfortable, and homelike environment in 12 of 15 resident rooms (238/239, 240/241, 242/243, 244/245, 260/261, and 262/263) on one of five halls (Blue Hall) including clogged sinks, dust buildup on bathroom vents, light fixtures with debris in globes, air conditoner units with dust/grime buildup and dirty filters. The facility census was 98. Finding include: Observations on 1/24/23 at 11:29 a.m. during initial tour and on 1/25/23 at 1:56 p.m. revealed the following: *room [ROOM NUMBER]/239 shared bathroom had a clogged bathroom sink, and very slow to drain. *room [ROOM NUMBER]/241 shared bathroom had debris buildup in the light fixture and dust buildup on the air vent on the ceiling. *room [ROOM NUMBER]/243 shared bathroom had dust buildup on the air vent on the ceiling. *room [ROOM NUMBER]/245 shared bathroom had dust buildup on the air vent on the ceiling. *room [ROOM NUMBER]/261 shared bathroom had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-01-26 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of the policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure one resident (R) R#19 was protected from neglect, by failing to answer a call light, when multiple staff members walked past her room over 50-minute timespan. The sample size is 37. Finding include: Review of the policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised 10/27/2020, revealed the policy of [name] is to actively preserve each resident's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, COVID-19, anemia, bipolar disorder, schizophrenia, adult failure to thrive 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 before2023-01-26 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, review of facility documentation, and policy review, the facility failed to report within the required timeframe (24 hours for incidents that do not result in serious bodily injury) to the State Survey Agency (SSA) an incident of resident-to-resident abuse, in which resident (R) R#74 hit R#59 with a pool noodle. The incident was documented to have happened on 10/19/2022, but was not reported to the SSA until 12/9/2022. The sample size was 37. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property dated 7/29/2019, procedure 1. any occurrence identified involving patient abuse, neglect, exploitation, mistreatment, and misappropriation of properties should be reported to the Administrator immediately. Procedure 2. The Administrator, or their designee should notify the appropriate state agency, the resident's physician, and the residents designated representative of allegation/incident 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 before2023-01-26 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of facility policy titled Dialysis Care Pre and Post Dialysis and SNF [Skilled Nursing Facility] Outpatient Dialysis Agreement, the facility failed to ensure that pre and post dialysis assessments were conducted for one of two residents (R) R#37, receiving dialysis services. In addition, the facility failed to maintain ongoing communication between the facility and the dialysis center for R#37. Findings Include: Review of the policy titled Dialysis Care Pre and Post Dialysis, revised 8/22/2022, revealed procedure I. Pre-Dialysis number 2. Take and record resident blood pressure and pulse and observe shunt access prior to resident transport to dialysis. II. Post-Dialysis number 2. Upon return from dialysis, take and record resident blood pressure, pulse, and observations of the dressing at the access site. Review of SNF Outpatient Dialysis Services Agreement with an effective date of 12/27/2012 and signed 1/3/2013, revealed under D. Mutual…
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 · F2019-07-19 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, Registered Dietician (RD), and staff interview, the facility failed to ensure that the staff designated as Director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. Findings include: During interview with the Dietary Manager (DM) on 7/15/19 at 11:00 a.m., she stated that she had been working as an Assistant Dietary Manager at the facility, before recently being appointed as the DM. During the interview she will complete the Certified Dietary Manager course at the end of the July 2019. During interview with the administrator on 7/16/19 at 9:57 a.m., he stated the DM was hired into the dietary manager position on 9/22/18. During interview with the RD on 7/18/19 at 10:15 a.m., she stated that the DM was hired for the facility in September 2018. The RD stated she comes into the facility two or three times a month. She said when she enters the facility, she reviews the weight report, wound report, census and completes updates with nurses on residents. The RD stated she…
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 before2019-07-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and staff interview the facility failed to ensure proper sanitization/cleaning of monitors for testing of blood glucose during 9 observations of 6 resident's (R) (R#36, R#136, R#18, R#117, R#139, and R#58) on 3 of 6 halls out of a total of 36 residents who receive glucose testing. One out of two nurses observed reforming finger sticks failed to clean the blood glucose monitoring equipment. Review of the Healthcare Professional Operator's Manual for the G3 Blood Glucose Monitoring System revealed on page 11 that the G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Clorox Healthcare Bleach Germicidal and Disinfectant Wipes have been approved for cleaning and disinfecting the G3 Meter. Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from 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 · D2019-07-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to obtain a concurring physician's signature on a DNR (Do Not Resuscitate) order form for two residents (R)(R#72 and R#118). A total of 41 residents' advance directives information was reviewed. Findings include: Review of the facility's Do Not Resuscitate Policy: Georgia revised 2/4/19 revealed: II: Requesting a DNR Order: A.the Social Worker/professional nurse shall be responsible for completing the process. C. If a patient/resident does NOT have decision making capacity: 1. A Durable Power of Attorney for Healthcare (DPOAHC) or Healthcare Agent, may consent orally or in writing to a DNR order along with the signature of the patient/resident's Attending Physician. 2. An Authorized Person who is not the patient/resident's DPOAHC or Healthcare Agent may consent orally or in writing to a DNR order. The patient/resident's DNR becomes effective upon the signature of the patient/resident's attending physician along with the signature of a concurring…
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 before2019-07-19 · 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 observation, record review and staff interview, the facility failed to implement the care plan related to nail care prn (as needed) for one totally-dependent resident (R) (R#52). The sample size was 68 residents. Findings include: Review of R#52's clinical record revealed that she had diagnoses including multiple sclerosis (MS), and muscle contractures of multiple sites. Review of R#52's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she was totally dependent for personal hygiene. Review of R#52's self care deficit related to progressive MS-functional quadriplegia care plan revealed an approach dated 6/5/19 to provide daily grooming, including nail care prn. Observation on 7/15/19 at 11:34 a.m. and 7/16/19 at 8:57 a.m. revealed that R#52's fingers were contracted into her palms, and the fingernails that could be seen were very long. Continued observation revealed that there was an unpleasant odor to the right hand. Observation on 7/16/19 at 9:26 a.m. revealed that Licensed Practical Nurse…
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 before2019-07-19 · 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, record review and staff interview, the facility failed to perform nail care for one totally-dependent resident (R) (R#52), who had bilateral hand contractures. The sample size was 68 residents. Findings include: Review of R#52's clinical record revealed that she had diagnoses including multiple sclerosis (MS); functional quadriplegia; spastic paralysis; dementia; and muscle contractures of multiple sites. Review of R#52's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a BIMS score between 0 and 7 indicates severe cognitive impairment); was totally dependent for personal hygiene; and had functional limitation in range of motion (ROM) of the upper and lower extremities. Review of R#52's self care deficit related to progressive MS-functional quadriplegia care plan revealed an approach dated 6/5/19 to provide daily grooming, including nail care prn (as needed). Review of an OT (Occupational Therapist)-Therapist Progress…
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 · D2019-07-19 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the physician ' s orders to discontinue a divided plate for one of one resident (R) (R#62), who was reviewed for adaptation devices for eating. Findings include: Review of the electronic current physician order history dated 6/26/19 revealed the divided plate was discontinued was ordered and approved by physician. Review of meal ticket dated 7/17/19 (Dinner) revealed Resident # 62 was to receive a divided plate. Review of the Quarterly Minimum Data Set (MDS) MDS dated [DATE] revealed a Brief Interview in Mental Status (BIMS) of 15 (a BIMS score between 13 - 15 reveals intact cognitive) and a functional status including independent for eating via section G of the quarterly MDS dated [DATE]. Review of the electronic medical record revealed Resident R #62 had a diagnosis including anemia, type II diabetes, and hypertension. Interview with R# 62 on 7/16/19 at 8:37 a.m. during breakfast stated her food is always cold because the plate…
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 · D2019-07-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, the facility failed to ensure that a urinary catheter was secured to the leg to prevent urethral traction for one resident (R) (R#52). A total of three residents were reviewed for urinary catheter use. Findings include: Review of R#52's clinical record revealed that she had a history of urinary calculi; frequent UTIs (urinary tract infections); and a neurogenic bladder with a Foley catheter. Review of R#52's Physician Orders revealed that they included: Catheter: Diagnosis neurogenic bladder. Gentamicin (an antibiotic) solution; 40 mg (milligrams)/mL (milliliter; amount: 2 ml; injection Special Instructions: Mix 1 vial Gentamicin in 500 cc (cubic centimeters) normal saline, place 100-150 cc in bladder and clamp for 30 minutes and release. Repeat qmwf (every Monday, Wednesday, and Friday) Once A Day. Nitrofurantoin (an antibiotic for preventing and treating UTIs) macrocrystal capsule; - Crushed; 50 mg; amount: One; oral Once A Day. Catheter: Catheter care…
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 before2019-07-19 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to communicate with the dialysis center for one resident (R) R #76. According to the facilities Resident Census and Conditions of Residents (CMS Form 672) there are two dialysis residents. The census is 147. Findings are as followed: Resident #76 diagnoses include; hypertensive chronic kidney disease with stage 5 chronic kidney disease, end-stage renal disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, dysphagia, mood disorder. Medications including but not limited to: citalopram (antidepressant) tablet 20mg x1 tab daily, famotidine (gastric-reflux) tablet 20mg x1 twice daily, Hydrocodone-acetaminophen (pain) tablet; 5-325mg x1 tab PRN, Renvela( phosphate binder) tablet 800mg x1 tab daily, sucralfate table (ulcers) 1gm x 1 tab twice daily. Review of the Quarterly Minimum Data Det (MDS) assessment dated [DATE] revealed Section C: Brief Interview for Mental Status (BIMS) score of 15/15…
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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2025-12-17 for 5 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 2.9 | -1.9 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 3 of 5 | 3.6 | -0.6 vs chain |
The other 94 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 94; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| UNITED HEALTH SERVICES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/27/2007 |
| SCROGGS, DELORES | Individual | W-2 MANAGING EMPLOYEE | — | since 08/21/2021 |
| WISE, JERRY | Individual | W-2 MANAGING EMPLOYEE | — | since 09/07/2021 |
| PRUITT, NEIL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 09/27/2007 |
| PRUITTHEALTH INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 09/27/2007 |
CMS files one row per role, so the 7 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 82% 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 $2.7M paid to related parties — landlords or management companies under common ownership — equal to about 24% 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 115345. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-03-21, 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 →
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