Warrenton Woods of Journey LLC
813 Atlanta Highway, Warrenton, GA 30828 · For profit - Limited Liability company · 110 certified beds · (706) 465-3328 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0568, F0569)
- a high number of inspection citations overall (28) — 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)
- its payroll-based staffing rating is low (2/5)
- about 20% 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) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 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 | 4 of 5 |
| Long-stay residentspeople who live here | 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 improved from 1 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 | 10.5% | 15.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.5% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 39.2% | 11.3% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.7% | 3.2% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 9.1% | 15.2% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.1% | 20.5% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.0% | 5.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.2% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 34.5% | 19.9% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.23 | 2.15 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.18 | 1.90 | 1.80 | worse |
† This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 29% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 38% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 5.6–15.5 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 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 110 beds and averages 48.5 residents a day — about 44% occupied, or roughly 62 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 4.13 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above 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 3.51 hrs/resident/day on weekends vs 4.38 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.70 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Dcited before2026-04-01 · 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 observations, staff and resident interviews, and record review, the facility failed to accurately complete a PASARR for one resident (R)52. This deficient practice could result in the resident not receiving appropriate services. The census was 51. Findings Include:The facility submitted a document titled admission Guideline The section titled What is a PASARR? states the following, A PASARR screening is completed prior to admission or for any significant status change to determine if they are indicators of mental and/or mental retardation. This screening is intended to assess whether an individual is appropriate for nursing home placement. If admitting from the hospital, the case manager or discharge planner at that facility will typically do the PASARR. If admitting from home, the PASARR is typically completed by the facility. This is usually done by the social worker but could also be completed by admissions or the business office manager. EVERY admission MUST HAVE A PASARR APPROVED PRIOR TO admission…
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 · D2026-04-01 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled Medication Administration, the facility failed to ensure that one of four sampled residents (R) (R35) was free from significant medication errors. This deficient practice had the potential to place R35 at increased risk of adverse effects from medications.Findings include:Review of the facility policy titled Medication Administration, revised 2/14/2024, revealed the Policy section stated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section included, . 10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare the medication source (bubble pack, vial, etc.) with the MAR to verify the resident name,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-02-24 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility's policy titled, Date Marking for Food Safety, the facility failed to discard refrigerator food by expiration dates and ensure proper food labeling, storage, and dating, and to ensure dishwasher and sink testing strips were not expired. The deficient practices had the potential to affect all residents who receive meals from the kitchen. Findings include: Review of the undated facility policy titled Date Marking for Food Safety revealed under Policy Explanation and Compliance Guidelines for Staffing: . 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. During the initial tour and observation of the kitchen on 2/22/2024 at 7:49 am with the Dietary Manager (DM) revealed two one-gallon pitchers of brown-like liquid labeled sweet-tea with an expiration date of 2/21/2025 and two five-pound bags of diced onions with an expiration date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-02-24 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, the facility failed to ensure essential kitchen equipment was in working order as evidenced by the kitchen hood extinguishing system not operating. This deficient practice had the potential to affect 50 residents receiving an oral diet from the kitchen. Findings include: A review of the facility-provided document titled Kitchen Auto Extinguishing Systems, dated 1/30/2025, revealed the kitchen hood passed the inspection, and inspection results documented that the exhaust fan(s) were not operable. A review of the facility's work order from an electrical service dated 2/22/2025 revealed an on-site inspection that documented there was no voltage to the kitchen hood motor, and the recommendation was made to order a motor. A review of the facility's work order from an electrical service dated 2/24/2025 revealed an on-site service visit documented the kitchen hood motor was operating, and it had no belt. The belt was replaced, and the hood was working. During the initial kitchen tour and observation on 2/22/2025 at 7:49 am,…
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 · D2025-02-24 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Promoting/Maintaining Resident Dignity, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of four residents (R) R51 who had an indwelling urinary catheter. Findings include: A review of the facility's undated policy titled Promoting/Maintaining Resident Dignity under the Compliance Guidelines section revealed, 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 12. Maintain resident privacy. Review of medical records revealed, R51 admitted with diagnoses but not limited to muscle weakness (generalized), megalencephalic leukoencephalopathy with subcortical cysts, hypo-osmolality and hyponatremia, other inflammatory disorders of penis. Review R51's admission Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 3, which…
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 · D2025-02-24 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 resident interviews, staff interviews, and review of the facility's policy titled, Resident Trust Fund Account, the facility failed to provide resident trust fund account quarterly statements for two of three residents (R) (R24 and R38) reviewed. There were 34 resident trust fund accounts that were managed by the facility. This deficient practice had the potential to affect all residents who had a personal funds account with the facility. Findings include: Review of the facility's policy titled Resident Trust Fund Account, dated 1/9/2022, revealed the Quarterly Statements section included, These are to be done quarterly. Resident Fund Management Service (RFMS) sends them to your facility to be given to the residents. Quarterly statements are to be distributed by the 15th of the month. 1. Review of R24's Minimum Data Set (MDS) End of Prospective Payment System (PPS) Part A Stay assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-02-24 · tag F0569 — isolatedNotify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and record review, the facility failed to ensure two of two residents' (R) (R38 and R8) trust fund accounts remained under the $2,000.00 limit to maintain eligibility for Medicaid services. There were 34 residents with trust fund accounts that were managed by the facility. This deficient practice had the potential to affect all residents who had a personal funds account with the facility. Findings include: Review of the facility's policy titled Resident Trust Fund Account, dated 1/9/2022, revealed the Spend Downs section included Accounts over $2,000 are to be spent down within 10 days of reaching that amount. 1. Review of R38's Resident Fund Statement dated 10/1/2024 through 12/31/2024 revealed a beginning balance of $2801.28 and an ending balance of $3743.51. 2. Review of the facility-provided document titled Trial Balance revealed that R8's balance on 2/22/2025 was $2075.58. In an interview on 2/23/2025 at 1:00 pm, the Regional Human Resource Coordinator confirmed that R38 and R8's accounts exceeded the $2,000 limit to maintain eligibility for Medicaid…
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 before2025-02-24 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled Safe and Homelike Environment, the facility failed to maintain a homelike environment for eight of 54 resident rooms on two of four halls and in the main dining room (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] on Hall 100 and Hall 307). These deficient practices had the potential to place residents at risk of living in an unsanitary and unsafe living environment and a potential for diminished quality of life. Findings include: Review of the facility's undated policy titled Safe and Homelike Environment revealed the Policy Explanation and Compliance Guidelines section included, 1. The facility will create and maintain, to the extent possible, a homelike environment that deemphasizes the institutional character of the setting. Observations on 2/22/2025 from 10:10 am to 10:40 am revealed eight ceiling tiles in 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 · D2025-02-24 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure that one of seven residents (R) (R36) receiving respiratory care received respiratory care in accordance with professional standards of practice and regulatory requirements. Specifically, the facility failed to obtain a physician's order for oxygen (O2) therapy and ensure proper storage and handling of O2 equipment. The deficient practice had the potential to place R36 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: A review of R36's face sheet revealed they were admitted with diagnoses not limited to chronic systolic (congestive) heart failure, paroxysmal atrial fibrillation, hyperlipidemia, cardiomyopathy due to drug and external agent, essential hypertension, chronic kidney disease, and hemiplegia following cerebral infarction. A review of R36's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has a Brief Interview for Mental Status (BIMS) score…
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 before2025-02-24 · 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 a review of the facility's policy titled, Blood Glucose Monitoring, the facility failed to ensure the infection control process was followed during glucometer (a device used to test blood sugar results) use for one of eight residents (R) R104) with a physician order for a glucometer reading. The deficient practices had the potential to place residents with a physician's order for glucometer testing at risk of infection due to cross-contamination and increase the spread of infection. Findings include: Review of the facility's undated policy titled Blood Glucose Monitoring, revealed the Policy Explanation and Compliance Guidelines section included .3. The nurse will abide by the infection control practices of cleaning and disinfection of the glucometer as per the manufacturer's instructions and in accordance with the facility's glucometer disinfection policy. An observation on 2/23/2025 at 11:05 am of Licensed Practical Nurse (LPN) AA performing a glucometer test on R104 revealed that LPN AA gathered the supplies, entered the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · F2023-10-31 · tag F0698 — failed to provide proper dialysis care — widespreadProvide 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, review of the Outpatient Dialysis Service Agreement, and review of policy titled Care of a Resident with End-Stage Renal Disease, the facility failed to ensure ongoing communication between the facility and the dialysis center for three of three residents (R) R22, R15, and R33 reviewed for dialysis. In addition, the facility failed to provide Physician Orders for dialysis services and ongoing monitoring for R22 dialysis access site. Substandard Quality of Care was identified related to Dialysis Findings include: Review of the policy titled Care for a Resident with End Stage Renal Disease revised September 2010, revealed the policy is residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Policy Interpretation and Implementation: 2. Education and training of staff includes, specifically: b. The type of assessment data that is to be gathered about the resident's condition on a daily or per shift…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-31 · 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 policy titled All foods stored will be properly labeled according to the following guidelines, the facility failed to ensure opened food items in the refrigerator were properly labeled, dated, and stored. This deficient practice had the potential to affect 47 of 48 residents who receive an oral diet from the kitchen. Findings included: Review of the policy titled Food Labeling and Dating revealed, under subsection titled, Discussion .B. Proper food labeling- All leftover foods or foods removed from their original containers require proper labeling when stored. Proper food labeling requires the following: NAME, IDENTIFICATION, DATE OF PREPARATION AND DATE FOODS ARE TO BE USED OR DISCARDED .2.(a) At the time food is being removed from its original container and placed in another container, DATE IT. During an initial kitchen tour with the Dietary Manager (DM) on 10/17/2023 at 8:47 am, an observation of the refrigerator revealed the following: *One medium size clear container of various chopped and shredded vegetables was…
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 · F2023-10-31 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespreadHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of policies titled Quality Assurance and Performance Improvement (QAPI) Committee and Quality Assurance Committee Report and Warrenton Health and Rehab QAPI Plan 2023, the facility failed to maintain and effective Quality Assurance and Performance Improvement (QAPI) program which systemically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility failed to show good faith in implementing the action plan, measure the success of the actions, and track performance related to Dialysis Communication Sheets for three of three residents receiving dialysis resources outside the facility. The census was 48. Findings include: Review of the policy titled Quality Assurance and Performance Improvement (QAPI) Committee dated July 2016, revealed Policy Interpretation and Implementation Number 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain, and oversee the QAPI program. Goals of the Committee: The primary goals of the committee…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-10-31 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and review of policies titled Surveillance for Infections, Legionella Water Management Program, Soiled Laundry and Bedding, and Handwashing/Hand Hygiene, the facility failed to maintain an effective Infection Prevention and Control Program (IPCP) that demonstrated ongoing surveillance, recognition, investigation, and control of infections to prevent the onset and spread of infections. Specifically, the facility failed to implement a procedure to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water system and failed to ensure infection control policies were followed during medication administration and handling and processing of linens, cleaning of lint traps, and personal items in the clean laundry storage. The facility census was 48. Findings include: 1. Review of the policy titled Surveillance for Infections revised September 2017 indicated the policy is the Infection Preventionist will conduct ongoing…
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 · F2023-10-31 · tag F0881 — failed to use antibiotics responsibly — widespreadImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of the policies titled, Surveillance for Infections and Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and document follow-up measures in response to the data for nine of nine months of infection control data reviewed (January 2023 through September 2023). The deficient practice had the potential to affect residents who were prescribed with an antibiotic. The facility census was 48 residents. Findings include: Review of the policy titled Surveillance for Infections with a revision date of September 2017, revealed the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventive interventions. 1. The purpose of the surveillance of infections is to identify both individual…
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 · F2023-10-31 · tag F0882 — widespreadDesignate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews the facility failed to ensure evidence that a qualified Infection Preventionist (IP) was serving in the position at the facility. This deficient practice had the potential for creating an ineffective infection prevention program that may contribute to the spread of infections for all residents in the facility. The census was 48 residents. Findings include: Interview on 10/18/2023 at 12:21 pm with Registered Nurse (RN) CC revealed he worked at the facility part-time and is currently working on the training modules to become certified as the IP for the facility. RN CC stated the Administrator asked him two weeks ago to step into the IP role. RN CC further stated the facility did not have a certified IP and he had not conducted any infection surveillance. Interview on 10/18/2023 at 12:25 pm with Administrator and Director of Nursing (DON) confirmed there was not a certified IP employed at the facility. Administrator stated she was not sure when the last IP left, as there was no one in the role when she started working at the facility a month ago. 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 · F2023-10-31 · tag F0940 — failed to train staff — widespreadDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews and review of the Facility Assessment, the facility failed to provide evidence of implementation and maintenance of an effective training program for all staff. This deficient practice had potential to adversely affect the care given to all residents in the facility. The facility census was 48. Review of the Facility Assessment 2023 revealed a listed acuity - diseases, conditions and treatments, cognitive, mental, and behavioral status, cultural, ethnic, and religious factors which the facility is equipped to care for. Under sections related to clinical staff cares on pages 27, 28, 30, 38, 41 revealed clinical staff are educated upon hire and checked off for skill competencies annually. Review of the undated form titled Annual Competency -LPN/RN revealed the competency covered introduction to the unit, policy and procedure books, resident chart, ordering supplies, emergency kits, phone and paging system, communication (24 hour report/EMR), universal precautions (hand hygiene/glove use), staff information/numbers, documentation guidelines, abuse, infection…
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 before2023-10-31 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of policy titled Quality of Life-Homelike Environment, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment in 11 of 49 resident rooms (101, 103, 104, 107, 108, 110, 112, 115, 118, 119, 318) and one of three shower rooms, as evidence by stained privacy curtains, stains on the bathroom floor tiles, broken drawer, baseboards, and curtain track, holes in ceiling tiles, scuffed walls and hole in wall, and lingering malodorous smell throughout the facility. Findings include: Review of the policy titled Quality of Life-Homelike Environment revised May 2017, revealed the policy is that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation Number 2 a. Clean, sanitary, and orderly environment; f. Pleasant, neutral scents. Observations on 10/17/2023 from 9:27 am to 3:27 pm…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-31 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of policy titled Abuse Prevention Program, the facility failed to obtain and complete reference checks for five of 10 employee records reviewed. Findings include: Review of the undated policy titled Abuse Prevention Program revealed Policy Interpretation and Implementation: Number 2: as a part of the resident abuse prevention, the administration will conduct background checks on employees and will not knowingly employe any individual found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, or mistreatment of residents or misappropriation of funds, or have a disciplinary action in effect against professional license by a state licensure body as a result of finding abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property. Review of employee files revealed reference checks were not completed for the Administrator, Director of Nursing (DON), Dietary…
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 · D2023-10-31 · 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 observations, record review, resident and staff interviews, and review of the policy titled Abuse Prevention Program, the facility staff failed to report an injury of unknown origin and potential abuse to the facility Administration and to the State Survey Agency (SSA) for one resident (R) R2 of 28 sampled residents. Specifically, Certified Nursing Assistant (CNA) GG was aware of bruising and open area to R2's left hand/arm and bruising to right hand, and failed to report it to Administration. Review of the policy titled Abuse Prevention Program revised December 2016, indicated the policy is that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention,…
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 · D2023-10-31 · 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 record review and staff interviews, the facility failed to ensure that a Discharge Minimum Data Set (MDS) assessment was transmitted within 31 days of completion to CMS (Center for Medicare and Medicaid Services) of Quality Improvement evaluation system (QIES) Assessment Submission and Processing (ASAP) for ten of 46 residents (R) (R17, R18, R22, R26, R29, R33, R40, R42, R48, and R50) sampled. Review of the Resident Assessment Task in the Long-Term Care Survey Process revealed MDS assessments identified as being more than 120 days old include: R17: Quarterly assessment dated [DATE] was coded as 'exported'; Quarterly assessment dated [DATE] coded as 'export ready'. R18: Quarterly assessment dated [DATE] was coded as 'export ready'. R22: Quarterly assessment dated [DATE] coded as 'exported' and end of PPS (Prospective Payment System) stay dated 8/31/2023 - end of PPS part A was coded as 'export ready'. R26: Annual assessment dated [DATE] was coded as 'exported' and Quarterly assessment dated [DATE] was…
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 before2023-10-31 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of the policy titled Behavioral Assessment, Intervention, and Monitoring, the facility failed to apply for Level two PASARR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for three of six sampled residents (R) (R16, R19, and R38) that were reviewed for Level two PASARR and found to have a positive Level I PASARR for mental illnesses prior to and on admission to the facility. The deficient practice had the potential for R16, R19, and R38 to be denied specialized services for psychological, psychiatric, and functional needs. Findings Include: Review of the policy titled Behavioral Assessment, Intervention, and Monitoring revised March 2019, revealed under Assessment 1. B. If the level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASARR representative for the Level two (evaluation 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 · D2023-10-31 · 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 5. Review of the care plan revised on 9/4/2023 for R5 revealed focus as requires assistance with ADLs related to dementia, limited mobility, right above the knee amputation, self-care deficit. She prefers a bed bath. The goals revealed staff will provide needed assistance with ADLs. Interventions included but were not limited to incontinent care on rounds and as needed. The position listed for this intervention was Certified Nursing Assistant (CNA), bathing/showering: assist with bed bath as scheduled (refer to bath sheets at nurse desk) and as needed. Avoid scrubbing and pat dry sensitive skin (date initiated 3/1/2022, revised on 3/24/2022) position listed for this intervention was CNA, LPN. Record review of Minimum Data Set (MDS) assessment dated [DATE] for R5 revealed in section G - Functional status required total assistance with 2+ person assistance for bed mobility, transfers, locomotion on and off unit, dressing, toilet use, personal hygiene, and bathing. Observation of CNA LL on 10/18/2023 at 10:42 am…
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 · D2023-10-31 · 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 observations, record review, resident and staff interviews, and review of the policy titled Supporting Activities of Daily Living (ADL), the facility failed to provide assistance with grooming for two of four dependent residents (R) (R44 and R15) related to nail care for Activities of Daily Living (ADLs). The findings include: Review of policy titled Supporting Activities of Daily Living revised March 2018, revealed residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate…
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 · D2023-10-31 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to provide treatment and services for one of 28 sampled residents (R) (R16) displaying symptoms of a known diagnosis of anxiety disorder, depression, bipolar disorder, schizophrenia, schizoaffective disorder, and altered mental status. Findings include: Record review of the admission Record for R16 revealed that she was initially admitted on [DATE]. A diagnosis included but was not limited to bipolar disorder, anxiety disorder, major depressive disorder, Schizophrenia, and schizoaffective disorder. Record review of the quarterly Minimum Data Set (MDS) for R16 dated [DATE] revealed under section O-Special Treatments, Procedures, and Programs-no therapies noted. Record review of a Behavior Note dated [DATE] R16 stated I am confused, where am I? throughout the beginning of pm shift. The resident required frequent redirection and positioning in bed to prevent issues or/and fall activities. Record review of a Behavior Note, dated [DATE] for R16 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.
- Potential for harm · D2023-10-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interviews, and review of the policy titled Antipsychotic Medication Use, the facility failed to ensure that psychotropic medications/antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) R16 reviewed for unnecessary medications. Findings include: Review of the policy titled Antipsychotic Medication Use, the policy statement revealed Antipsychotic medications will be prescribed at the lowest dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Review of the admission Record for R16 revealed the following diagnoses but not limited to bipolar disorder, anxiety disorder, major depressive disorder, schizophrenia, and schizoaffective disorder. Record review of the most recent quarterly Minimum Data Set (MDS) for R16 dated 8/4/2023 revealed section C- Cognitive Patterns-Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, section E-Behaviors-no behaviors exhibited, I-Active…
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 · D2023-10-31 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and review of the policy titled Administering Medications, the facility failed to ensure medications and biologicals were discarded by the expiration date and failed to ensure that all medications were secured and stored properly, for one of four medication carts. Findings include: Review of the policy titled Administering Medications, dated April 2019, revealed Policy Interpretation and Implementation Number 12: The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. Number 19: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation 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 · D2023-10-31 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interviews, review of training records, and review of the Alliant Health Solutions Staff Development, the facility failed to maintain an in-service training program to ensure the continuing competency of Certified Nurse Aides (CNAs) for the required 12 hours of annual in-service training. The census was 48. Findings include: Review of the Alliant Health Solutions staff development review dated 7/13/2023 indicated please ensure in the future that your yearly in-services include Quality of Care, transfers, turning and positioning, incontinent care/skin care, weight loss, and dining techniques (feeding, assistive devices . etc.) Also, the facility may want to include more in-service hours for Alzheimer's, cognitively impaired, and dementia. Interview on 10/19/2023 at 2:00 pm with Certified Medication Aide (CMA) HH revealed she did not remember the last time they received in-services on dining, Alzheimer's, dementia, transfers, turning and positioning, or quality of care. Interview on 10/19/2023 at 2:30 pm with Certified Nursing Assistant (CNA) FF stated she was unable 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.
“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 JOURNEY HEALTHCARE — 32 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 | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 2.3 | -0.3 vs chain |
| Staffing | 2 of 5 | 1.5 | +0.5 vs chain |
| Quality measures | 4 of 5 | 2.7 | +1.3 vs chain |
The other 31 homes this chain runs (chain average 1.9★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SELECTIS HEALTH INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/21/2021 |
| BALLER, LANCE | Individual | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 06/21/2021 |
| DAY, SARAH | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/26/2021 |
| DESMOND, ADAM | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/01/2023 |
| ECKHART, KRYSTAL | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/21/2021 |
| SELECTIS MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/21/2021 |
| CAMPBELL, KERON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/19/2025 |
| FERGUSON, LAURA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/12/2023 |
| HAHNER, MICHELLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/13/2023 |
| KUHN, SHAWN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/17/2022 |
| MCCORKLE, SHERRY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/14/2022 |
| OTHMAN, MOHAMED | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/08/2025 |
| PEACOCK, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/21/2021 |
| SMALL, NOVETTA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/15/2024 |
| TROST, JAMIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 09/08/2022 |
| FURSTENBERG, DAVID | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/24/2025 |
| NEUMAN, CLIFFORD | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | — | since 12/24/2025 |
CMS files one row per role, so the 35 rows in the source record cover these 17 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 88% 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 $660K paid to related parties — landlords or management companies under common ownership — equal to about 20% 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 115321. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-01, 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.