Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Archway Transitional Care Center during CMS and state inspections, most recent first.
A cognitively impaired resident with hemiplegia and severe communication deficits was not adequately protected from sexual abuse by a severely cognitively impaired roommate with dementia and psychiatric history. Staff observed the roommate at the bedside with his penis exposed and masturbating near the resident, attempted redirection, and notified supervisory staff, law enforcement, and an NP. However, despite facility policies requiring immediate protection of alleged victims, increased supervision, and possible room or staffing changes, the two residents continued to share a room while staff relied on hourly checks and environmental measures, and the alleged victim later reported a prior similar incident that had not been reported to staff.
Administration and nursing leadership failed to protect a resident from alleged sexual abuse by a roommate and did not provide adequate safeguards during the subsequent investigation. Despite job descriptions assigning the Administrator and DON responsibility for abuse prevention and regulatory compliance, the two residents were kept in the same room, and the facility relied on hourly monitoring rather than separating them. The Administrator reported that the resident was not sent to the ER because an NP did not order it, and the DON initially agreed with the hourly monitoring interventions based on the aggressor’s prior behavior history. The situation was later determined to constitute Immediate Jeopardy due to noncompliance with requirements intended to prevent abuse.
The facility failed to timely report an allegation of resident-to-resident physical abuse to the State Survey Agency (SSA) as required by its abuse reporting policy. A nurse documented that two residents were involved in an altercation in the dining room in which one resident reportedly walked up to another and began hitting him in the head, after which the aggressor was escorted back to his room and assessed for injury. The facility’s incident report and subsequent follow-up to the SSA listed an incorrect incident date, causing the allegation to be reported outside the required 2-hour window. During interview, the Administrator could not explain why the incident report was submitted late.
Staff did not ensure that resident room and dining room furniture was maintained in good repair, with multiple armchairs and dressers found damaged and all dining room chairs observed to have torn or missing upholstery and exposed cushioning. Facility leadership confirmed the need for repairs, and records showed ongoing requests for new furniture and parts, but no documented work orders or inspections.
Staff failed to ensure the medication error rate remained below five percent, with three errors observed among 35 opportunities. Errors included administering an incorrect dose of an inhaler to a resident with heart and lung conditions, preparing an expired allergy medication for a resident with multiple chronic illnesses, and incorrectly administering a disintegrating antipsychotic tablet. Nursing staff confirmed these were medication errors.
A resident with cognitive impairment and psychiatric diagnoses alleged sexual abuse by another resident during a hospital stay. Although law enforcement and the resident's family were notified, facility staff did not report the allegation to the State Survey Agency as required by policy, instead deciding internally that it was not a reportable event.
The facility failed to maintain a sanitary dumpster area, as two dumpster lids were damaged and debris was present. Staff interviews revealed a lack of awareness and communication regarding responsibilities for maintaining the area. The Maintenance Director and Dietary Manager confirmed the observations, while the Housekeeper Supervisor and Administrator were unaware of the issues.
A resident with COPD was observed receiving oxygen at 2.5 LPM instead of the prescribed 2.0 LPM. The facility's policy requires adherence to physician orders for oxygen therapy, which was not followed in this case. The DON confirmed the discrepancy during an observation and interview.
Failure to Protect Cognitively Impaired Roommate From Sexual Abuse and Inadequate Protection During Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident (R1) from sexual abuse by his roommate (R2) and to provide adequate protection for R1 during the subsequent investigation. R1 had major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, a cognitive communication deficit, muscle weakness, and a contracture of the right hand. His admission MDS showed a BIMS score of 5, indicating severe cognitive impairment. R2 had diagnoses including insomnia, major depressive disorder recurrent severe without psychotic features, a history of non‑suicidal self‑harm, and unspecified dementia with psychotic disturbance, with a five‑day MDS BIMS score of 2, also indicating severe cognitive impairment. On the evening of 12/20/2025, CNAs observed R2 standing at R1’s bedside with his penis out of his pants, moving his hands in an up‑and‑down motion near R1. The CNAs attempted to redirect R2 to the restroom and then to his side of the room, but he refused to enter the restroom and, after being guided back and separated by a privacy curtain, he snatched the curtain back and sat in a chair at R1’s bedside. When the LPN entered, R2 was seated on R1’s side of the room. The LPN questioned R2 about exposing himself, which he denied, and assessed R1, who denied that R2 had touched him, pulled back his covers, or touched him with his private parts. Nursing notes documented that the Administrator and DON were notified, law enforcement was contacted, and the NP was informed and initiated behavior protocol and a psychiatry referral. Despite the facility’s written Abuse Prohibition – Reporting and Investigating policy requiring immediate response to protect the alleged victim, increased supervision of the alleged victim and residents, and possible room or staffing changes at the discretion of administrative staff, R2 remained in the same room with R1 following the incident. Hourly checks and keeping the door open with the privacy curtain pulled were implemented, but R1 and R2 continued to share the room for several days after the event. In a later interview, R1 reported that his roommate had previously sat on his bed near the foot of the bed, naked from the waist down with his penis in his hand, and that he told him to leave but did not report the incident to staff. The facility’s actions and inactions, including not immediately separating the residents and relying on hourly monitoring while both residents with severe cognitive impairment remained roommates, failed to provide the level of protection outlined in the facility’s abuse policies.
Failure to Protect Resident From Sexual Abuse and Inadequate Safeguards During Investigation
Penalty
Summary
Administration failed to maintain an environment free from sexual abuse and to provide adequate protection during the investigation of an alleged sexual abuse incident involving two residents sharing a room. The Administrator’s job description assigned responsibility for directing day-to-day operations in compliance with regulations and assuming responsibility for procedural guidelines related to prevention and reporting of patient abuse, while the DON’s job description assigned responsibility for directing nursing services in accordance with applicable regulations. Despite these responsibilities, after an allegation that one resident sexually abused their roommate, the facility did not remove the alleged aggressor from the room or otherwise separate the residents at the time of the incident. The Administrator later stated that the facility did not send the alleged victim to the ER because the NP did not issue an order to do so and only ordered a psychiatry referral. The DON reported that evening staff notified her of the incident and explained the interventions that had been put in place, including hourly monitoring, which she initially considered appropriate because the alleged aggressor had not previously exhibited such behavior and was described as usually well-mannered. The Administrator stated she decided to implement hourly monitoring and believed the facility had done everything needed to keep the alleged victim safe, emphasizing that the alleged aggressor had no prior history of such behavior. However, both residents continued to reside in the same room from the date of the incident until surveyors questioned the Administrator about placement options for the alleged aggressor, at which point the alleged victim was moved to a different room. The noncompliance was determined to have the likelihood to cause serious injury, harm, impairment, or death and was identified as Immediate Jeopardy beginning on a specific date.
Failure to Timely Report Allegation of Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse to the State Survey Agency (SSA) as required by its own policy and federal expectations. The facility’s Abuse Prohibition – Reporting and Investigation policy, revised 12/27/2024, states that all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than 2 hours. A nurse’s note for Resident 6 dated 12/12/2025 at 7:36 p.m. documented that the nurse was summoned to the dining room regarding an altercation between Resident 6 and another male resident (Resident 7), during which witnesses stated that Resident 6 walked up to Resident 7 and started hitting him in the head. Resident 6 was escorted back to his room and assessed, and bleeding was noted from the index finger on the right hand from a previous injury. However, the Facility Incident Report Form (FRI) was completed with the incident date and time recorded as 12/13/2025 instead of 12/12/2025, and the follow-up report submitted to the SSA on 12/19/2025 also identified the incident date as 12/13/2025. This incorrect dating resulted in the allegation of abuse not being reported to the SSA within the required 2-hour timeframe from the actual occurrence on 12/12/2025. During an interview on 1/7/2026 at 11:35 a.m., the Administrator stated she was not sure why the FRI was reported late.
Failure to Maintain Resident and Dining Room Furniture in Good Repair
Penalty
Summary
Facility staff failed to maintain resident room and dining room furniture in good repair, as evidenced by observations of seven armchairs in resident rooms and the day room with missing and torn upholstery, exposing cushion material on seats, arms, and backs. Dressers in resident rooms were also found with broken handles and missing drawer fronts. In the dining room, all 55 chairs were observed to be in disrepair, with torn or missing upholstery and exposed or missing cushioning, including four chairs with missing arm padding that left sharp metal corners exposed. These conditions were confirmed during interviews with the Administrator and Maintenance Supervisor, who acknowledged the need for repairs and stated that parts had been ordered but not yet delivered. Review of facility records and email correspondence revealed that requests for new furniture and replacement parts had been made to the corporate office over a period of two years. However, there was no evidence of furniture repair requests or inspections documented in the facility's electronic system. The Maintenance Supervisor indicated that work orders for furniture repairs had not been received, and the Administrator noted that chairs with missing armrests had been removed but continued to reappear in the building. The failure to maintain furniture in good repair was directly observed and confirmed by facility leadership.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by policy, resulting in three medication administration errors out of 35 observed opportunities. For one resident with hypertensive heart disease, pulmonary hypertension, and dementia, a Certified Medication Aide (CMA) administered two puffs of Anoro Ellipta inhaler instead of the prescribed one puff. The CMA acknowledged the error after administration. For another resident with Guillain-Barre syndrome, chronic respiratory failure, and COPD, a CMA prepared loratadine from an expired container and was preparing to administer it before being stopped by a surveyor. Additionally, the same CMA administered an olanzapine disintegrating tablet without instructing the resident to allow it to dissolve in the mouth, resulting in the resident swallowing the tablet whole. Both the CMA and supervisory nursing staff confirmed these were medication administration errors.
Failure to Report Alleged Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency as required by its own policy. A resident with diagnoses including paranoid schizophrenia, generalized anxiety disorder, and hallucinations, and who was assessed as cognitively impaired, was hospitalized following a fall. During her hospital stay, she alleged that she had been raped multiple times by another resident approximately six weeks prior. The hospital notified law enforcement, the resident's family, and a facility RN of the allegation. However, there was no evidence that the facility reported this allegation to the State Survey Agency. Interviews with facility staff confirmed that the Director of Nursing and Administrator were made aware of the allegation via text message, and the matter was discussed in a staff meeting. The staff decided not to report the allegation to the State Survey Agency, believing it was not a true reportable event. This decision was made despite the facility's policy requiring immediate reporting of all abuse allegations, and no initial report was submitted to the State Survey Agency regarding the resident's rape allegation.
Unsanitary Dumpster Area Due to Damaged Lids and Debris
Penalty
Summary
The facility failed to maintain the dumpster area in sanitary conditions, as observed during a survey. The facility's policy on storage areas required that the dumpster area be free of trash and debris, and that containers be kept in good condition and covered. However, observations revealed that two of the three dumpster lids were badly damaged, preventing secure closure. Additionally, broken pallet pieces and large pallets covered with dirt and debris were found on the ground between two dumpsters. These conditions were confirmed by the Dietary Manager and the Maintenance Director during the survey. Interviews with facility staff revealed a lack of awareness and communication regarding responsibilities for maintaining the dumpster area. The Maintenance Director stated that vendors deliver supplies on pallets every Tuesday, and the Housekeeping Staff were supposed to unload the delivery truck and place the pallets in the dumpsters. However, the Housekeeper Supervisor was unaware that her staff was assigned this task. The Administrator also reported being unaware of the damaged lids and the presence of broken pallets on the ground, although she expected staff to maintain the dumpster area in a sanitary manner and report any damages or concerns.
Oxygen Therapy Not Administered Per Physician's Order
Penalty
Summary
The facility failed to administer oxygen therapy to a resident in accordance with the physician's order. The resident, who has a diagnosis of chronic obstructive pulmonary disease (COPD), was observed receiving oxygen via a nasal cannula at 2.5 liters per minute (LPM) instead of the prescribed 2.0 LPM. This discrepancy was noted during observations on two separate occasions. The facility's policy on the use of oxygen therapy requires that oxygen be administered as per the physician's order, which in this case specified 2.0 LPM for shortness of breath or wheezing. The Director of Nursing (DON) confirmed the deviation from the physician's order during an observation and interview, acknowledging that the resident was receiving a higher oxygen flow than prescribed.
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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.
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Nursing homes near Macon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherry Blossom Health And Rehabilitation | 2.1 mi | ★★★★★ | 8 | 0 |
| Pruitthealth - Macon | 2.9 mi | ★★★★★ | 0 | 0 |
| Medical Management Health And Rehab Center | 3.1 mi | ★★★★★ | 6 | 0 |
| Blossom Healthcare & Rehabilitation Center | 3.3 mi | ★★★★★ | 13 | 0 |
| Macon Rehabilitation And Healthcare | 4.9 mi | ★★★★★ | 8 | 0 |
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