Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altamaha Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and insufficient oversight was observed.
Grievance Policy Missing Required Resident Rights and Complaint Procedures: The facility’s grievance policy did not include required procedures for residents to file grievances orally or in writing, file anonymously, receive a written response within a reasonable timeframe, or obtain contact information for the grievance official and outside entities. The policy also lacked language on protecting residents from discrimination or reprisal, making prompt efforts to resolve grievances, and providing residents with information on how to file a grievance or complaint. The Administrator and RNC confirmed the policy did not meet regulatory requirements.
Unlocked Medication Carts: The facility failed to keep medication carts locked when they were out of the nurse's sight, contrary to its Medication Administration policy. An unlocked cart was observed in the 300 Hall while the nurse was in a room down the hall, and another unlocked cart was found by a room with three medication bottles on top. An LPN stated she should have locked the cart when she walked away, and the LPN Unit Manager, DON, and Administrator all stated carts must be locked when not in the nurse's sight.
Delayed Saturday Mail Delivery: Residents did not receive mail delivered to the facility's locked mailbox on Saturdays until Monday morning. Six residents reported the delay during Resident Council, and the AD stated weekend mail stayed in the mailbox if she was not at work. The DON was unaware of the Saturday process, and the Administrator had not considered weekend mail delivery.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 22.2% medication error rate, with multiple errors during med pass observations. An LPN omitted ordered meds for one resident and gave the wrong insulin dose without priming the pen needle; other LPNs also failed to prime insulin pen needles for two additional residents, and one LPN UM did not hold the pen in place long enough during Lantus administration. Staff stated they did not know the pen needles needed to be primed, while the DON, NP, and Administrator confirmed insulin pens should be primed before use.
An LPN failed to clean and disinfect a glucometer between resident blood sugar checks and also touched medication with bare hands during administration. In addition, respiratory equipment for two residents was observed improperly cleaned and stored, including a nebulizer mask and canister left with fluid and a CPAP mask left with debris and no proper storage bag. The facility’s own policies and the manufacturer’s instructions required cleaning and disinfection between uses and proper storage of respiratory devices.
Failure to obtain informed consent for psychotropic medication: A resident with vascular dementia, seizures, and moderate cognitive impairment received quetiapine for behavior management before proper consent was obtained. The resident stated they did not know what the medication was for and signed the form only after being told it would be given for a couple more days. Staff interviews showed confusion over who was responsible for obtaining psychotropic medication consents, and the DON and Administrator stated consent should be obtained before the medication is administered.
Failure to report allegations of abuse and neglect involving two residents. One resident with intact cognition and frequent incontinence reported that a CNA was rough during care and did not provide incontinence care for an entire shift. Another resident with moderate cognitive impairment and bowel and bladder incontinence reported that the same CNA yelled at them after a BM. The DON and Administrator stated both incidents were abuse allegations that should have been reported to the state agency.
Failure to Investigate Allegations of Abuse and Neglect: The facility did not document investigations for two residents after allegations involving a CNA were reported. One resident with chronic pain and intact cognition said the CNA did not provide incontinence care during an entire shift and was rough during care. Another resident with moderate cognitive impairment and bowel/bladder incontinence reported the CNA yelled at them after a BM accident. The Administrator and RNC could not find evidence of an investigation, despite the facility policy requiring thorough investigation of all alleged abuse or neglect.
Failure to update PASARR after new mental illness diagnoses. A resident with vascular dementia, anxiety, and bipolar disorder had an MDS showing moderate cognitive impairment and active anxiety and bipolar diagnoses, with care plan entries for anti-anxiety and antidepressant use. The record showed no evidence that a new PASARR Level I was completed after the new diagnoses were identified, and staff interviews confirmed that a new PASARR should have been submitted but was not.
Failure to provide nail care for a resident with diabetes and cognitive impairment. The resident’s toenails on both feet were observed to be long and extended past the toes on repeated observations, and the resident was not listed in the podiatry visit history. Staff interviews showed CNA staff handled cleaning, nurses handled trimming, and podiatry was expected to address toenails, but the LPN UM stated the resident should have been on the podiatry list and was not sure why they were not.
A resident with seborrheic dermatitis and other skin integrity risks had outside dermatology recommendations for triamcinolone, ketoconazole cream, and fluorouracil, but the facility only had an order for after-care to the forehead area. The NP, treatment LPN, LPN UM, DON, and Administrator all stated the dermatology consult was not followed up on or received, and the Administrator acknowledged this resulted in a delay in treatment.
A resident with OSA and an active CPAP order did not have a functioning mask and tubing available for use. Staff observed the CPAP machine on the nightstand, but the mask was missing or not attached during multiple checks. The resident said they had been asking for a new mask for months and reported worse sleep and snoring. An LPN said the request was passed on but not followed up, and the DON said she had not yet contacted the family or DME company for replacement parts.
Incomplete and Inaccurate Resident Records: The facility failed to keep accurate medical records for two residents. One resident’s smoking status was inconsistent across the MDS, smoking assessment, care plan, and staff/resident interviews, with the resident and multiple staff stating the resident smoked cigarettes despite a record showing the resident did not smoke. A second resident’s MAR showed numerous medications, including insulin, potassium chloride, Lasix, and other scheduled meds, were documented as given one hour or more late; staff stated the meds were given on time but signed out later, and leadership stated documentation should occur when the medication is given.
The facility failed to maintain food safety and sanitation standards, risking food-borne illness for 52 residents. Observations showed improper food storage, expired items not disposed of, and bare-hand contact with ready-to-eat food. Moldy strawberries were found, and staff lacked awareness of proper food handling procedures.
The facility failed to follow infection control protocols, including proper cleaning of a glucometer between residents and maintaining TB testing records for staff. A nurse used a glucometer without cleaning it per manufacturer's instructions, and six staff files lacked required TB test documentation. Additionally, the facility did not maintain a current infection surveillance program for 2024.
The facility failed to provide written information about the right to formulate an advance directive to five residents or their representatives. Despite the facility's policy requiring this information to be given upon admission or readmission, documentation was missing for these residents, including those with varying levels of cognitive impairment. The Social Services Director confirmed the lack of documentation, indicating a systemic issue in the facility's process.
The facility did not follow its policy to conduct background and criminal checks for four staff members, including CNAs, an LPN, and a DA. The Administrator could not provide the necessary documentation, attributing the lapse to the absence of a Human Resource Director responsible for managing this information.
The facility failed to provide written transfer notices to residents and their representatives during emergent hospital transfers, as required by policy. This affected several residents with various medical conditions, including severe cognitive impairments. Staff interviews revealed uncertainty about responsibility for issuing these notices, and the Administrator confirmed that transfer notices had not been sent to the Ombudsman since taking over the role.
The facility failed to provide written bed hold notices to several residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through record reviews and staff interviews, revealing a lack of clarity about responsibility for issuing these notices. Residents with various medical conditions, including severe cognitive impairments, were affected by this oversight.
A facility failed to update a resident's care plan to include fall interventions such as a low bed, geri chair, and fall mats, despite the resident's moderately impaired cognition and recent falls. Additionally, required care plan conferences were not documented since the resident's admission, as confirmed by staff interviews.
The facility failed to document proper assessments and alternatives for bed rail use for three residents. One resident was observed with assist bars despite no documented failed alternatives, while another had no recent bed rail assessment. The administrator confirmed the lack of documentation, increasing potential risks associated with bed rail use.
A resident in the facility did not receive several prescribed medications due to delays in pharmacy delivery and lack of follow-up documentation. The medications, including Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, were not administered as ordered, and there was no documentation explaining the missed doses. Staff interviews revealed issues with pharmacy delivery times and procedures for handling unavailable medications.
Facility nurses failed to document behaviors and nonpharmacological interventions before administering Seroquel IM to a resident with moderately impaired cognition. The resident's EMR showed orders for Haldol IM for agitation, but the MAR lacked documentation of behaviors or interventions prior to medication administration. The Regional Operations Manager confirmed the absence of documentation, indicating non-compliance with the facility's behavior management policy.
A significant medication error occurred when a resident with diabetes did not receive insulin as ordered due to its unavailability. A registered nurse attempted to administer insulin but found it belonged to another resident. The resident missed multiple insulin doses, and the facility's policy for medication administration was not followed. The Medical Director stated that he could have arranged for the insulin from a local pharmacy if notified of the delay.
The facility failed to post daily nurse staffing information accurately for three out of four survey days, affecting the transparency of available nursing staff for 52 residents. Observations revealed missing postings, and the Administrator confirmed the oversight.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision in the area, as directly observed by surveyors.
Grievance Policy Missing Required Resident Rights and Complaint Procedures
Penalty
Summary
The facility failed to develop a grievance policy that met all regulatory requirements. Review of the facility’s Grievance Policy, dated January 2025, showed it did not include procedures to notify residents of their right to file a grievance in writing or orally, the right to file anonymously, the reasonable timeframe for a completed review, the right to receive the review in writing, the required contact information for the grievance official, or the contact information for outside entities where grievances could also be filed. The policy also did not identify the grievance official or include steps to prevent any further potential violation of a resident’s rights during the grievance review. The policy further did not describe how the facility supported a resident’s right to voice grievances without discrimination, reprisal, or fear of reprisal, how it made prompt efforts to resolve grievances, or how information on filing a grievance or complaint was made available to residents. During interviews, the Administrator stated the grievance policy was the only policy the facility had and she was not aware of any other policy. The RNC stated the grievance policy did not meet the regulatory requirements and noted that some requirements were addressed under resident rights but were not reflected in the grievance policy. The Administrator later stated she used the policies provided by the company and ensured they were followed, and that her expectation was for the grievance policy to cover all areas of the regulation.
Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that medication carts were locked when they were out of the sight of the licensed nurse, as required by the facility's Medication Administration policy. The policy dated 1/2025 stated that medication carts are to be kept locked at all times and under the visual supervision of the licensed nurse. During an observation on 8/4/2025 at 11:22 am, the medication cart in the 300 Hall was unlocked while the nurse was in a room down the hall. During a concurrent observation and interview on 8/6/2025 at 8:45 pm, a medication cart located by room [ROOM NUMBER] was unlocked and had three bottles of medications on top of it: iron, melatonin, and docusate sodium. The LPN stated the cart should have been locked when she walked away from it, but a resident needed something from her. The LPN Unit Manager, DON, and Administrator each stated the cart should be locked at all times when not in the nurse's sight.
Delayed Saturday Mail Delivery
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when Saturday mail was not delivered to residents until Monday morning. Mail was delivered by the post office to a locked box outside the facility on Saturdays, but no staff retrieved it for resident distribution until the next business day. The facility's policy titled Resident Rights & Dignity Management, dated January 2025, stated the facility would make every effort to assist each resident in exercising their right to be treated with respect, kindness, and dignity. During a Resident Council meeting, six residents stated they did not receive mail on Saturdays and reported that the Activities Director delivered weekend mail on Monday mornings. The Activities Director stated that if she was not at work when mail was delivered, it remained in the mailbox until she returned on Monday. The DON stated she had believed the AD retrieved and distributed the mail and was unaware of what occurred with Saturday mail. The Administrator stated she had not considered weekend mail delivery and had no expectations for Saturday distribution until she later stated the manager on duty would check and distribute residents' mail on Saturdays. The Regional Operations Manager stated the facility did not have a policy related to mail delivery.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained at 5% or less. Surveyors identified 6 medication errors out of 27 opportunities, resulting in a 22.2% medication error rate for 3 of 5 residents observed during medication administration. The facility policy titled Medication Administration required staff to review the MAR, compare it with each medication label, and verify the right person, medication, date, time, route, dose, and expiration date. For one resident with orders for omeprazole, quetiapine, senna, and Novolin R insulin, an LPN did not administer the omeprazole, quetiapine, or senna. The LPN checked the resident’s blood glucose, which was 347 mg/dL, but did not prime the insulin pen needle after attaching it to the Novolin R pen and turned the dose knob to 6 units instead of the ordered 8 units. The LPN stated he did not know the insulin pen needle needed to be primed and later stated he should have followed the five rights and double checked that all medications were given. For another resident receiving Basaglar Kwik Pen insulin, an LPN did not prime the needle after attaching it to the pen and turning the dose knob to 30 units. The LPN stated she did not know the needle needed to be primed. For a third resident receiving Lantus Solostar insulin, the LPN UM did not prime the needle after attaching it to the pen and turning the dose knob to 15 units, and did not hold the pen in place for a count of 10 during injection. The LPN UM stated she did not know the needle needed to be primed. The DON, NP, and Administrator stated insulin pen needles should be primed before administration and staff were expected to follow the manufacturer’s guidelines and standards of practice.
Infection Control Failures With Glucometers, Medication Handling, and Respiratory Equipment
Penalty
Summary
The facility failed to ensure infection control practices were followed for five sampled residents involving glucometer use, medication handling, and respiratory equipment care. The report states that the facility did not ensure glucometers were cleaned and disinfected between resident uses for three residents, did not ensure medication was not touched with bare hands during administration for one resident, and did not ensure respiratory equipment was cleaned and stored appropriately for two residents. The facility policies and the manufacturer’s instructions required glucometers to be cleaned and disinfected between each resident use, and the respiratory management policy required CPAP/BiPAP and nebulizer equipment to be cleaned and stored in a sanitary manner. For one resident with type 2 diabetes mellitus, intact cognition, and insulin use, an LPN obtained a fingerstick blood sugar, cleaned the glucometer with an alcohol wipe, and allowed it to air dry. The same LPN then popped a pill from a medication card into his bare hand and placed it into a medication cup before being stopped; he admitted he had touched the pills and discarded them before obtaining new pills. For two other residents with diabetes and insulin use, one LPN had a glucometer on the medication cart, used it for one resident, placed it on the resident’s bed while waiting for results, then used it for another resident without cleaning or disinfecting it first. The LPN later stated she was supposed to clean the glucometer between each use with germicidal wipes but had forgotten and could not initially find the wipes on the medication cart. The report also identified respiratory equipment issues for two residents. One resident with shortness of breath had a nebulizer machine in the room with the tubing attached and the mask and medication canister lying on top of the machine; later observations showed the mask and canister sitting on the nightstand with a small amount of fluid still in the canister. The resident stated staff had not rinsed the equipment out. Another resident with obstructive sleep apnea and CPAP use had a CPAP machine on the nightstand with the mask lying on top of the machine, dried debris in the mask, and no bag available to store it. Staff interviews reflected that the nebulizer and CPAP equipment should have been rinsed, cleaned, dried, and stored in a bag, but the observed equipment was not maintained that way.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to discuss the risks and benefits of a psychotropic medication and obtain informed consent before administering quetiapine fumarate to one resident. The resident had diagnoses of vascular dementia, seizures, and nontraumatic subdural hemorrhage, and the MDS assessment showed a BIMS score of 12, indicating moderate cognitive impairment. The care plan identified the resident’s use of psychotropic medications for behavior management and dementia and directed staff to educate the resident, family, or caregivers about the risks, benefits, side effects, and toxic symptoms of psychotropic medications. The resident’s psychotropic medication informed consent for quetiapine was signed by the resident with no date and by an LPN with an August 5 signature date without a year. The MAR showed quetiapine 50 mg at bedtime was administered daily for 16 days beginning July 14, then quetiapine 25 mg at bedtime was administered beginning July 31 and continued into August, before the consent was obtained. During interview, the resident stated they did not know what the medication was or what it was for and signed the paper only after being told it would be given for a couple more days. Staff interviews showed the LPN who obtained the consent was not aware consents were needed for psychotropic medications, the LPN UM believed nursing staff were responsible for completing the forms, the DON stated the social worker was responsible but nursing had been doing them in the social worker’s absence, and the Administrator stated consent should be obtained prior to administration.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report two allegations of abuse and neglect to the state agency involving two residents. The facility policy titled Freedom of Abuse - Abuse Prevention: Fast Alerts stated that alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made if the events involve abuse or result in serious bodily injury, or not later than 24 hours if they do not involve abuse and do not result in serious bodily injury. For one resident, the record showed a history of chronic pain, intact cognition with a BIMS score of 15, and dependence on staff for toileting hygiene with frequent urinary and bowel incontinence. The resident’s medical record included an Employee Counseling Form stating the resident reported that CNA15 did not check on them or provide incontinence care for the entire 12-hour shift and was rough during care. The resident requested that CNA15 have no further contact with them. The former DON stated she did not think the incident was reported to the Abuse Coordinator or the state agency, and the Administrator stated the allegation was abuse and neglect that should have been reported. For the second resident, the record showed diagnoses of moderate intellectual disabilities and irritable bowel syndrome, a BIMS score of 12 indicating moderate cognitive impairment, and dependence on staff for toileting hygiene with frequent urinary incontinence and always incontinent of bowel. The resident’s grievance and employee warning documents stated CNA15 yelled at the resident for having a bowel movement on themself, and the resident was upset and did not want CNA15 to provide care in the future. The former DON and Administrator both stated the allegation was abuse and should have been reported to the state agency, and the Administrator stated the former Administrator should have reported both allegations within two hours but did not.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect for two residents, R14 and R66, after reports were made involving CNA15. The facility policy titled "Freedom of Abuse - Abuse Prevention: Fast Alerts" stated that all alleged violations involving mistreatment, sexually inappropriate behaviors, abuse, or neglect would be thoroughly investigated under the direction of the Administrator and in accordance with state and federal law. However, staff interviews and record review found no documented evidence that an investigation was completed for either resident. R66 had a history of chronic pain, was cognitively intact with a BIMS score of 15, and was dependent on staff for toileting hygiene with frequent urinary and bowel incontinence. An Employee Counseling Form documented that R66 reported CNA15 did not check on them or provide incontinence care during an entire 12-hour shift and that CNA15 was rough during care; R66 requested no further contact with CNA15. R14 had diagnoses including moderate intellectual disabilities and irritable bowel syndrome, had a BIMS score of 12 indicating moderate cognitive impairment, and was dependent on staff for toileting hygiene with frequent urinary incontinence and постоян bowel incontinence. A Resident Grievance/Concern/Complaint Report documented that R14 was upset that CNA15 yelled at them for having a BM on themself, and a Worksite Employee Warning Notice documented that R14 said CNA15 yelled at them for soiling their sheets and did not want CNA15 to provide care in the future. The Administrator and Regional Nurse Consultant both stated they could not locate evidence of an investigation and acknowledged that an investigation should have been conducted.
Failure to Update PASARR After New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) Level I was updated and resubmitted after a resident developed new mental illness diagnoses. The resident had a medical history that included vascular dementia with anxiety, generalized anxiety disorder, and other bipolar disorder. A Quarterly MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment, and listed active diagnoses of anxiety disorder and bipolar disorder. The care plan also reflected use of anti-anxiety medication related to anxiety disorder and antidepressant medication related to bipolar disorder. The resident’s record contained no evidence that a new PASARR Level I was completed when bipolar disorder was diagnosed or when anxiety was diagnosed. During interviews, the Regional Nurse Consultant stated that a PASARR Level II review should have been requested when the new diagnoses appeared and was unsure why it was not done. The MDS Coordinator stated that if a resident acquired a new mental illness diagnosis, a new PASARR would be completed, and that one should have been completed for this resident. The Administrator also stated that the resident should have had a new PASARR submitted and was not sure why it was not done.
Failure to Provide Nail Care for a Resident with Diabetes
Penalty
Summary
The facility failed to ensure nail care was provided for one resident who had diagnoses of type 2 diabetes mellitus and required assistance with personal care. The resident’s MDS indicated severe impairment in cognitive skills for daily decision-making and dependence on staff for bathing. The care plan directed staff to check nail length, trim and clean nails on bath day and as needed, and report changes to the nurse. The facility policy titled Resident Hygiene stated that nail care includes daily cleaning and regular trimming, with diabetic residents’ nail trimming done per MD order and podiatry care scheduled as needed for residents with identified podiatry needs. During observations, the resident’s toenails on both feet were noted to be long and extended approximately a half inch past the ends of the toes, and this condition remained unchanged on a later observation. Review of the resident’s records showed the resident was not included on the facility’s podiatry visit history list. Staff interviews reflected that CNA staff handled cleaning, nurses handled trimming, and podiatry was expected to trim toenails, but the LPN UM stated the resident should have been on the podiatry list and was not sure why they were not. The DON and Administrator stated that if staff could not clip the toenails, the resident should have been referred to podiatry, and the Administrator stated there was no reason the resident’s toenails should be long.
Failure to Follow Up on Dermatology Recommendations Delayed Treatment
Penalty
Summary
The facility failed to follow up on outside dermatologist recommendations for a resident with a history of seborrheic dermatitis, eczema, edema, fragile skin, limited mobility, diabetes mellitus, and peripheral vascular disease. The resident’s dermatology office visit note recommended triamcinolone and ketoconazole 2% cream for seborrheic dermatitis on the face and ears, and fluorouracil for actinic keratosis on the body, but the facility record showed only an order for treatment of the right forehead area with triamcinolone mixed with moisturizer and a bandage. There was no evidence of orders for the ketoconazole or fluorouracil recommendations. During interviews, the NP stated she had not received the dermatology consultation and had not seen the recommendations for the other areas of concern. The treatment LPN stated she only received basic after-care orders and did not get the dermatology notes or recommendations. The LPN UM and DON stated the nurse assigned to the resident or the UM should have followed up when the resident returned without paperwork, and the Administrator stated there was a delay in treatment because no follow-up was done. The resident stated it took a year to get the dermatology appointment for removal of skin cancer from the left temple, and the NP stated the missing dermatology records made the resident’s record inaccurate and caused a delay in treatment.
CPAP Equipment Not Available for Resident
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with obstructive sleep apnea and dependence on other enabling machines and devices when the facility failed to ensure CPAP equipment was available and functioning properly. The resident had an active physician order for CPAP at bedtime and naps as tolerated, and the care plan directed staff to titrate pressure per physician orders using a nasal pillow, nose mask, or full-face mask based on the resident’s preferences and tolerance. The facility’s respiratory system management policy stated that CPAP/BIPAP is provided to residents with a physician’s order and that the nurse or respiratory therapist should observe the resident with the mask on for proper fit. During observations, the resident’s CPAP machine was seen on the nightstand with the mask lying on top of it, then later with the mask not visible, and later with no mask or tubing attached. The resident stated they had been asking for a new CPAP mask for about three months and had been told to contact the company that provided the machine, but they did not have that information. The resident also stated their sleep was getting worse and their snoring was bad. An LPN stated the resident had reported needing a new mask and hose, but the concern was only passed on and not followed up on. The DON stated the resident told her about the CPAP mask and that she had not yet contacted the family or equipment company, and later stated the facility should reach out to the durable medical equipment company for replacement parts and was responsible for ensuring supplies were available for ordered care.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for two sampled residents. For one resident with a history of cerebral infarction due to thrombosis of an unspecified precerebral artery, the annual MDS with an ARD of 7/1/2025 showed a BIMS score of 12, indicating moderate cognitive impairment, and indicated the resident currently used tobacco. However, the resident’s smoking assessment stated the resident did not smoke, vape, or dip, while the care plan had a smoking focus area initiated in 2022. Interviews and record review showed the smoking information was inconsistent with what staff and the resident reported. The resident stated they smoked cigarettes, a CNA stated the resident smoked cigarettes, the LPN UM stated the resident smoked and required staff supervision while outside smoking, and the AD stated she had known the resident to smoke since she began working at the facility. The DON stated there was a smoking assessment in the electronic record dated December 2024, but later stated she was not sure why that assessment indicated the resident did not smoke. The Administrator stated she was aware the resident smoked and was unsure why the assessment was not accurate. For a second resident with diagnoses including polyneuropathy, shortness of breath, insomnia, type 2 diabetes mellitus, seasonal allergic rhinitis, anemia, and essential hypertension, the quarter MDS with an ARD of 5/12/2025 showed a BIMS score of 15 and listed multiple medications including insulin, antidepressant, antibiotic, diuretic, opioid, and hypoglycemic medications. A Medication Administration Audit Report for 8/1/2025 through 8/6/2025 showed numerous medications were documented as administered one hour or more later than ordered, including insulin lispro, potassium chloride, cranberry, Glycolax, Lasix, docusate sodium, ferrous sulfate, losartan, protein oral liquid, multivitamin with minerals, Claritin, Mucinex, clonidine, gabapentin, Tresiba, and trazodone. An LPN stated medications were given on time but were sometimes signed out later when she had more time, while the DON, Administrator, and Nurse Practitioner stated medications should be documented at the time they were given and that documenting at a different time made the record inaccurate.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which could potentially lead to food-borne illness among the 52 residents receiving meals from the facility kitchen. Observations revealed that food was improperly stored, with sixteen boxes of canned foods and perishables found resting directly on the pantry floor. Additionally, expired foods were not disposed of in a timely manner, as evidenced by opened cartons of thickened juices and turkey lunch meat being kept beyond their acceptable use-by dates. Interviews with kitchen staff indicated a lack of awareness regarding the proper disposal timelines for these items. Further deficiencies were noted during meal service, where a cook was observed handling dinner rolls with bare hands, touching various surfaces without washing hands in between. Moldy food was also found in storage, with a 16oz. carton of strawberries discovered in a refrigerated reach-in. A dietary aide confirmed that staff did not consistently check produce upon arrival to ensure it was still edible. These actions and inactions demonstrate a failure to maintain proper food safety and sanitation practices as outlined in the facility's Nutrition Services Manual.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically in the cleaning and disinfecting of a glucometer between residents' use. During an observation, a registered nurse used a glucometer on a resident without cleaning it according to the manufacturer's instructions, which required the use of Medline Micro-Kill Bleach Germicidal Bleach Wipes. Instead, the nurse used an alcohol wipe after being prompted and admitted to not receiving any formal training on the proper cleaning procedure. The facility's policy required the glucometer to be cleaned and disinfected between each patient, but there was no evidence of training provided to the staff, including the nurse involved in the incident. The facility also failed to comply with pre-employment and annual tuberculosis (TB) testing guidelines. Six out of nine personnel files reviewed lacked documentation of the required two-step TB test at the time of employment, and two personnel files did not have the annual TB test documentation. The administrator confirmed the absence of this information and attributed it to the lack of a Human Resource Director, who was responsible for maintaining these records. This oversight in maintaining proper health records for staff could potentially compromise the safety and health of both staff and residents. Additionally, the facility did not maintain a current infection surveillance program for 2024. The Director of Nursing was unable to provide documentation of infection tracking and trending for the year, as the previous records were not organized or available. The new Director of Nursing, who had been in the position for a short time, was in the process of establishing a new program but had not yet implemented it. The administrator acknowledged the expectation of having an infection surveillance program in place, but no documentation from 2024 was available to demonstrate compliance.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an advance directive to five residents or their representatives. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy, dated 08/09/22, mandates that the Social Service Director must inform and educate residents or their Power of Attorney in writing about the right to an advance directive upon admission or readmission. However, documentation was missing for five residents, indicating that they were not provided with the necessary information. Resident 48, with moderate cognitive impairment, and Resident 18, with intact cognition, were not documented as having received this information. Similarly, Resident 12, who had severe cognitive impairment, and Resident 24, had no documentation of receiving advance directive information. Resident 4, who was cognitively intact, confirmed that they had not received this information until recently, despite being in the facility since 2016. The Social Services Director confirmed the lack of documentation for these residents, highlighting a systemic issue in the facility's process for informing residents about their rights to formulate an advance directive.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to adhere to its policy of conducting background and criminal checks at the time of employment for four out of nine employee files reviewed. This deficiency involved two Certified Nurse Aides (CNAs), one Licensed Practical Nurse (LPN), and one Dietary Aide (DA). The facility's policy, dated December 21, 2023, mandates that background checks, including criminal history and fingerprinting, be conducted upon submission of an employment application. However, the Administrator was unable to provide the required background and criminal check information for these employees, citing the absence of a Human Resource Director responsible for uploading this information into the computer system.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to seven residents and their representatives, as required by policy, during emergent hospital transfers. The policy titled 'Discharge Plan/Transfers' did not address the need for a written notice of transfer, its required contents, or the provision of the notice to the resident and their representative. This oversight was identified through a review of the facility's records, which showed no evidence of written transfer notices for the residents involved. Resident 27, who had multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without a written notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was admitted to the hospital from dialysis without receiving a written transfer notice. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, revealed uncertainty about who was responsible for issuing these notices. Additional residents, including those with severe cognitive impairments, were also transferred without the required documentation. For instance, Resident 116 was sent to a behavioral hospital due to behavioral issues, and Resident 44, with a BIMS score indicating severe cognitive impairment, was transferred following a change in condition. The facility's Administrator acknowledged the lack of documentation and stated that since taking over the role, transfer notices had not been sent to the Ombudsman, further highlighting the systemic nature of the issue.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to seven residents or their representatives during hospital transfers or therapeutic leaves. This deficiency was identified through a review of records, interviews, and facility policy. The facility's policy mandates that residents or their responsible parties receive written information about the bed hold policy at admission and before any transfer. However, the facility did not adhere to this policy for the residents reviewed. Resident 27, who has multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without receiving a written bed hold notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was also transferred without the required documentation. Interviews with staff, including the Director of Nursing, revealed a lack of clarity about who was responsible for providing the bed hold notice, indicating a systemic issue in the facility's process. Other residents, including those with severe cognitive impairments, were also transferred without receiving the necessary written notices. For instance, Resident 116, with a BIMS score indicating severe cognitive impairment, was sent to a behavioral hospital without documentation of a bed hold notice. Interviews with the Social Service Director and the Administrator confirmed that there was no documentation of the bed hold policy being provided to residents or their representatives, highlighting a consistent failure across multiple cases.
Failure to Revise Care Plan and Conduct Conferences
Penalty
Summary
The facility failed to revise the care plan for a resident to include necessary fall interventions and did not conduct care plan conferences as required. The resident, who had a moderately impaired cognitive status, was observed in various settings, including a geri chair and with a fall mat next to the bed, but these interventions were not documented in the care plan. The resident had returned from the hospital and experienced falls, yet the care plan was not updated to reflect the use of a low bed, geri chair, or fall mats. Additionally, there was no evidence of care plan conferences being held since the resident's admission, despite the facility's policy requiring such conferences after the completion of the Minimum Data Set (MDS) and during quarterly reviews. Interviews with staff, including the MDS Coordinator, confirmed the absence of documentation for care plan conferences and the lack of updates to the care plan to include the necessary interventions for fall prevention.
Failure to Document Bed Rail Assessments and Alternatives
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for three residents. Resident 5 was observed with bilateral assist bars in the up position on multiple occasions, yet their electronic medical record (EMR) showed no documented failed alternatives to bed rails. The assessments conducted did not justify the use of side rails as an enabler to promote independence. Similarly, Resident 38 was observed with bilateral assist bars, despite stating they did not use them. The EMR for Resident 38 also lacked documentation of failed alternatives, and no documentation was provided upon request. The facility's administrator confirmed that alternatives should have been documented prior to bed rail use. Resident 3 was found with half side rails on both sides of their bed, but their EMR lacked a recent bed rail assessment. The last assessment was incomplete, and the previous one indicated the family's request for side rails. The administrator acknowledged the absence of recent assessments and confirmed the incomplete status of the last assessment. These deficiencies in documentation and assessment increased the potential risks associated with bed rail use, including injury, entrapment, and death.
Medication Administration Deficiency Due to Pharmacy Delays
Penalty
Summary
The facility failed to ensure timely provision of medications from the pharmacy, resulting in a deficiency in medication administration for a resident. The resident, who was admitted with diagnoses including atherosclerotic heart disease and diabetes mellitus, did not receive several prescribed medications as ordered by the physician. These medications included Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, which were not administered on multiple occasions as documented in the Medication Administration Record (MAR). There was no follow-up documentation to indicate why these medications were not administered. Interviews with facility staff revealed that the medication orders were automatically sent to the pharmacy upon a resident's admission, and the pharmacy delivered medications twice a day. However, it was noted that if a resident was admitted in the afternoon or later, medications might not be delivered until the following morning. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that if a medication was unavailable, it should be sourced from the emergency kit, and a progress note should be documented in the electronic medical record (EMR) to explain the unavailability. Despite these procedures, there was no documentation in the EMR to account for the missed doses. The Director of Nursing acknowledged that pharmacy deliveries had been problematic, with instances of medications not arriving as scheduled. The Medical Director stated that in cases where medications were not available upon admission, the nursing staff should have arranged for the medication to be held until it arrived or sourced it from a local pharmacy. The lack of timely medication delivery and absence of documentation for missed doses contributed to the deficiency identified by the surveyors.
Failure to Document Behaviors and Interventions Before Antipsychotic Administration
Penalty
Summary
The facility nurses failed to document the behaviors and nonpharmacological interventions attempted prior to administering antipsychotic medication, Seroquel IM, to a resident. This oversight was identified during a review of the facility's policy on behavior management, which mandates that targeted behaviors be identified and monitored, and appropriate nonpharmacological interventions be implemented before administering psychoactive medication. The resident in question, who had a moderately impaired cognition with a BIMS score of 12 out of 15, was admitted to the facility and had returned from the hospital. The resident's EMR indicated orders for Haldol IM as needed for agitation, but the MAR did not document any behaviors or interventions prior to the administration of the medication. The Regional Operations Manager confirmed during an interview that there was no documentation of behaviors or nonpharmacological interventions in the resident's records. The absence of documentation suggests that these steps were not completed, which could lead to the resident receiving unnecessary medication. The facility's failure to adhere to its policy on behavior management and documentation was evident in this case, as the necessary steps to justify the use of antipsychotic medication were not recorded.
Significant Medication Error Due to Insulin Unavailability
Penalty
Summary
The facility nurse failed to follow the physician's order and provide a resident with insulin according to the sliding scale order, resulting in a significant medication error. The resident, who was diagnosed with diabetes mellitus and had moderately impaired cognition, did not have the insulin available for administration. During an observation, a registered nurse (RN) attempted to administer six units of Humulin R insulin to the resident based on the Medication Administration Record (MAR), but discovered that the insulin belonged to another resident. The RN reported the unavailability of the correct insulin to the Regional Operations Manager and ordered the insulin, but the resident did not receive the insulin as ordered. The resident missed insulin doses at multiple designated times, and the facility's July MAR indicated that the resident routinely received sliding scale Humulin R insulin prior to the incident. The facility's policy required staff to compare the MAR with the medication label multiple times before administration, which was not followed in this case. The Medical Director stated that the facility should have contacted him if there was a delay in receiving the insulin, as he could have arranged for the medication to be obtained from a local pharmacy. Additionally, the nurses were expected to perform Accu-Chek tests to monitor the resident's glucose levels and notify the Medical Director of any elevated levels.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted to accurately reflect the actual staff hours available to care for the 52 current residents. This deficiency was observed on three out of four survey days. Specifically, observations on 07/28/24 at 6:43 PM, 07/29/24 at 9:30 AM and 10:40 AM, and 07/30/24 at 6:05 PM revealed that the daily nurse staffing was not posted. During an interview on 07/31/24 at 8:15 AM, the Administrator confirmed that the staffing information should have been posted in the glass display window near the front of the facility each day, but it was not posted for three of the four survey days.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jesup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Health Systems Jesup | 0.4 mi | ★★★★★ | 7 | 0 |
| Jesup Ridge Of Journey Llc | 2.9 mi | ★★★★★ | 0 | 0 |
| Coastal Manor | 12.1 mi | ★★★★★ | 0 | 0 |
| Glenvue Health & Rehab | 22.6 mi | ★★★★★ | 0 | 0 |
| Appling Nursing And Rehabilitation Pavilion | 28.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Altamaha Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.