Brentwood Health Center by Harborview
115 Brentwood Drive, Waynesboro, GA 30830 · For profit - Corporation · 103 certified beds · (706) 554-4425 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 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 | 14.7% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 8.0% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.9% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 2.5% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 31.5% | 11.3% | 6.5% | check this† — see note marked dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.5% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 23.5% | 15.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 24.9% | 20.5% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.6% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 5.6% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 12.1% | 15.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.2% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.6% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 90.6% | 78.4% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 15.6% | 25.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 11.7% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 4.01 | 2.15 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.12 | 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.
Met the expected recovery: 52.2% 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 23 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 26% 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 | 11.6%CMS range 7.9–18.3 | 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 | 52.2% | 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 | 56.5% | 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 | 43.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 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 | 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 | 0.0% | 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 | 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 | 0.84 | 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 103 beds and averages 95.3 residents a day — about 93% occupied, or roughly 8 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.12 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 3.88 hrs/resident/day on weekends vs 3.92 on weekdays — 1% thinner on weekends. RN hours go from 1.03 to 1.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · F2025-06-15 · 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 policies titled Labeling and Dating Guidelines and Standard of the Week Labeling and Dating, the facility failed to ensure food items were labeled with open and/or discard dates and discarded on or before the discard dates. This had the potential to place 64 residents who received an oral diet from the kitchen at risk of food-borne illness. Findings include: Record review of the facility's undated policy titled Standard of the Week Labeling and Dating included, Upon receipt, all items should be inspected and marked with the date it was received into your facility and the date it should be discarded (if the item has a use by or discard date already on it, then you may use this date. After opening any item, the date it was opened must be clearly labeled on the front of the package, and any adjustments to the discard date should be made at this time. Review of the facility's undated policy titled Labeling and Dating Guidelines included, Upon receipt, all items should have a received date and a use 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 · F2025-06-15 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, record review, and review of the facility policy titled Garbage and Rubbish Disposal, the facility failed to maintain two of three facility dumpsters in a sanitary condition by ensuring the dumpsters had fitted lids and doors to prevent exposure to insects and rodents. The deficient practice created the potential to promote the harboring of pests, insects, and other organisms, and create the potential for disease transmission by pests and rodents. Findings include: Review of the facility policy titled Garbage and Rubbish Disposal, dated 2008, revealed the Policy Statement of Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. The Policy Interpretation and Implementation section included . 8. Outside dumpsters provided by garbage pick-up services must be kept closed and free of litter around the dumpster area. Concurrent observation and interviews on 6/13/2025 at 8:22 am, with Dietary Aide (DA), HH, and Maintenance Assistant GG, revealed three dumpsters with large gaps between the lids,…
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 · F2025-06-15 · 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, staff interviews, and review of the facility policy titled Infection Prevention and Control Program, the facility failed to ensure soiled and clean linen carts were not stored together on three of five halls (300 Hall, 400 Hall, and 500 Hall). The deficient practice had the potential to increase the probability of the spread of infection from the soiled linen to the clean linen used while care services were being provided to residents. Findings include: Review of the facility policy titled Infection Prevention and Control Program, dated 8/24/2022, revealed under Policy statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Under Prevention of infection: The facility will follow recommended and required guidelines to help mitigate or prevent infections as listed below: 1. Identifying possible infections or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-15 · 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
Based on observations, staff interviews, and record review, the facility failed to ensure that one of 29 sampled residents (R) (R6) was treated in a manner that maintained or enhanced his/her dignity. Specifically, staff provided care to R6 without providing full visual privacy. This deficient practice had the potential to place R6 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of R6's electronic health record (EHR) revealed diagnoses including, but not limited to, moderate intellectual disability, epilepsy, chronic kidney disease, and anxiety disorder. Review of R6's Annual Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed Section C (Cognitive Patterns) documented a Brief Mental Status Score (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required assistance with Activities of Daily Living (ADLs). Section H (Bladder and Bowel) documented that the resident was incontinent.…
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 · D2025-06-15 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to ensure one of five residents (R) (R28) with a qualifying diagnosis was referred to the Georgia Preadmission Screening and Resident Review (PASRR) Utilization Management for review. This deficient practice had the potential to increase the probability of R28 not having her mental and psychological care needs met. Findings include: Review of R28's admission Record revealed admission on [DATE] with the diagnoses including, but not limited to, bipolar II disorder, obsessive-compulsive behavior, major depressive disorder, anxiety disorder, and psychosis. Review of R28's Annual Minimum Data Set (MDS), dated [DATE], revealed Section A (Identification Information) revealed the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active diagnoses) documented diagnoses including, but not limited to, anxiety disorder, depression, bipolar disorder, 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 · D2025-06-15 · 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
2. Review of R11's EHR revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, pulmonary candidiasis, and unspecified atrial fibrillation. Review of R11's Care Plan Report revealed a Focus Area, created 6/5/2024, for oxygen therapy. Interventions included oxygen as ordered. Review of R11's Physician Order revealed an order dated 517/2024 for O2 at 5 LPM every shift. Observations on 6/13/2025 at 10:07 am and at 1:04 pm revealed R11 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 10:13 am, with LPN EE, revealed R11 receiving O2 therapy by oxygen concentrator at 7 LPM via a NC. LPN EE confirmed that the flow rate was set in error and against the physician's order of 5 liters per minute, and adjusted the flow rate. 3. Review of R122's EHR revealed an admission date of 6/9/2025, with diagnoses including, but not limited to, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and presence of an automatic (implantable)…
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 · D2025-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, the facility failed to ensure one of 29 sampled residents (R) (R6) received care and services to avoid preventable falls. This deficient practice had the potential to place R6 at risk of injury related to avoidable falls. Findings include: Review of R6's electronic health record (EHR) revealed diagnoses including, but not limited to, epilepsy, chronic moderate intellectual disability, chronic kidney disease, age relate nuclear cataract, bilateral, anxiety disorder, and hypertension. Review of R6's Annual Minimum Data Set (MDS) assessment, dated 4/1/2025, revealed Section C (Cognitive Patterns) documented a Brief Mental Status Score (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required assistance with Activities of Daily Living (ADLs). Section V (Care Area Assessment [CAA] Summary) documented that falls were triggered. Review of R6's Fall Risk Assessment assessed the resident as a high risk for falls. Review of R6's Care Plan Report…
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 · D2025-06-15 · 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 2. Review of R11's EHR revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, pulmonary candidiasis, and unspecified atrial fibrillation. Review of R11's Annual MDS assessment, dated 5/21/2025, revealed Section J (Health Conditions) revealed R31 exhibited shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Section O (Special Treatments, Procedures, and Programs) revealed R31 received O2 therapy while a resident. Review of R11's Physician's Orders included an order dated 5/17/2024 for O2 via NC at 5LPM continuous every shift. Observations on 6/13/2025 at 10:07 am and at 1:04 pm revealed R11 receiving O2 therapy by oxygen concentrator at 3.5 LPM via a NC. Observation on 6/14/2025 at 10:13 am, with LPN EE, revealed R11 receiving O2 therapy by oxygen concentrator at 7 LPM via a NC. LPN EE confirmed that the flow rate was set in error and against the physician's order of 5 liters per minute, and adjusted the flow…
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 · D2023-08-24 · 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 a review of the facility's policy titled, MDS Completion and Submission Timeframes, the facility failed to ensure that the Minimum Data Sets (MDS) assessments were submitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion to ensure current and accurate data for five of 27 Residents (R) (#19, R#20, R#145, R#3, and R#17) reviewed for MDS assessments. Findings include: A review of facility policy titled MDS Completion and Submission Timeframes, last revised 4/10/2017 revealed The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to Center for Medicare and Medicaid Services (CMS) QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. It also revealed that data for assessment types; Admission, Annual, Significant Change in Status, and Significant Correction to prior MDS, were required to be transmitted within 14 days…
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 · D2023-08-24 · 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
2. Record review revealed R#244 had a diagnosis of depression, anxiety disorder, and chronic pain syndrome. Record review of the Physician Orders for R#244 revealed an order for lorazepam oral concentrate 2 milligrams (mg)/milliliters (ml), give 0.5 ml by mouth every 3 hours as needed for restlessness. The stop date on the order stated indefinite. Record review of the Medication Administration Record (MAR) for R#244, dated August 2023, revealed that the resident had received a one-time dose of lorazepam upon admission, and a subsequent lorazepam PRN order had been received on 8/17/2023. The MAR indicated a start date for the lorazepam, but no end date. An interview on 08/24/2023 at 2:00 p.m. with DON confirmed that the physician order for R#244 regarding the PRN lorazepam did not have an expiration date. She stated that since the resident was on hospice, the pharmacist should automatically call within 14 days to see if the physician wanted to continue the order, even if there was not a designated stop date on the order. A phone interview on 8/23/2023 at 3:10 p.m. with Registered…
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.
- No harm found · C2025-06-15 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, review of facility documentation, and review of the facility policy titled Posting Direct Care Daily Staffing Numbers, the facility failed to ensure the number of nursing personnel responsible for providing direct care to residents was posted daily for staff and visitors to review while in the facility. Findings include: Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, dated 3/23/2017, revealed under policy statement: Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Under Policy Interpretation and Implementation: 1. Within two (2) hours of the beginning of the shift, the number of Licensed Nurses (RNs [Registered Nurse], LPNs [Licensed Practical Nurse], and LVNs [Licensed Vocational Nurse]) and the number of unlicensed nursing personnel (CNAs [Certified Nurses Assistant]) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable…
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.
- 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 HARBORVIEW HEALTH SYSTEMS — 22 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 | 2.1 | -0.1 vs chain |
| Staffing | 2 of 5 | 2.4 | -0.4 vs chain |
| Quality measures | 3 of 5 | 2.3 | +0.7 vs chain |
The other 21 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 | Since |
|---|---|---|---|
| MID GA HEALTH PROPERTIES LLC | Organization | DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 05/01/2023 |
| DAVIS III, WILLIAM C | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| DAVIS, WILLIAM | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| ORNE, DAVID | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| PARKER, DAVID | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| WESTBURY, JAMES R | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| WINDHAM, ASHTON | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| WINDHAM, SPENCER | Individual | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2023 |
| CROSSROADS MEDICAL MANAGEMENT, INC. | Organization | ADP OF THE SNF | since 05/01/2023 |
| DAVIS & CLEVELAND CPAS, LLC | Organization | ADP OF THE SNF | since 05/01/2023 |
| MGHP RE BRENTWOOD LLC | Organization | ADP OF THE SNF | since 05/01/2023 |
| PARKER FINANCIAL SOLUTIONS, LLC | Organization | ADP OF THE SNF | since 05/01/2023 |
| WINDCORP CONSULTANTS LLC | Organization | ADP OF THE SNF | since 05/01/2023 |
| STAFFORD, ELISE | Individual | ADP OF THE SNF | since 02/09/2024 |
CMS files one row per role, so the 29 rows in the source record cover these 14 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.
6 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.
This home reported $540K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 115361. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-15, 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.