Christian City Rehabilitation Center
7300 Lester Road, Union City, GA 30291 · For profit - Individual · 200 certified beds · (770) 964-3301 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 24% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 4 to 2 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 | 5.3% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.3% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 1.5% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.8% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 14.8% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 73.7% | 95.0% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 3.5% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 6.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 10.3% | 19.9% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 87.7% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.8% | 25.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 10.2% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.26 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.22 | 1.90 | 1.80 | better |
§ 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.
64.3% 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 240 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 66.3% 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 92 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 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 20% 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 | 64.3%CMS range 58.8–69.5 | 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 | 12.1%CMS range 9.5–15.4 | 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 | 66.3% | 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 | 62.0% | 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 | 46.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 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 | 4.0% | 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 | 9.7%CMS range 6.6–14.4 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 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 200 beds and averages 176.2 residents a day — about 88% occupied, or roughly 24 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 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.61 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.20 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.17 hrs/resident/day on weekends vs 3.95 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.67 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 40% 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.
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2025-11-21 · 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, family and staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to follow the care plan for one of three sampled residents (R) R1 related to a two-person assist with transfers. This failure caused R1 to suffer a fall while being assisted by one staff member and placed the resident at risk of injury. Findings include:Review of the facility's policy titled, Care Plans last revised 10/21/2025, documented on page 3: the comprehensive care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Muscle weakness (generalized), Other abnormalities of gait and mobility, Body mass index [BMI] 45.0-49.9, other muscle spasm, and spinal stenosis of cervical region.Review of the most recent Quarterly 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.
- Potential for harm · D2025-11-21 · 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 family and staff interviews, record review, and review of the facility's policy titled, Occurrences, the facility failed to provide assistance to prevent a fall for one of three sampled residents (R) (R1) assessed for falls. This deficient practice had the potential to cause injury to the resident. Findings include:Review of the facility's policy titled, Occurrences last revised on 11/17/2025 documented on page 1: Occurrence hazards are physical features in the healthcare center environment which may pose a risk to a patient/resident's safety, including but not limited to any event, accident, or incident, on or off healthcare center property which results in an injury or has the potential for an injury.Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses that included but not limited to: Muscle weakness (generalized), Other abnormalities of gait and mobility, Body mass index [BMI] 45.0-49.9, other muscle spasm, and spinal stenosis of cervical…
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 · E2025-04-30 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record reviews, and a review of the facility's policy, the facility failed to ensure medication was refilled before the medication ran out and over-the-counter medication was available for one of six residents (Residents (R) 129) observed during the medication administration and two residents (R436 and R98) out of a total of 51 sampled residents. This failure had the potential for adverse effects if medications were not administered due to a lack of timely refills or short supply. Findings include: Review of the facility's policy titled, Ordering Medications from the Pharmacy, revised [DATE], stated The healthcare center will transmit physician orders to the pharmacy using facsimile or other technology in order to receive medications on a timely basis. Facilities with EMAR: All orders will be entered into the system and transmitted to pharmacy. The policy under Reordered Medications (Refills) section stated some of the requirements as follows: Medication orders requiring…
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 · D2025-04-30 · 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, resident and staff interviews, and policy review, the facility failed to ensure the call devices used were tailored to meet the individual physical needs of the residents and failed to respond promptly to the call system for two residents, (Resident (R) 25 and R238), out of a sample of 51 residents. This failure placed R25 and R238 at risk of experiencing unmet care needs. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/02/23 stated, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. The call light system procedure included the following: .Essentia Points .Unless indicated in the care plan, each patient/resident, when in their room or in bed, must have the call light placed within reach at all times, regardless of staff assessment of patient/resident's ability to use it. When the patient/resident is in bed, the call bell should be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · 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
Based on observations, resident and staff interviews, and document review, the facility failed to create a homelike environment by ensuring resident rooms were clean or in good repair for four residents (Resident (R) 125, R106, R98, and R56) in the sample of 51 residents. Findings include: Review of the facility's undated admission Agreement revealed residents' rights: The Facility desires to provide the Resident with a homelike environment. 1. Observation on 04/27/25 at 10:50 AM of R125's room revealed the molding under the wall mounted air unit was peeled back with approximately 15 inches of it protruding into the room and exposing wood underneath. Paint was missing in spots around the bathroom door frame. During an interview on 04/27/25 at 10:50 AM, R125 reported the room did not look homelike. 2. Observation on 04/27/25 at 12:44 PM of R106's room revealed an area of the wall where the outer layer of drywall was missing in patches with the largest two areas measuring approximately six to eight inches by five inches. During an interview on 04/27/25 at 12:45 PM, R106 stated 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 · D2025-04-30 · 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 2. Review of R197's undated Face Sheet located under the Resident tab of EMR revealed R197 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and encounter for orthopedic aftercare, cognitive communication deficit. R197 was discharged to an assisted living facility on 04/09/24. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24, provided by the Administrator, documented there was a late grievance received by the facility Administrator on 10/23/24 after R197 was discharged on 04/09/24. The Grievance form documented the following: wound RP [responsible party] not informed. fall-p't [patient] trapped by male nurse. showers. feeding. weight lost. Resident RP reported issues to [R197's Insurance company name] .forward concerns to facility. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24 under the Summary documented the following: no male was assigned to Resident during stay. Res. (resident) did have fall on 4/21 from bed…
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 · D2025-04-30 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI), the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in a resident's status for one of eight residents reviewed for a change in condition (Resident (R) 120) out of a total sample of 51 residents. This failure placed the residents at risk for unmet care needs. Findings include: Review of the RAI dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed a significant change in status MDS assessment must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. A 'significant change' is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by…
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 · D2025-04-30 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for two out of 51 sampled Residents (R) (R 131 and R154) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes. Findings include: Review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument RAI (Resident Assessment Instrument) Manual, dated 10/1/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed discharge assessments were to be completed no later than the discharge date plus 14 calendar days. In addition, they were to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to code pressure ulcers on a Minimum Data Set (MDS) assessment for two of 11 Resident (R) (R194 and R98) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the RAI (Resident Assessment Instrument) Manual, dated 10/01/2024 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed . items on the assessment should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [interdisciplinary team] completing the assessment. Review of the facility's policy titled, MDS Assessment Accuracy revised 12/6/2022 revealed, Each ARD [Assessment Reference Date] will be chosen to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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's policy titled, Care Plans, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one of 51 sampled Residents (R) (R192) reviewed for baseline care plan. This failure had the potential for the residents to have unmet care needs. Findings include: Review of the facility's policy titled, Care Plans dated 7/27/2023 revealed, Upon a new admission. A baseline care plan will be developed .The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission. Review of R192's Electronic Medical Record (EMR) admission Record located under the Profile tab indicated R192 was admitted to the facility on [DATE] with a diagnosis of: Orthopedic aftercare following surgical amputation (amputation of Left Lower Leg), Type II Diabetes Mellitus (too much sugar in the blood) End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste 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.
Show the remaining 15 citations
- Potential for harm · D2025-04-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to develop a comprehensive care plan for one of 11 Residents (R194) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs. Findings include: Review of the facility's policy titled Care Plans revised 7/27/2023 revealed: Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors [CMD], or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. Review of R194's Face Sheet tab of the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and 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 · D2025-04-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, the facility did not ensure that two of the 51 sampled Residents (R) (R98 and R151) received nail care. This failure had potential to increase the risk of infectious disease and nail damage for R98 and R151. Findings include: Review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, revised 12/2/2023 stated It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. 1. Review of R98's Face Sheet located under the Resident tab of the Electronic Medical Record (EMR) revealed R98 was admitted to the facility with diagnoses that included but not limited to diabetes and multiple sclerosis (chronic and unpredictable neurological disorder that affects the brain, spinal cord, and optic nerves.) Review of R98's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/25/2025 located in the RAI [Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · 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 record reviews, staff interviews, and a review of the facility's policy, the facility failed to administer long-acting insulin in accordance with physician orders for two residents (Resident (R) 436 and R98) out of 51 sampled residents. This failure had the potential to have adverse effects on residents if their insulin was not given or their dose was reduced without a physician's order. Findings include: 1. Review of R436's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R436 was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R436's Medication Administration Report (MAR) located in the Resident tab of the EMR under Report revealed the nursing staff documented R436's blood glucose (BG) as low at 123 and 142. The nurse withheld R436's insulin Lantus (long-acting insulin) without a physician's order as follows: Physician's order: Lantus Solostar U-100 Insulin (long-acting insulin) pen 100 units/ml (3ml), give 10 units…
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 · D2025-04-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to identify pressure ulcers and initiate treatment orders in a timely manner for one of 11 residents reviewed for pressure ulcers (Resident (R) 194) out of 51 total sampled residents. This had the potential for residents' pressure ulcers to decline. Findings include: Review of R194's Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] and had a hospital stay from 7/17/2024 to 7/20/2024. R194 had diagnoses including hemiplegia and hemiparesis following cerebral infarction (stroke) and diabetes. Review of R194's Braden Scale for Predicting Pressure Sore Risk dated 6/27/2024 and located in the Observations section of the EMR revealed the resident scored at high risk for developing pressure ulcers. Review of a Skin Note dated 6/28/2024 and located in the Observations section of the EMR revealed R194 had no skin issues. No further Skin Notes were found from 6/28/2024 through when…
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 · D2025-04-30 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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, and interviews, the facility failed to provide restorative nursing services for one of two residents (Resident (R) 98) reviewed for position and mobility out of a total sample of 51 residents. This failure had the potential to negatively affect Resident 98's ability to perform activities of daily living (ADL) and place R98 at risk of ADL decline. Findings include: Review of the facility's policy titled, Restorative Nursing Program, revised 11/4/2021, included the statement as follows: It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and maintaining optimal physical, mental, and psychological functioning and wellbeing of the patient/resident. Restorative nursing program is under the supervision of a Registered Nurse (RN) or a Licensed Practical Nurse (LPN), and restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to have physician orders and an indication for an indwelling catheter for one (Resident (R) 85) of three residents reviewed for urinary catheters out of a total sample of 51 residents. This failure increased the risk of urinary catheters being implemented without an acceptable indication. Findings include: Review of the Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R85 was originally admitted to the facility on [DATE]. An observation of R85 on 4/27/2025 at 10:09 am revealed the resident in bed resting. On the right side of the resident's bed, hung a catheter bag, covered in a blue privacy bag. Review of the Minimum Data Set (MDS), located in the EMR under the RAI tab, with an Assessment Reference Date (ARD) of 3/3/2025, indicated that R85 had an indwelling catheter and Brief Interview for Mental Status (BIMS) of five out of 15 indicating severely impaired cognition. Review of the Progress Notes…
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 · D2025-04-30 · 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, interview, and policy review, the facility failed to obtain and document weight for one of nine residents (Resident (R) 197) reviewed for nutrition out of a total of 51 sampled residents. This failure had the potential to place R197 at risk of weight loss if the weight was not obtained and monitored in a timely manner to provide accurate information for nutrition need calculation. Findings include: Review of the facility's policy titled, Weight Monitoring Program, revised 6/2/2023, documented New Admissions. Initial weight and height will be obtained and documented on the Yearly Weight Record Form within 24 hours of admission to the healthcare center. New admissions will be weighed weekly for four weeks and/or until weight is stable. Review of R197's undated Face Sheet located under the Resident tab of the electronic medical record (EMR) revealed R98 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and pneumonia. R197 was discharged to an assisted…
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 · D2025-04-30 · 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, staff interviews, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms used between the facility and the dialysis center were completed for one of two residents reviewed for dialysis (Resident (R) 106) out of 51 sampled residents. This had the potential to affect the health of residents receiving dialysis. Findings include: Review of the facility's policy titled, Dialysis Care Pre and Post Dialysis, revised 8/22/2022, revealed the use of a Dialysis Center Communication Form. The policy documented the procedure that facility staff were to take and record the resident's blood pressure and pulse, and observe shunt access prior to and upon return of the resident's transport to and from dialysis. Review of R106's Face Sheet tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease and dependence 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 · D2025-04-30 · 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, interviews, record reviews, and a review of the facility's policy, the facility failed to adequately label insulin pens and failed to properly dispose of expired medication in the designated disposal container for one of the four medication carts (MC) that were observed during medication administration on [DATE]. This failure had the potential to increase the risk of medication administration errors and posed a potential biohazard. Findings include: Review of the facility's policy titled, Medication Storage in the Healthcare Centers, revised [DATE], stated Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Types of medications and routes of administration are stored based on package type .Medication labeled for individual patients/residents .in closed and labeled containers. During the fourth-floor medication administration observation on [DATE], at 8:37 AM, Licensed Practical Nurse (LPN) 2 assigned to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policy titled, Procedure: Blood Glucose Monitoring, the facility failed to ensure infection control practices were followed during a blood glucose (BG) check for one of two residents (Resident (R) 151) observed during medication administration observation. These failures placed all the residents who received a BG check and insulin from the medication cart at risk of contracting infectious diseases. Findings include: Review of the facility's undated policy titled, Procedure: Blood Glucose Monitoring, under Considerations, stated An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B ], HCV [hepatitis C], and HIV [human immunodeficiency virus]) through contaminated equipment and supplies that are shared (e.9., blood glucose meters, fingerstick devices, insulin pens). The current FDA [Food and Drug Administration], /CDC [Centers for Disease Control and Prevention] recommendation is to use a separate blood glucose meter and spring-loaded lancet (if used)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-03-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and review of the facility policies titled, Foodborne Illness, Patients/Residents' Personal Food', and Labeling, Dating, and Storage, the facility failed to properly thaw frozen foods by not allowing running water to overflow to prevent potential harmful particles/bacteria to run freely. The facility also failed to ensure resident nourishment refrigerators and freezers were clean, resident foods were labeled and dated, as well as food items discarded past the use by date. The deficient practice had the potential to affect 170 residents receiving an oral diet. The facility census was 174. Findings include: Review of the facility policy titled Foodborne Illness revealed under Procedure, 2. Foods will be used before the expiration date, use by date, best by date, and sell by date indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. 7. Meats will be thawed and cooked to appropriate internal temperatures to prevent foodborne illness. Thaw meats under refrigeration at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-03 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure an application for Preadmission Screening and Resident Review (PASRR) Level I that included a diagnosis of schizophrenia was submitted prior to or on admission to the facility for evaluation and determination of specialized services for one of 43 sampled Residents (R) (R32). This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: Review of R32's Face sheet revealed she was admitted to the facility with diagnoses that include but are not limited to schizophrenia, unspecified. Review of R32's most recent annual Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: no PASRR Level II; Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13, indicating intact cognition; Section D-Mood: Total Severity score of 0 (zero); Section E-Behavior: no behaviors indicated. Review of R32's care plans included but not limited to:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-06-23 · 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, and record review the facility failed to ensure the kitchen was maintained in clean and sanitary condition. This deficient practice had the potential to affect all residents receiving an oral diet. As indicated on the facility's Form Centers for Medicaid and Medicare Services (CMS)-672, Resident Census and Conditions of Residents Form, the facility's census on 6/21/22, was 170 residents. Findings include: Review of the facility Cleaning Schedule Policy with an effective date of 9/1/01 and a revised date of 3/22/16 revealed it is the policy of the corporation that the Dietary Manager prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. During the initial tour of the kitchen on 6/21/22 at 10:00 a.m. the floor was observed to have brown/black/and yellow stains throughout the kitchen with debris and was slick. The food warmer, just inside the door…
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 · D2022-06-23 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
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 interviews and record review the facility failed to ensure that one of 16 sampled residents (R) (R#35) was provided Activities of Daily Living (ADL) care related to incontinence care. Findings include: A review of the clinical record revealed R#35 was admitted to the facility on [DATE] with a diagnosis to include but not limited to sepsis, cellulitis of left lower limb, chronic respiratory failure with hypoxia, COPD, unspecified abnormalities of gait and mobility, pressure ulcer of sacral region, stage four. During an interview on 6/21/22 at 9:00 a.m., R#35 stated that the staff only changes her once per shift. She stated that she wets the bed and needs to be changed more frequently. A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R#35 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment in cognitive skills for daily decision making. The resident was assessed in Activities of Daily Living (ADL) functional status to require 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 · D2022-06-23 · 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 observation, record review, resident and staff interview, the facility failed to obtain a Physician's Order for oxygen use, including the frequency of use and flow rate for one of 57 sampled residents (R) (R#281). Findings include: A review of R#281's clinical record revealed that she was admitted on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertension, depression, and anxiety. An observation of R#281 on 6/21/22 at 1:59 p.m. revealed that she had oxygen tubing attached via nasal cannula and the oxygen flow rate was at two liters per minute via an oxygen concentrator. An observation of R#281 on 6/22/22 at 8:29 a.m. revealed that oxygen was in use via nasal cannula at a flow rate of two liters per minute via an oxygen concentrator. During an observation of R#281 on 6/22/22 at 1:00 p.m., she was in therapy gym and was noted with oxygen via nasal cannula in use via oxygen tank. A review of an admission Minimum Data Set…
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.
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 | 3 of 5 | 2.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 2.5 | +0.5 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 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 | Since |
|---|---|---|---|
| DAVIS, TONI | Individual | W-2 MANAGING EMPLOYEE | since 02/07/2022 |
| GERHARDT, SUZANNE | Individual | W-2 MANAGING EMPLOYEE | since 11/23/2020 |
| KITTLES, MICHELE | Individual | W-2 MANAGING EMPLOYEE | since 03/14/2021 |
| POWERS, JOY | Individual | W-2 MANAGING EMPLOYEE | since 12/02/2021 |
| PRUITT, NEIL | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 03/27/2009 |
CMS files one row per role, so the 6 rows in the source record cover these 5 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.7M 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 115573. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.