Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Blossom Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
Undated and expired food items were found in the kitchen during an initial tour with the DM present. Two freezer bags of chicken were unlabeled and missing a use-by/discard date, a bag of chopped ham had an expired date, a container of gravy was missing a use-by date, and opened cut potatoes had no open or use-by date. The DM confirmed the ham had expired and stated staff forgot to discard it, and also stated the chicken should have been labeled with open and discard dates.
Unlocked medication and wound care carts, expired supplies, and unsanitary medication storage were observed. An LPN left a medication cart unattended and unlocked with medications on top, and a wound care cart was also found unlocked. Expired wound care and medication-room supplies were identified, and multiple inhalers/nasal sprays on two medication carts were missing covers; one cart also had a sticky substance and a medication box stuck inside a drawer.
The facility failed to follow its abuse reporting policy when two residents with intact cognition reported that a CNA handled them roughly during ADLs and was verbally rude. A social worker documented the grievances, and the administrator interviewed the residents but did not report these abuse allegations to the State Survey Agency, ombudsman, law enforcement, or physicians within the required time frame, contrary to the facility’s written policy that mandates immediate reporting of suspected abuse to specified authorities.
Two cognitively intact residents reported through grievances that a CNA handled them roughly during ADL care, including pushing on a shoulder while turning and being rude and rough during care. Facility records showed documentation of one resident’s pain complaint and a skin assessment, but no comprehensive, documented investigations of either abuse allegation were found. The Administrator acknowledged only interviewing the residents about the CNA’s alleged verbal and physical abuse and not completing or documenting the thorough investigations required by the facility’s abuse-reporting policy.
Medications Left at Bedside Without Self-Administration Assessment: Three residents had medications left at the bedside without a physician order or documented self-administration assessment. One resident had legal blindness and cataracts, one had dementia with severe cognitive impairment, and one had COPD with moderate cognitive impairment. Observations found eye drops, topical diclofenac, inhalers, and nasal spray in the rooms, and an LPN confirmed the medications had been left there even though the residents were not assessed as capable of self-administering them.
A facility failed to develop or implement complete person-centered care plans for four residents. One resident with severe cognitive impairment and dependence for transfers had a care plan that addressed bed rails as assist bars, but surveyors observed bilateral upper and lower bed rails in use without a corresponding order. Three residents receiving O2 had care plans that did not match the ordered flow rates or, in one case, did not include O2 in the care plan at all; surveyors observed O2 concentrator settings above the ordered 2 LPM, and an LPN/UM and the MDS Coordinator confirmed the discrepancies.
A resident with a PICC line had orders for daily IV daptomycin and SASH flushing of the line. During a medication pass, an LPN flushed the PICC with NS and started the infusion without aspirating for blood return to verify patency, despite the facility PICC procedure stating blood flow should be aspirated before every flush and infusion. The LPN acknowledged the omission, and the ADON and DON stated blood return should be checked before infusing medications.
Oxygen flow rates were not set as ordered for multiple residents receiving oxygen therapy. Surveyors observed an LPN/UM and other staff finding oxygen concentrators set above the physician-ordered LPM for residents with diagnoses including COPD, heart failure, acute respiratory distress, and acute respiratory failure with hypoxia. One resident stated she did not change her oxygen setting, and staff confirmed the flow rates were not at the ordered levels.
Improper Use of Four Bed Rails for a Resident: A resident with severe cognitive impairment, significant mobility limitations, and a history of falls had bilateral upper and lower bed rails in the up position despite no physician order for that setup. The bed rail assessment and consent form described the rails as assist bars for repositioning or mobility, but repeated observations showed all four rails up, and the resident, an LPN, a CNA, and the DON all confirmed the setup was not appropriate and could be a restraint.
The facility failed to follow infection control practices in laundry services and for a resident using oxygen and nebulizer equipment. A Laundry Aide handled clean linens against her shirt and sorted dirty linen without a gown or access to one, despite the facility policy requiring PPE for contaminated linens. In addition, a resident with COPD had nebulizer tubing and mask left uncovered on a nightstand and portable oxygen tubing lying uncovered over a rollator, which was confirmed by an LPN and the ADON.
The facility lacked an effective training program for staff, impacting resident safety and care quality. The DON admitted to difficulties in ensuring staff attendance and tracking training completion. Interviews with the Administrator and DCO confirmed the absence of a formal program, highlighting a significant deficiency in staff training.
The facility failed to ensure adequate pillowcases for residents, affecting their right to a homelike environment. A cognitively impaired resident had to use personal pillowcases, while another resident reported frequent shortages. Observations confirmed the lack of pillowcases, and staff acknowledged the issue.
The facility failed to inform two residents and/or their representatives about the risks and benefits of antipsychotic medications. One resident with Alzheimer's Disease was given Depakote and Risperdal without proper documentation of informed consent, and their Power of Attorney was unaware of these medications. Another resident with Huntington's Disease was started on Mirtazapine and Trazodone without notifying the representative or explaining the risks and benefits. The DON and MDS Coordinator confirmed the lack of communication and documentation regarding psychotropic medications.
A facility failed to provide a NOMNC to a resident 48 hours before the end of their Medicare-covered Part A stay. The resident signed the NOMNC on their last covered day, rather than two days prior as required. Both the Social Worker and Administrator acknowledged the error in timing.
Undated and Expired Food Items in Kitchen
Penalty
Summary
Food items in the kitchen were found without required dating and with expired dates during an initial kitchen tour with the Dietary Manager present. Two freezer bags of chicken were unlabeled and missing a use-by/discard date, one freezer bag of chopped ham was labeled with an expired date of 1/4/2026, one plastic container of gravy was missing a use-by date, and one bag of opened, cut potatoes in a box had no open or use-by date present. During interview, the Dietary Manager confirmed the chopped ham had expired and stated staff forgot to throw it out on 1/4/2026. The Dietary Manager also stated the chicken should have been labeled with an open and discard date and that all open food items should have an open and discard date.
Unlocked Medication and Wound Care Carts, Expired Supplies, and Unsanitary Medication Storage
Penalty
Summary
The facility failed to ensure that one of three medication carts and one wound care cart were locked and secured when they were out of the direct sight of the nurse. During observation, a medication cart in the hallway was left unlocked and unattended while an LPN entered a resident room to administer medication, and medications were observed on top of the cart. The LPN confirmed that she had not locked the cart, that medications were left on top of it, and that the cart was not in her view. A wound care cart on the 100 Hall was also observed unlocked and unattended, and the LPN confirmed that it should have been locked because it contained medications. The facility also failed to discard expired medical supplies in one of four supply rooms and failed to store medications on two of three medication carts in a sanitary manner. In the wound care room, expired disinfectant wipes and xeroform gauze dressing were observed. In the medication room at Nurse's Station Two, expired sting-free, derma prep, and disinfectant wipes were observed. On the 100 Unit medication cart, one inhaler had no mouthpiece cover, one nasal spray had no top cover, and one mouth spray had no cover; on the 300 Unit medication cart, one nasal inhaler was missing its top cover. A medication cart was also observed with a sticky substance on it and a medication box stuck to the bottom of a drawer, and staff confirmed the cart should be kept clean.
Failure to Report Resident Abuse Allegations to Required Authorities
Penalty
Summary
The facility failed to follow its abuse reporting policy by not reporting two residents' allegations of rough handling and verbal abuse to the State Survey Agency (SSA) and other required authorities. The facility's written policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states that all reports of resident abuse, neglect, exploitation, or misappropriation must be reported to local, state, and federal agencies as required, and that suspicions must be reported immediately to the administrator and appropriate external agencies. The policy defines "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury, and within 24 hours for allegations that do not involve abuse or result in serious bodily injury. Record review showed that these reporting requirements were not followed for two residents. One resident, with a Quarterly MDS BIMS score of 13 indicating little to no cognitive impairment, filed a grievance stating that a CNA was very rough while changing her brief and pushed on her shoulder while trying to turn her. Another resident, also with a BIMS score of 13, filed a grievance stating that the same CNA handled the resident very roughly and was rude, which the Social Worker documented as verbal abuse. The Social Worker reported that she took both complaints, and the Administrator confirmed she had interviewed both residents regarding the allegations. The Administrator further confirmed that she did not report these abuse allegations to the SSA, Ombudsman, police, or the residents' medical doctor, and record review confirmed that the allegations were not reported within the required time frame.
Failure to Thoroughly Investigate Resident Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal and physical abuse in accordance with its policy titled "Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating" for two residents. The policy required that all reports of resident abuse be thoroughly investigated by facility management, with the Administrator initiating the investigation and the individual conducting the investigation documenting it completely and thoroughly. One resident, with a Brief Interview for Mental Status (BIMS) score of 13 indicating little to no cognitive impairment, reported via a grievance that a CNA was very rough while changing her brief, pushing on her shoulder while trying to turn her. Progress notes documented that this resident complained of shoulder pain and stated the CNA was rough when turning her, and a subsequent skin assessment was completed. However, there was no additional documentation related to the abuse allegation reported on that date and no record of a thorough investigation of the allegation. A second resident, also with a BIMS score of 13 indicating little to no cognitive impairment, filed a grievance stating that the same CNA handled the resident very roughly and was rude during care. Record review revealed no documented thorough investigation of this resident’s allegation of abuse. Interviews with facility leadership confirmed that the Administrator only interviewed the two residents about the CNA being verbally abusive and handling them roughly during ADL care and did not conduct or document any further investigations into the allegations, despite the facility’s policy requiring comprehensive investigation and documentation of all abuse allegations.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that three sampled residents were assessed for medication self-administration before medications were left at the bedside. The facility policy stated residents may self-administer medications only when specifically authorized by the attending physician and in accordance with self-administration procedures. Review of records and observations showed no physician orders or self-administration assessments for R61, R19, or R43, and no care plans addressing medication self-administration for any of the three residents. R61 had diagnoses including legal blindness and age-related cataracts, with a BIMS score of 14. Active orders included eye medications for dry eyes, but there was no order for self-administration or bedside medications. The EMR contained no assessment showing R61 was capable of self-administration. During observation, GenTeal Tears Severe Day/Night ophthalmic gel and Artificial Tears ophthalmic solution were found on the bedside table. R61 stated he used the eye drops morning and night and that the nurse left them in the room. An LPN stated the medication should not have been left at the bedside, and another LPN stated she had left the eye drops in the room because she had to go to the bathroom and did not return to put them away. R19 had diagnoses including dementia and osteoarthritis, with a BIMS score of 7 and care plan documentation of impaired cognitive function and thought processes. The resident had an active order for Voltaren Arthritis Pain gel, but there was no physician order for self-administration. A self-administration assessment dated 1/6/2026 stated R19 was not capable of storing or self-administering medication. Despite this, diclofenac gel and a medicine cup with cream were observed on the bedside table, and an LPN confirmed the medication was present and stated the resident had not been assessed for self-administration. R43 had diagnoses including COPD and obstructive hypertrophic cardiomyopathy, with a BIMS score of 12 and care plan interventions for administering medications and puffers as ordered. Active orders included Advair HFA, azelastine nasal spray, and Proventil HFA, but there was no order or assessment for self-administration. An Advair inhaler, Proventil inhaler, and azelastine nasal spray were observed at the bedside, and R43 stated the nurses left the medications there in case she needed them. An LPN confirmed leaving the medications at the bedside and stated R43 was not assessed to safely self-administer medications.
Incomplete and inaccurate care plans for bed rail use and oxygen therapy
Penalty
Summary
The facility failed to develop or implement a comprehensive person-centered care plan for four sampled residents. The report states that the interdisciplinary team was responsible for resident care plans and that each plan should include measurable objectives and timetables to meet physical, psychosocial, and functional needs. Surveyors found that the care plans for R21, R46, R76, and R4 did not accurately reflect or support the residents’ documented care needs related to bed rail use and oxygen therapy. For R21, the Quarterly MDS documented severe cognitive impairment with a BIMS score of 5, substantial to maximal assistance needs for bed mobility, and dependence for transfers. The care plan addressed use of bed rails on both sides of the bed as assist bars for positioning, but the physician orders contained no order for bilateral upper and lower bed rails. Surveyors observed bilateral upper and lower bed rails in the up position on multiple occasions, and R21 stated he was not sure why all four rails were up and said he did not use the bottom rails. An LPN confirmed the bed had bilateral upper and lower bed rails in the up position, while the MDS Coordinator confirmed the care plan only included upper rail assist for positioning and did not include bilateral upper and lower bed rails. For R46 and R76, both residents had diagnoses involving respiratory conditions and were receiving oxygen, but the oxygen flow rates observed by surveyors did not match the physician orders. R46’s care plan addressed altered respiratory status and supplemental oxygen per order, and the order specified oxygen at 2 LPM via NC as needed; however, surveyors observed the concentrator set between 3 and 4.5 LPM on different occasions, and an LPN/UM confirmed the setting was incorrect. R76’s care plan also addressed altered respiratory status and supplemental oxygen per order, with an order for oxygen at 2 LPM via NC as needed and as tolerated per resident every shift; however, surveyors observed the concentrator set at 3 to 3.5 LPM, and an LPN/UM confirmed the setting was above the ordered rate. For R4, the MDS documented oxygen use, the physician order specified oxygen at 2 LPM via NC, and surveyors observed the concentrator set at 3 LPM. The care plan for R4 did not include a care area for oxygen, and the MDS Coordinator acknowledged that oxygen therapy had not been added to the resident’s care plan.
PICC Line Patency Not Checked Before IV Antibiotic Infusion
Penalty
Summary
The facility failed to ensure that care for one resident with a PICC line was provided in accordance with professional standards of quality. The resident had an order dated 1/6/2026 for daptomycin 750 mg IV every 24 hours and an order for the single-lumen PICC line in the right upper extremity to be flushed using the SASH protocol one time a day. The facility document titled PICC Lines Procedures stated that blood flow should be aspirated before every flush and infusion. During observation of the medication pass on 1/7/2026 at 9:41 a.m., an LPN applied PPE, cleaned the PICC lumen, connected a 5 mL syringe of 0.9 percent normal saline, flushed the line, and did not aspirate to check for blood return before connecting the daptomycin infusion. In interview, the LPN stated she flushed the line with normal saline and did not aspirate to check for blood flow before infusing the antibiotic, and stated she should have checked for blood return prior to infusing the medication. The ADON later stated that the nurse should draw back blood to check patency of the PICC line before infusing medications, and the DON stated that PICC line management included SASH, including blood return to check for patency.
Oxygen Flow Rates Not Set as Ordered
Penalty
Summary
The facility failed to ensure that oxygen was provided at the physician-ordered flow rates for four residents who were receiving oxygen therapy. The facility policy stated that oxygen therapy was to be administered per a physician's order, and the policy directed staff to turn on the oxygen supply and set the flow meter to the rate ordered by the physician. Surveyors observed that the oxygen concentrators for these residents were set above the ordered rates during multiple observations. For one resident with diagnoses including COPD and obstructive hypertrophic cardiomyopathy, the physician ordered oxygen at 3 LPM via NC, but observations showed the concentrator set between 4 and 4.5 LPM on multiple occasions, and an LPN/UM confirmed the setting was above the ordered rate. For another resident with chronic diastolic heart failure and generalized anxiety disorder, the order was for oxygen at 2 LPM via NC as needed, but observations showed the concentrator set between 3 and 4.5 LPM, and the LPN/UM confirmed the flow rate was not set correctly. A third resident with diagnoses including COPD and acute respiratory distress had an order for oxygen at 2 LPM via NC as needed and as tolerated, but observations showed the concentrator set at 3 to 3.5 LPM, and the LPN/UM confirmed the order was for 2 LPM. A fourth resident with diagnoses including acute respiratory failure with hypoxia and a history of COVID-19 had an order for oxygen at 2 LPM via NC, but observations showed the flow rate set at 3 LPM, and an LPN confirmed it should have been set at 2 LPM. The report also identified a fifth resident with COPD and acute exacerbation whose oxygen was observed at 3 LPM despite an order for 2 LPM, and the resident stated she did not change her oxygen setting.
Improper Use of Four Bed Rails for a Resident
Penalty
Summary
The facility failed to ensure that one of 34 sampled residents, R21, was free from bedrail restraint. R21 had diagnoses including history of TIA, cerebral infarction, muscle weakness, unsteadiness on feet, muscle wasting, lack of coordination, history of falling, and macular degeneration. The quarterly MDS documented a BIMS score of 5, indicating severe cognitive impairment, and Section GG showed the resident required substantial to maximal assistance with bed mobility and was dependent for transfers. The physician orders reviewed did not include an order for bilateral upper and lower bed rails. The facility’s bed rail assessment, dated 6/18/2025, documented bilateral assist rails for positioning, and the Assist Bar Consent Form, dated 6/16/2025, stated the purpose of assist bars was to assist with repositioning or mobility. However, observations on 1/6/2026, 1/7/2026, and 1/8/2026 showed bilateral upper and lower bed rails in the up position on R21’s bed. During interview, R21 stated he was not sure why all four rails were up and said he did not use the bottom rails. An LPN confirmed the bed had all four rails up and stated it should not have been that way, and a CNA stated she had just provided restorative care and should have notified the nurse that the resident had four rails up. The DON stated the resident should not have bilateral upper and lower bed rails in the up position and that such use could be a restraint.
Infection Control Lapses in Laundry Handling and Oxygen Equipment Storage
Penalty
Summary
The facility failed to ensure that laundry staff followed infection control processes while performing laundry services. Review of the facility’s Soiled Laundry and Bedding Policy stated that soiled laundry and bedding are to be handled, transported, and processed according to best practices for infection prevention and control, including hand hygiene and the use of appropriate PPE such as gloves and gowns while sorting and handling contaminated linens. During observation, a Laundry Aide was seen placing clean linens against her shirt and later sorting dirty linen without a gown. She confirmed she did not have a gown on and did not have access to one, and stated she had never been informed that she needed to wear a gown while sorting laundry. The Housekeeping and Laundry Supervisor later confirmed that the Laundry Aide was not wearing a gown while sorting linen and did not have access to gowns. The facility also failed to ensure infection control measures were followed for a resident receiving oxygen and nebulizer treatment. The resident had diagnoses including COPD and acute respiratory distress, and the care plan noted altered respiratory status and difficulty breathing related to COPD. Physician orders included oxygen at 2 LPM via nasal cannula as needed and ipratropium-albuterol inhalation solution. Observations showed the resident’s nebulizer tubing and mask lying uncovered on the nightstand and exposed to the environment, and the portable oxygen tubing lying over a rollator. These conditions were observed on multiple occasions, and an LPN/Unit Manager confirmed the nebulizer mask and tubing were uncovered and the portable oxygen tubing was lying uncovered over the rollator.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for all new and existing staff members, as revealed by the In-Service Deficiency Report. The report indicated that there were 19 training topics that should be provided to employees annually, including critical areas such as elopement, emergency operation plan training, abuse policy and procedure, communication training, fire safety, trauma-informed care, and more. However, the Director of Nursing (DON) admitted that there was no formal training program in place, and although she attempted to provide training on various topics, there was difficulty in ensuring staff attendance. The DON acknowledged the importance of training for resident care and safety but confirmed the absence of documentation to track which staff had been trained in specific areas. Interviews with the Administrator and the Director of Clinical Operations (DCO) further confirmed the lack of a formal training program for existing staff. They acknowledged that the training provided did not ensure all staff attended, which could potentially impact the quality of care provided to residents. The absence of a structured training program and the inability to hold staff accountable for attending training sessions were significant factors contributing to the deficiency. The facility's failure to ensure comprehensive staff training posed a risk to resident safety and the overall quality of care provided.
Deficiency in Providing Adequate Pillowcases
Penalty
Summary
The facility failed to provide a sufficient supply of clean pillowcases for three residents, compromising their right to a safe, clean, comfortable, and homelike environment. Resident 52, who is cognitively impaired, had to rely on a family member to provide pillowcases, as the facility was out of stock. During an observation, it was noted that Resident 52 had a pillowcase with his name written on it, indicating it was brought from outside the facility. Resident 6, who is cognitively intact, reported frequent shortages of pillowcases, resulting in some of her pillows being uncovered. Similarly, Resident 285, who is severely cognitively impaired, was observed lying on a pillow without a pillowcase. The Director of Nursing and Unit Manager confirmed the shortage of pillowcases in the linen closets, and the Housekeeping Supervisor admitted to not ordering enough pillowcases despite increased usage. The facility's Administrator acknowledged the deficiency, agreeing that every resident should have enough pillowcases for all their pillows.
Failure to Inform Residents of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that two residents and/or their representatives were informed of the risks and benefits of physician-ordered antipsychotic medications. Resident 24, diagnosed with Alzheimer's Disease, was administered Depakote and Risperdal without documentation that the resident or their representative was informed of the associated risks and benefits. The resident's Power of Attorney was unaware of the medication changes and had previously requested the discontinuation of mood-altering medications. The Director of Nursing admitted that consents were not obtained due to a general consent to treat signed upon admission, and staff failed to document discussions about medication risks and benefits. Similarly, Resident 78, diagnosed with Huntington's Disease, was started on Mirtazapine and Trazodone without notifying the resident's representative of the new medications or explaining their risks and benefits. The Director of Nursing and the MDS Coordinator confirmed that they did not provide information about the risks and benefits of psychotropic medications to the resident or family. A family member was only informed about a medication for sleep but not about the other psychotropic medications. The facility did not provide a policy related to psychotropic medications and consents before the survey exit.
Failure to Timely Issue NOMNC
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident, identified as R134, 48 hours before the end of their Medicare-covered Part A stay. The resident was admitted and later readmitted to the facility, with a discharge date of 06/16/24. The NOMNC indicated that R134's Medicare services would end on 06/16/24, and the resident signed the document on the same day, which was their last covered day. During an interview, the Social Worker acknowledged that the NOMNC should have been issued two days prior, on 06/14/24, but was not. The Administrator also agreed that the NOMNC should have been issued timely, two days in advance.
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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) |
|---|---|---|---|---|
| Archway Transitional Care Center | 3.3 mi | ★★★★★ | 5 | 2 |
| Cherry Blossom Health And Rehabilitation | 3.9 mi | ★★★★★ | 8 | 0 |
| Pruitthealth - Macon | 5.7 mi | ★★★★★ | 0 | 0 |
| Medical Management Health And Rehab Center | 6.3 mi | ★★★★★ | 6 | 0 |
| Pruitthealth - Warner Robins Llc | 7.4 mi | ★★★★★ | 2 | 0 |
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