Winder Center For Nursing And Healing
263 E May Street, Winder, GA 30680 · For profit - Limited Liability company · 163 certified beds · (770) 867-2108 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $17,074 in federal fines (most recent 2024-10-18)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
- about 18% 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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 held steady at 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.4% | 15.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 7.4% | 5.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.7% | 2.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.3% | 11.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 2.9% | 3.2% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 15.9% | 15.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.3% | 20.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 96.3% | 95.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 5.6% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 21.1% | 15.8% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.1% | 19.9% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.2% | 2.6% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 85.9% | 78.4% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 28.9% | 25.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 11.9% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.81 | 2.15 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.34 | 1.90 | 1.80 | better |
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
51.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 171 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 68.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 91 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 0.29 therapist hours per resident per day in 2026Q1 — more than 44% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 14% 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 | 51.8%CMS range 41.8–59.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.3%CMS range 9.2–15.3 | 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 | 68.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 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 | 44.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.7% | 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 | 93.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 94.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 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 | 2.0% | 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 | 8.9%CMS range 5.7–12.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 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 163 beds and averages 140.5 residents a day — about 86% occupied, or roughly 22 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.32 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.60 on weekdays — 19% thinner on weekends. RN hours go from 0.41 to 0.09 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% 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 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.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · J2024-10-18 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy titled Care Plan, Comprehensive Person-Centered, and staff interviews, the facility failed to follow the care plan for skin assessments for one resident (R) (R145) of six residents reviewed for pressure ulcers. On 10/10/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Operations, Regional Director of Clinical Operations, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 10/10/2024 at 10:53 am. The noncompliance related to the IJ was identified to have existed on 2/16/2024. An Acceptable IJ Removal Plan was received on 10/11/2024. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and 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.
- Immediate jeopardy · J2024-10-18 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, review of facility policy titled Pressure Injury Prevention and Management, and staff interviews, the facility failed to provide the necessary care and services to prevent the development and worsening of pressure ulcers for one of six residents (R) (R145) reviewed for pressure ulcers. Specifically, the facility failed to ensure weekly skin assessments and wound observations were completed for R145 and failed to provide the recommended treatment for a sacral pressure ulcer. On 10/10/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Regional Director of Operations, Regional Director of Clinical Operations, and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 10/10/2024 at 10:53 am. The noncompliance related to the IJ was identified to have…
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 · F2026-01-22 · tag F0628 — widespreadProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and a review of the facility policies titled Transfer and Discharge [including Against Medical Advice (AMA)] and Bed Hold Prior to Transfer, the facility failed to provide residents and their Resident Representatives (RR) with the required written transfer and bed-hold notices following emergent hospital transfers for four of four sampled residents (R) (R93, R10, R155, and R34). This failure limited residents' and representatives' ability to understand appeal rights and access Ombudsman information, placing all residents at risk for potential denial of readmission and loss of their residence after hospitalization.Findings included:A review of the facility's policy titled Transfer and Discharge [including Against Medical Advice (AMA)], dated March 2025, revealed that the facility's transfer/discharge notice will be provided to the resident and resident representative; the notice will include all of the following at the time it is provided: A. The specific reason and basis for transfer or discharge. B. The effective date of transfer or discharge. C.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-01-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, and a review of the facility policy titled Sanitation, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried pots, pans, and food service equipment before storage. This failure increased the potential risk of foodborne illness and had the potential to affect 143 of the 146 residents receiving dietary services.Findings included:A review of the facility policy titled Sanitation, dated April 2024, revealed that the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves, and equipment shall be kept clean and maintained in good repair. All equipment, utensils, and food contact surfaces shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Food preparation equipment and utensils that are washed and sanitized will be allowed to air dry.During an observation and interview on 1/19/2026 at 9:40 am, the Dietary Manager (DM) confirmed six pans, 6 inches by 12 inches by 4…
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 · F2026-01-22 · 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, interviews, and a review of the facility's policy titled Food-Related Garbage & Rubbish Removal, the facility failed to ensure proper disposal and containment of waste in two of the two dumpsters. This failure had the potential to affect all 146 residents, as well as visitors and staff, and increased the risk of attracting pests.Findings included:A review of the facility's policy titled Food-Related Garbage & Rubbish Removal, dated April 2024, revealed that food-related garbage and rubbish shall be disposed of in accordance with current local and state laws regulating such matters. All garbage and rubbish containing food waste shall be kept in containers. Garbage and rubbish containing food waste will be stored in a manner that is inaccessible to vermin. Outside dumpsters provided by garbage pick up services will be kept closed, have a drain plug in place, and be free of surrounding litter.During an observation and interview on 1/19/2026 at 10:00 am with the Dietary Manager (DM) of the enclosed area in the parking lot behind the building, where the trash…
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 · F2026-01-22 · 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 document review, interviews, and a review of the facility's policy titled Antibiotic Stewardship Program, the facility failed to ensure antibiotics were prescribed only when a diagnosed infection was present for eight of 12 months of antibiotic stewardship reviewed. This failure had the potential to affect all residents in the facility and to increase the risk of adverse events, including the development of antibiotic-resistant organisms, due to unnecessary or inappropriate antibiotic use.Findings included:A review of the facility's policy titled Antibiotic Stewardship Program, dated October 2025, indicated, It is the policy of this facility to implement an Antibiotic Stewardship Program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines. 4. The program included antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols . ii. Laboratory testing shall be in accordance with current standards of practice. Iv. 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 · D2026-01-22 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as 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 interviews, record review, and a review of the facility policy titled Resident Assessment- Coordination with PASRR Program, the facility failed to complete a Level II pre-admission screening and resident review (PASARR) evaluation after a resident received a post-admission mental illness diagnosis for one of 32 sampled residents (R) (R41). This deficient practice could lead to residents not receiving necessary services.Findings included:A review of the facility policy titled Resident Assessment- Coordination with PASRR Program, revised Decemebr 2024, revealed that the facility coordinates assessments with the preadmission screening and resident review [PASARR] program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-22 · tag F0804 — failed to serve food at safe, palatable temperature — isolatedEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews, record review, and review of the facility's policy titled Food Preparation and Service, the facility failed to ensure residents were served food that was palatable to four of 32 sampled residents (R) (R131, R93, R160, and R48). Findings included:A review of the undated facility policy titled Food Preparation and Service revealed that food service employees shall prepare and serve food in a manner that complies with safe food handling practices. The Cooking and Holding Temperatures and Times section noted that the danger zone for food temperatures is between 41 degrees and 135 degrees, and that this temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses. The facility policy failed to address specific temperatures for food being served other than actual cooking temperatures. 1. A review of R131's electronic medical record (EMR) Face Sheet indicated an admission date of 1/26/2023 and a readmission date of 3/12/2025. A review of R131's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD)…
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 · D2026-01-22 · 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, interviews, record review, and a review of the facility's policy titled Handwashing/Hand Hygiene, the facility failed to ensure hand hygiene was performed following the administration of inhaled medication for one of six residents (R) (R53) observed during medication administration. The failure to perform proper hand hygiene created a risk for bacterial contamination of medication cart supplies and increased the potential for infection transmission.Findings included:A review of the facility's undated policy titled Handwashing/Hand Hygiene revealed that the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; alternatively, soap [antimicrobial or non-antimicrobial] and water for the following situations: Before and after direct contact with residents.A review of R53's electronic medical record (EMR) Face Sheet revealed an admission date of 2/11/2025. R53 had diagnoses including chronic obstructive pulmonary disease (COPD).A review of R53's Orders tab of the EMR…
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 · D2026-01-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and a review of the facility's policy titled Pneumococcal Vaccine (Series), the facility failed to ensure that one of five residents (R) (R41) was offered and administered pneumococcal vaccinations in accordance with nationally recognized standards. Specifically, the facility failed to offer or administer the appropriate pneumococcal vaccine to R41, who was eligible to receive either Prevnar 20 (PCV20) or PCV15 one year after receiving Pneumovax 23 (PPSV23). Additionally, the facility failed to obtain a complete vaccination history, provide education regarding the pneumococcal vaccine, and secure a signed consent indicating refusal of the vaccine for a resident (R58). These failures had the potential to increase residents' risk of contracting pneumonia.Findings included:A review of the facility's policy titled, Pneumococcal Vaccine (Series), dated April 2022, indicated, Policy: It is the policy to offer our residents . immunization against pneumococcal disease in accordance…
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 · D2026-01-22 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interviews, and a review of the facility's policy titled COVID-19 Vaccination, the facility failed to ensure that one of five residents (R) (R58) reviewed for Coronavirus disease 2019 (COVID-19) immunization received education regarding the risks and benefits of the COVID-19 vaccine/booster before declining vaccination.Findings included:A review of the facility's policy titled, COVID-19 Vaccination, dated December 2025, indicated, It is the policy of this facility . by educating and offering our residents . the COVID-19 vaccine . Policy Explanation and Compliance Guidelines . 11. COVID-19 vaccination will be offered to residents . 14. The facility will educate and offer the COVID-19 vaccine to residents and maintain documentation of such . 21. The resident's medical record will include the documentation of the following: a. Education to the resident . regarding the risks, benefits, and potential side effects of the COVID-19 vaccine . c. If the resident did not receive the COVID-19 vaccine due to . refusal . A review of R58's EMR Face Sheet indicated an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and resident and staff interviews, the facility failed to ensure the advanced directive was documented accurately throughout the Electronic Medical Record (EMR) for one resident (R) (R397) of 40 residents reviewed for advanced directive. Findings include: Review of the EMR revealed R397 was originally admitted to the facility on [DATE] with multiple diagnoses including, but not limited to Sepsis, Chronic Diastolic (Congestive) Heart Failure, Acute Kidney Failure, Respiratory Failure with Hypoxia, Psoriatic Arthritis and Hyperlipidemia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R397 had a Brief Interview for Mental Status (BIMS) score of 13, indicating R397 is cognitively intact. Review of the Physician Order for Life-sustaining Treatment (POLST) form dated 7/24/2024, revealed R397's code status as Allow Natural Death- Do Not Attempt Resuscitation. The POLST code was signed by R397, the Medical Director and an additional facility physician. Review…
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 5 citations
- Potential for harm · D2024-10-18 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interviews, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (Form CMS-10123), and facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS-100550) to two of three residents (R) (R94 and R397) reviewed that were discharged from Medicare Part A coverage. Findings include: Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed the following: 1. R94 was discharged from Medicare Part A skilled services on 9/23/2024 and remained in the facility. 2. R397 was discharged from Medicare Part A skilled services on 9/24/2024 and returned home. There was no documented evidence that the SNF ABN and/or NOMNC were provided to either R94 and R397 or their respective responsible parties. During an interview on 10/3/2024 at 4:22 pm, the Business Office Manager (BOM) revealed the facility did not provide the SNF ABN and NOMNC documents to R94 or R397. The BOM stated the Social Services and Therapy employees were new to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed records review, interviews, and review of facility policy titled Blood Glucose Monitoring, the facility failed to ensure professional standards were followed for blood sugar monitoring of one resident receiving insulin of seven residents (R) (R146) reviewed for unnecessary medications. Findings include: Review of the facility policy titled Blood Glucose Monitoring dated March 2024 revealed it is the policy of the facility to perform blood glucose monitoring to a diabetic resident as per physician orders. There was no documentation related to the protocol for blood glucose monitoring for resident's receiving insulin. R146 was admitted to the facility on [DATE]. R146's diagnoses included diabetes. Review of the care plan dated 6/21/2024 revealed the resident has Diabetes Mellitus with interventions including but not limited to diabetes medication as ordered by doctor, and monitor/document for side effects and effectiveness. Review of the admission history and physical (H/P) dated 6/21/2024,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-18 · tag F0691 — failed to provide colostomy / ostomy care — isolatedProvide appropriate colostomy, urostomy, or ileostomy 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 staff/resident interviews, record review and review of the facility policy titled Ostomy Care-Colostomy, Urostomy and Ileostomy, the facility failed to obtain a physician order for colostomy care for one of one resident (R) (R396) who required colostomy services. Findings include: Review of the facility policy titled Ostomy Care-Colostomy, Urostomy and Ileostomy, last reviewed in January 2024 revealed that as part of the comprehensive assessment and care planning process, a licensed nurse will determine the actual type of ostomy through physical assessment, medical record, and collaboration with the attending physician. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R396 had a Brief Interview for Mental Status (BIMS) score of 14; indicating R396 was cognitively intact. Additionally, review of Section H of the MDS - under ostomy (including urostomy, ileostomy, and colostomy) was marked yes. Review of R396's Electronic Medical Record (EMR), R396 was originally…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-08-11 · 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, interviews, and policy review, the facility failed to maintain sanitary conditions of the kitchen equipment including the ice maker, interior sides of the beverage cooler, mixer, two deep fryers, knifes, and the floors and walls of the dry storage area. In addition, the facility failed to label and date items in an upright cooler. The census was 100 residents, and the sample size was 33. Findings include: 1. Review of the policy titled Cleaning and Sanitation of Dining and Food Service Areas dated 2017, revealed the director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department, designate tasks, and post a cleaning schedule for all tasks. It is the Dietary Manager's (DM) responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Observations on 8/9/22 between 8:45 a.m. through 9:20 a.m. during the initial tour with the Assistant Dietary Manager (ADM), revealed the following concerns: Ice maker had brown debris on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · 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 policy review, the facility failed to ensure resident's dignity was maintained by not displaying confidential clinical information indicating clinical status or care needs for two residents' (R) (R#51 and #24) openly posted in the resident's room. The sample size was 38. Findings include: Review of the policy titled Resident Rights dated 2017, revealed Number 8. Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and residential groups. Review of the policy titled HIPAA Security Measures revised 2/20/22, revealed the policy is to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information. 1.Review of the clinical record…
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
$17,074 in federal fines across 2 penalties.
- $8,537 — penalty dated 2024-10-18
- $8,537 — penalty dated 2024-10-18
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EMPIRE CARE CENTERS — 20 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 1.9 | -0.9 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 1 of 5 | 1.5 | -0.5 vs chain |
| Quality measures | 3 of 5 | 3.0 | ≈ chain avg |
The other 19 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 |
|---|---|---|---|---|
| ENSH CONSULTING LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 95% | since 02/01/2023 |
| DONATH, BARRY | Individual | W-2 MANAGING EMPLOYEE | — | since 02/01/2023 |
| NG, SCOTT | Individual | W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
| HELLER, SHLOMO | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
| EMPIRE CARE CENTERS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/04/2023 |
| NUSSBAUM, EPHRAIM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
| SWERDLOFF, ARYEH | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 02/01/2023 |
CMS files one row per role, so the 9 rows in the source record cover these 7 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 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.5M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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 115536. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-22, 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.