Average — CMS composite of the measures below.
The next survey window likely opens 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 Blue Ridge Care Center Llc during CMS and state inspections, most recent first.
Dietary staff did not label or date opened food items and failed to properly discard expired milk. Unlabeled opened cheese and teriyaki sauce were found in storage, and expired chocolate milk was stored with other milk without appropriate signage. The DOD confirmed these lapses and acknowledged responsibility for oversight.
Surveyors found that the facility's dish machine was not properly sanitizing dishware, as temperature gauges were not functioning and sanitizer was not being dispensed, despite multiple tests and recent repairs. This deficiency was identified while nearly all residents were receiving oral diets, and was confirmed through staff interviews and direct observation.
A resident with paraplegia and severe cognitive impairment had personal and medical information posted on their wall, including birthday, gender, medical ID, and a picture. This posting was observed on multiple occasions, and interviews with a family member, the UM, and the DON confirmed that such information should not have been displayed, violating privacy policies.
A resident with depression, anxiety, and other medical conditions received PRN alprazolam for anxiety beyond the 14-day limit required by facility policy. The order was entered with an indefinite stop date, and the medication was administered on multiple occasions past the allowed timeframe. Staff confirmed the expectation for a 14-day limit on PRN psychotropic medications, but the order and administration did not comply with this policy.
The facility did not develop or implement comprehensive care plans for four residents with specialized needs, including those with indwelling urinary catheters, oxygen therapy, and psychotropic medication use. Despite physician orders and documented assessments, care plans lacked necessary focus areas and interventions, as confirmed by staff interviews and record reviews.
A resident with severe cognitive impairment and protein calorie malnutrition was not given a physician-ordered frozen nutritional supplement with meals due to a supply shortage and miscommunication among dietary staff. The supplement was omitted from the resident's lunch tray, and no alternative was provided, despite facility policy requiring supplements to meet assessed needs.
Two residents received oxygen therapy not in accordance with physician orders, including continuous administration when only as-needed use was ordered and at higher flow rates than prescribed. Staff failed to document oxygen administration and did not specify whether oxygen saturation readings were on room air or oxygen. Additionally, required equipment maintenance and safety signage were not followed, as oxygen concentrators lacked filters and 'oxygen in use' signs were missing.
A resident with severe cognitive impairment and a diagnosis of protein calorie malnutrition was not served the lunch meal as written on the facility menu or tray slip. Instead of chicken parmesan, the resident received plain steamed chicken, despite staff and family confirming the discrepancy. Both the Administrator and DOD acknowledged the resident should have received chicken parmesan without sauce, as is the usual practice for residents preferring no sauces.
A CNA did not follow proper hand hygiene and glove-changing protocols while providing catheter care to a resident with an indwelling urinary catheter. The CNA performed care tasks without washing or sanitizing hands between steps and did not change gloves as required, contrary to facility policy and physician orders.
The facility did not revise its CLIA certificate within the required 30 days after a change in ownership, continuing to operate under the previous owner's certificate for approximately seven months. The Administrator confirmed the ongoing use of the prior waiver, and the State CLIA Department verified the facility was out of compliance.
Surveyors observed that bath linens provided to residents were often torn, tattered, or insufficient across multiple hallways. Staff and residents reported frequent shortages, with some towels being cut up to make washcloths. Linen carts were found lacking, and several residents displayed damaged linens from their rooms. Facility leadership acknowledged that such linens should not be used.
Surveyors observed expired food items, including a loaf of bread with visible mold and sandwiches and apples past their use-by dates, stored in resident snack areas on two units. Staff confirmed these items should have been discarded per facility policy, indicating a failure to follow professional standards for food storage and safety.
A CNA assisted multiple residents with eating without performing hand hygiene before or between assisting different individuals, despite touching her own hair, face, cell phone, and food directly with bare hands. Interviews with staff and review of facility policy confirmed that hand hygiene was required before and after assisting with meals, but these protocols were not followed during the observed lunch meal service.
A resident was observed eating at a table that was too high, with her upper lip at table height, making it difficult for her to see her food and eat independently. Staff interviews confirmed that the resident should have been seated at a smaller or adjustable table to promote dignity and facilitate eating.
The facility failed to maintain clean oxygen concentrator filters for two residents requiring oxygen therapy. Observations revealed that the filters were covered with a thick, white substance, indicating they had not been cleaned as required by the facility's policy. Interviews with staff confirmed the deficiency, highlighting a lapse in adherence to the maintenance schedule.
Failure to Label Opened Food Items and Discard Expired Milk
Penalty
Summary
Dietary staff failed to label and date opened food items and did not properly discard expired milk, as required by facility policy. Observations revealed a five-pound bag of shredded cheddar cheese and a one-gallon container of teriyaki sauce that had been opened and stored without an open date. The Director of Dietary (DOD) confirmed these items were not labeled as required and stated that all dietary staff were responsible for labeling and dating, but she was ultimately responsible for checking compliance. The DOD had not yet checked the walk-in refrigerator on the day of the observation. Additionally, a full crate of eight-ounce chocolate milk cartons with a sell-by date that had passed was found stored next to other milk crates without a 'do not use' sign. The DOD acknowledged that expired milk should be separated and marked accordingly but admitted to noticing the expired crate and forgetting to move it and label it. At the time of the survey, the facility census was 163, with 162 residents receiving an oral diet.
Failure to Maintain Proper Dish Machine Sanitization
Penalty
Summary
The facility failed to ensure that the dish machine used for sanitizing dishware was functioning properly to prevent foodborne illness. Observations revealed that the large conveyor belt type dish machine, which operates as a low temperature chemical sanitizing unit, had non-functioning temperature gauges and was not dispersing sanitizer as required by facility policy. Multiple attempts to test the sanitizing solution using paper test strips showed no indication of sanitizer being present, as the strips remained white instead of turning black to indicate the required concentration. Staff, including the dietary aide, Director of Dietary (DOD), and Director of Maintenance (DOM), confirmed these findings during the survey. The issue persisted despite staff checking chemical buckets, tubing, and replacing the sanitizer bucket. The temperature gauges on the dish machine were also not registering any temperatures for the wash or rinse cycles during several observations. The DOD and DOM both confirmed that the dish machine had recently undergone repairs and had been out of operation for several days while waiting for a part. However, even after the machine was reported as fixed and the temperature gauges began working again, repeated tests continued to show no sanitizer being dispensed. The deficiency was observed while 162 out of 163 residents were receiving an oral diet, indicating that the majority of residents could have been affected by improperly sanitized dishware. The failure to maintain essential equipment in safe working order was confirmed through direct observation, staff interviews, and review of facility policy, with the dish machine only beginning to dispense sanitizer after multiple interventions and repeated testing.
Failure to Protect Resident Health Information Privacy
Penalty
Summary
The facility failed to protect the privacy of a resident's health information by posting instructions on the resident's wall that disclosed personal details, including birthday, gender, medical identification, and a picture. This posting was observed on two separate occasions and was titled with the resident's shower day, making private medical information visible. The facility's policy on promoting and maintaining residents' dignity specifically requires maintaining resident privacy, which was not followed in this instance. The resident involved had a diagnosis of paraplegia and severe cognitive impairment, as indicated by a BIMS score of 00 on the most recent assessment. Interviews with a family member, the Unit Manager, and the DON confirmed that the posting of such information was inappropriate and not in line with facility policy or HIPAA requirements. The family member was unaware of the posting, and both the Unit Manager and DON acknowledged that staff should not post residents' medical information in this manner.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders were limited to 14 days as required by policy for one resident. The policy on the use of psychotropic medications specified that PRN orders should not exceed 14 days unless the prescriber documents a rationale for extending the order and specifies a duration. However, a review of the electronic medical record (EMR) for a resident with diagnoses including depression, anxiety, diabetes mellitus type 2, and urinary tract infection revealed an order for alprazolam 0.25 mg every 12 hours as needed for anxiety, with an indefinite stop date. The resident was cognitively intact, as indicated by a BIMS score of 15, and the care plan did not address the use of antianxiety or antidepressant medications. Medication administration records showed that alprazolam was administered multiple times beyond the 14-day limit set by policy, with doses given on several dates in both November and December after the initial order date. Staff interviews confirmed that PRN psychotropic medications are expected to be limited to 14 days, but the order in question was entered with an indefinite stop date by the Nurse Practitioner. Both the LPN and DON verified that the medication was administered outside the required timeframe, confirming the deficiency in following the facility's policy regarding PRN psychotropic medication orders.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for four residents, as required by facility policy and professional standards. Specifically, one resident with an indwelling urinary catheter did not have a care plan addressing catheter care, despite physician orders detailing the need for ongoing catheter management and enhanced barrier precautions. The MDS Coordinator confirmed that no care plan was in place for this resident, acknowledging that such a plan should have been completed following the admission assessment. Two other residents who were receiving oxygen therapy also lacked care plans addressing their oxygen use. Both residents had documented orders for oxygen administration and were observed receiving oxygen during the survey. Staff interviews confirmed that the care plans did not include focus areas or interventions related to oxygen therapy, even though this was documented in their assessments. The DON and MDS Coordinator both verified that oxygen use should have been included in the care plans for these residents. A fourth resident, who was prescribed antianxiety, antidepressant, and hypoglycemic medications, did not have a care plan addressing the use of these psychotropic and high-risk medications. The resident's medication use was documented in the MDS assessment, but the care plan lacked any focus areas, goals, or interventions related to these medications. Multiple staff members, including LPNs and the DON, confirmed that interventions for these medications should have been present in the care plan and were unable to explain why they were missing.
Failure to Provide Ordered Nutritional Supplement with Meals
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of unspecified protein calorie malnutrition was not provided with a physician-ordered frozen nutritional supplement during a lunch meal. The resident had a severely impaired cognitive status, as indicated by a Brief Interview for Mental Status (BIMS) score of one out of 15. Review of the resident's electronic medical record confirmed an active order for the supplement to be given with meals. During observation, the lunch tray did not include the supplement, and the resident was only offered a meal plate, iced tea, and Italian ice. The resident's family member confirmed the absence of the supplement and noted that the resident had previously received and enjoyed it. Interviews with facility staff revealed that the dietary department was out of the frozen nutritional supplement and was awaiting a new supply from their food supplier. The Director of Dietary (DOD) was unaware that the supplement was to be given with meals, mistakenly believing it was to be provided between meals. The registered dietitian confirmed the supply issue and stated that the resident had previously refused liquid supplements, but no alternative, such as regular ice cream, was offered during the shortage. The facility's policy required providing nutritional supplements consistent with assessed needs, but this was not followed in this instance.
Failure to Administer Oxygen Therapy as Ordered and Maintain Equipment Protocols
Penalty
Summary
The facility failed to ensure that oxygen was administered as ordered by the physician for two residents who were receiving oxygen therapy. For one resident with diagnoses including epilepsy, acute respiratory distress, and pneumonia, the physician's order specified oxygen at two liters per minute (LPM) via nasal cannula (NC) only if oxygen saturation fell below 90%, with instructions to call the physician immediately after placement. However, the resident was observed receiving oxygen at four LPM continuously, despite no documentation of oxygen saturations below 90% or respiratory distress, and staff confirmed there were no changes in orders or status to justify this deviation. For another resident with shortness of breath and asthma, the physician's order was for oxygen at two LPM via NC as needed for oxygen saturation below 90%, with a requirement to call the physician after placement. This resident was observed receiving continuous oxygen, and staff confirmed that the order was for as-needed use, not continuous administration. Additionally, there was no care plan addressing oxygen use for this resident, and documentation did not specify whether pulse oximeter readings were taken on room air or while on oxygen. Staff also failed to document the administration of oxygen as required by the as-needed order. Further deficiencies were observed in the maintenance and safety protocols for oxygen therapy. The oxygen concentrator for the second resident was missing a required filter, which should have been cleaned or replaced weekly according to physician orders. There was also no 'oxygen in use' signage on the resident's doorway, as required by facility policy. Staff interviews confirmed these lapses in following physician orders and facility protocols for oxygen administration and equipment maintenance.
Failure to Serve Menu Meal as Written for Resident with Malnutrition
Penalty
Summary
The facility failed to serve a lunch meal as written on the menu for one sampled resident who had a diagnosis including unspecified protein calorie malnutrition and severely impaired cognition. The resident had a physician order for a regular diet, regular texture, and regular consistency. According to the facility's posted menu, the lunch meal was supposed to include chicken parmesan, spaghetti, tomato sauce, Italian mixed vegetables, garlic roll, margarine, Italian ice, and whole milk. However, the resident's meal tray slip listed substitutions, including fried chicken with no sauce, noodles with no gravy, and other items. Observation revealed the resident was served plain steamed chicken thigh, Italian mixed vegetables, garlic bread, iced tea, and Italian ice, rather than the chicken parmesan specified on both the menu and the tray slip. Interviews with the resident's family member, the Administrator, and the Director of Dietary confirmed that the resident was not served the chicken parmesan as indicated. The family member reported that the resident was often not served what was indicated on the meal tray slip. Both the Administrator and the Director of Dietary acknowledged that, despite the resident's preference for no sauces or gravy, the resident should have been served chicken parmesan without sauce, as per the menu and tray slip. The Director of Dietary also stated that cooks typically set aside unsauced chicken parmesan for residents who prefer no sauces, but this was not done in this instance.
Failure to Follow Hand Hygiene Protocol During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection control practices during catheter care for a resident with an indwelling urinary catheter. The CNA was observed double-gloving before entering the resident's room and did not clean the bedside table before setting up supplies. During the catheter care process, the CNA removed only the outer pair of gloves after cleaning the catheter insertion site but continued the remainder of the care, including rinsing, drying, and repositioning the resident, with the same inner gloves. At no point during the procedure did the CNA wash or sanitize her hands when transitioning between clean and dirty tasks, nor did she don new gloves as required by facility policy and professional practice standards. The resident involved had a history of urinary retention, severely impaired cognition, and was dependent on staff for all activities of daily living. The resident's care plan did not include specific interventions for the indwelling urinary catheter, despite physician orders outlining catheter care and enhanced barrier precautions. Facility policy and audit tools specifically required hand hygiene and glove changes during catheter care, but these protocols were not followed during the observed incident.
Failure to Update CLIA Certificate After Change of Ownership
Penalty
Summary
The facility failed to update its Clinical Laboratory Improvement Amendments (CLIA) certificate within 30 days following a change in ownership, as required by regulations. Approximately seven months after the new owner acquired the facility, the CLIA Certificate of Waiver and the CLIA Certificate of Compliance remained in the name of the previous owner and previous laboratory service owner, respectively. During an interview, the facility's Administrator acknowledged that the facility was still operating under the previous owner's waiver as part of the transition. The State CLIA Department confirmed that the facility was out of compliance and should have requested a revised CLIA certificate using the CMS-116 application within the required timeframe.
Failure to Provide Adequate and Clean Bath Linens
Penalty
Summary
Surveyors found that the facility failed to provide bath linens in good condition across seven of nine hallways. During multiple observations, linen carts were found to have either no towels or washcloths, or only those that were torn and in disrepair. Staff were seen using tattered washcloths, and some reported that they often lacked adequate linens, with new linens only being provided during the survey. Residents confirmed that towels had been cut up to make washcloths, and several displayed torn and shredded linens from their personal supplies. Resident Council minutes and grievance logs documented ongoing complaints about daily linen shortages affecting all units. Interviews with staff and administration revealed that families and residents had been cutting up towels to create washcloths, and that staff sometimes had to ration or redistribute available linens. The Environmental Service Supervisor and Administrator acknowledged the issue, with the Administrator stating that linens should not be cut up or used in a damaged state. Photographic evidence of shredded washcloths was presented to facility leadership, who agreed that such items should not be in use.
Expired Food Found in Resident Snack Storage Areas
Penalty
Summary
Staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by the presence of expired food in resident snack storage areas. On two separate units, surveyors observed an unopened loaf of bread with an expiration date several months past, which was hard and showed green discoloration, and a refrigerator containing turkey sandwiches and cups of apples that were past their use-by dates. Staff interviews confirmed that these food items should have been discarded according to facility policy, which requires perishable and leftover foods to be labeled with preparation and discard dates and disposed of within a specified timeframe.
Failure to Perform Hand Hygiene During Meal Assistance
Penalty
Summary
Staff failed to perform proper hand hygiene during the lunch meal service in the Nursing Unit Main Dining Room, as observed with three residents. A Certified Nursing Assistant (CNA) assisted residents with eating without using hand sanitizer or washing hands before or between assisting different residents. The CNA was observed touching her own hair, face, and cell phone, as well as handling utensils and food directly with bare hands, and then continuing to assist residents with their meals without performing hand hygiene. The CNA also distributed meal trays and adjusted the television without washing hands before returning to assist residents with eating. Interviews with the CNA, the Nursing Unit Manager (LPN), the Director of Nursing (DON), and facility administrators confirmed that staff are expected to use hand sanitizer or wash hands before serving or feeding residents, and after touching their face or hair. The facility's policy on hand hygiene requires the use of alcohol-based hand rub before and after assisting a resident with meals. The observed failure to follow these protocols occurred during the lunch meal and involved multiple residents who required assistance with eating.
Failure to Provide Appropriate Table Height Compromises Resident Dignity During Meals
Penalty
Summary
A deficiency occurred when a resident was not provided with a dining table of appropriate height, resulting in the resident being unable to see her food while eating. Observations showed the resident seated in a lowered wheelchair at a table where her upper lip was at table height, making it difficult for her to eat independently and with dignity. Staff interviews confirmed awareness of the issue, with a CNA noting that the resident should have been seated at a smaller table to allow her to see her food. The DON and Administrator acknowledged that the resident should have been provided with an adjustable or smaller table, and the Regional Director of Operations also stated that the resident should sit at a smaller table. The failure to provide a suitable table height compromised the resident's dignity during mealtime.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain a clean oxygen concentrator filter for two residents, R56 and R119, who required oxygen therapy. The facility's policy mandated that the oxygen concentrator filter be cleaned weekly and as needed, with documentation on the Medication Administration Record (MAR). However, observations revealed that the filters on both residents' oxygen concentrators were covered with a thick, white substance, indicating they had not been cleaned as required. Interviews with staff, including the Dementia Unit Manager and the Director of Nursing, confirmed that the filters appeared unclean and that the maintenance was supposed to be conducted by the third shift nurse every Wednesday and as needed. R56 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD) and emphysema and had a care plan that required regular maintenance of the oxygen concentrator. Despite this, multiple observations on consecutive days showed that the filter was not cleaned. The Dementia Unit Manager confirmed that the filter did not appear to have been cleaned during the previous third shift as indicated on the MAR. Similarly, R119, who was admitted with acute respiratory failure with hypoxia, also had an unclean oxygen concentrator filter. Observations and interviews confirmed that the filter was covered with a thick, white substance, and the Dementia Unit Manager verified that it did not appear to have been cleaned as required. Interviews with a Certified Nursing Assistant and a Licensed Practical Nurse revealed that the responsibility for cleaning the oxygen concentrator filters lay with the nurses assigned to the residents' hall. The Director of Nursing stated that her expectation was for the third shift nurse to clean the concentrators weekly and document the activity, but all nursing staff were responsible for ensuring the equipment was clean and free of debris. Despite these expectations, the observations and interviews indicated a failure to adhere to the facility's policy, leading to the deficiency in maintaining clean oxygen concentrator filters for the residents involved.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ross Memorial Health Care Ctr | 11 mi | ★★★★★ | 0 | 0 |
| Cottages At Rockmart, The | 11.8 mi | ★★★★★ | 3 | 0 |
| Powder Springs Center For Nursing & Healing | 12.2 mi | ★★★★★ | 3 | 0 |
| Rockmart Health | 12.4 mi | ★★★★★ | 1 | 0 |
| Presbyterian Village | 14.1 mi | ★★★★★ | 6 | 0 |
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