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 Brown's Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and a BIMS of 15 had no self-administration assessment, no care plan for self-administration, and no orders authorizing self-administration, yet surveyors found OTC and prescription meds stored at the bedside and dresser. The resident stated the meds were being used without staff supervision, and the ADON confirmed the same meds were also being administered from the med cart. RN AA reported the resident and family had a history of bringing in unauthorized meds.
An unsecured oxygen cylinder was found on the floor in a resident’s room, within reach of a resident with severe cognitive impairment and active oxygen-related orders. RN and LPN staff were unaware of the tank, and the RN removed it after stating hospice staff most likely left it there. A CNA also reported not seeing the cylinder earlier that day, and the ADON stated all staff were responsible for monitoring oxygen cylinder safety.
The facility did not provide four residents with written information about their rights to accept or refuse medical or surgical treatment, as required by policy. Despite having intact cognition, these residents were not informed or given documentation regarding their rights upon admission or readmission. Interviews confirmed the lack of communication, and the facility's Admission Packet was missing necessary language to inform residents of their rights.
A resident was transferred to a hospital without receiving a written notice of transfer, as required. The facility lacked a policy for providing such notices, and staff interviews confirmed that no written information was given to residents. The resident, who had little to no cognitive impairment, was not informed in writing about the transfer, highlighting a deficiency in the facility's procedures.
A facility failed to provide a written bed hold notice to a resident during a hospital transfer, as required by their policy. Despite the policy stating that residents or their representatives should receive this notice at admission and before transfers, the resident did not receive it, which was confirmed by staff interviews and record reviews.
A facility failed to include smoking in a resident's care plan, despite the resident having a physician's order for supervised smoking and being listed as a smoker. The resident, with multiple health conditions including COPD and dementia, was observed participating in smoke breaks. The omission was confirmed by facility staff, highlighting a lapse in care planning.
The facility failed to follow physician orders for two residents, leading to the administration of pain medication at incorrect intervals. This caused the residents to become lethargic and required emergency treatment with Narcan. The nurse responsible was inconsistent in documenting medication administration and was terminated following the incident.
The facility failed to ensure that two residents were free from significant medication errors, resulting in both being transferred to the ER and treated with Narcan. An LPN administered multiple doses of oxycodone without reviewing the MAR, leading to lethargy and difficulty in arousing the residents. The DON confirmed that no documented narcotic audit was conducted at the time, and the nursing staff has since been educated on medication administration.
Unauthorized Medications Stored at Bedside
Penalty
Summary
The facility failed to ensure that unauthorized medications were not stored at the bedside for one sampled resident, R25. The resident had diagnoses including osteomyelitis, atrial fibrillation, cardiac arrhythmia, hypertension, and GERD. The admission MDS documented a BIMS score of 15, indicating little to no cognitive impairment. The care plan contained no plan for medication self-administration, and the EHR showed no self-administration assessment or evaluation. Active physician orders included Omega-3 oral capsule 1000 mg and Nasonex nasal suspension 50 mcg/actuation, but there were no orders authorizing self-administration. During observation in the resident's room, surveyors found a bottle of OTC nasal spray and a prescription bottle of mometasone fumarate nasal spray on the bedside rolling table, as well as a bottle of Omega Acid Ethyl pills and a prescription bottle of potassium pills on the dresser stand. R25 stated the medications were being used without staff supervision. The ADON later confirmed the medications were in the room and stated she was unaware of them, and she confirmed the resident was at risk of receiving additional doses because the same medications were also on the nurse's medication cart and were being administered daily. RN AA also confirmed the medications had been removed from the room and stated that R25 and the family had a history of bringing in unauthorized medications and had previously received education about the risk of self-administering medications without nurse supervision.
Unsecured Oxygen Cylinder Found in Resident Room
Penalty
Summary
The facility failed to ensure an environment free from an accident hazard when an oxygen cylinder was found unsecured in R50’s room. R50 had diagnoses including senile degeneration of the brain and Parkinson’s disease, and the quarterly MDS documented a BIMS score of 7, indicating severe cognitive impairment. The active physician orders included oxygen saturation checks every shift for shortness of breath and oxygen at 2 LPM via nasal cannula for O2 sats less than 90%, and the hospice care plan included use of oxygen as needed for comfort. During observation, an unsecured oxygen cylinder tank was seen sitting on the floor between R50’s bed and a dresser, within the resident’s reach. RN AA and LPN CC stated they were unaware the tank was in the room, and RN AA removed it, stating hospice staff most likely left it there. CNA BB reported she had provided ADL care earlier that morning and did not see the tank, and she stated she had received in-services about monitoring unsecured oxygen cylinders and the danger of not using a cylinder holder. The ADON stated she was also unaware of the unsecured cylinder and said all staff, including non-nursing staff, were responsible for monitoring oxygen cylinder safety.
Failure to Provide Information on Treatment Rights
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding their right to accept or refuse medical or surgical treatment, as well as the right to formulate an advance directive. This deficiency was identified for four residents, each of whom had intact cognition as evidenced by their Brief Interview for Mental Status (BIMS) scores of 15. The facility's policy, revised in October 2023, mandates that the Social Services Director inform and educate residents or their Power of Attorney in writing about these rights upon admission or readmission. However, the facility's Admission Packet lacked the necessary language to fulfill this requirement. Interviews with the residents revealed that none of them had been informed about their rights to accept or refuse treatment, nor had they received any written information or signed any acknowledgment regarding these rights. The Social Services Director confirmed that the facility did not provide the required information, and the President of Regulatory Compliance acknowledged the absence of evidence supporting that the residents or their representatives had been advised of their rights. This oversight had the potential to impact the residents' ability to make informed decisions about their care.
Failure to Provide Written Transfer Notice to Resident
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident, identified as R19, or their representative, which is a requirement when transferring residents to a hospital. This deficiency was identified during a review of resident and staff interviews and medical records. R19, who has a BIMS score indicating little to no cognitive impairment, was transferred to the hospital without receiving any written notification about the transfer. The facility did not have a policy in place for providing such notices, as confirmed by the President of Regulatory Compliance. Interviews with staff, including an LPN and an RN, revealed that while a transfer form was completed in the electronic medical record and sent to the hospital, no written information was provided to the resident. The RN mentioned that the transfer document included details like medications and insurance information but did not state the reason for the transfer. The President of Regulatory Compliance acknowledged that nothing in writing was given to residents upon transfer, and residents were only verbally informed of the reason for their transfer.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written notice of the bed hold policy to a resident, identified as R19, at the time of transfer to a hospital or within 24 hours, as required by their policy. The facility's policy, dated 3/3/2020, mandates that all residents or their responsible parties are informed in writing about the bed hold policy at the time of admission and prior to a resident's transfer to a hospital or start of a therapeutic leave. However, upon review of R19's medical records, it was found that no such notification was provided when R19 was transferred to the hospital on 8/9/2024. Interviews with the resident, medical records clerk, RN Unit Manager, and the Director of Nursing confirmed that the bed hold notice was not given to R19 or uploaded into the electronic medical record. R19, who has a BIMS score indicating little to no cognitive impairment, confirmed not receiving the notice. The medical records clerk stated that if the notification was not in the electronic medical record, it was not completed or given. The Director of Nursing and RN Unit Manager also confirmed the oversight, and the President of Regulatory Compliance acknowledged the failure to provide the notice.
Failure to Include Smoking in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who smoked, despite having a policy in place that required such plans to be completed within a specific timeframe. The resident, identified as having chronic obstructive pulmonary disease (COPD), depression, type 2 diabetes mellitus, unspecified dementia with anxiety, and other behavioral disturbances, was admitted with a physician's order allowing supervised smoking. However, the resident's care plan did not include any interventions or care areas related to smoking, even though smoking assessments were completed and the resident was listed as a smoker by the facility. Observations and interviews confirmed that the resident regularly participated in smoke breaks, escorted by a Certified Nursing Assistant (CNA). Despite this, the care plan lacked any mention of smoking, which was acknowledged by the facility's Administrator and the Regional President of Regulatory Compliance. This oversight increased the potential for the resident not to receive care according to their needs, as the care plan did not address the resident's smoking habits or the necessary supervision required.
Failure to Follow Physician Orders Resulting in Harm
Penalty
Summary
The facility failed to ensure that two residents were protected from not following physician orders, resulting in actual harm. On 3/6/2024, pain medication with sedative effects was administered to two residents, causing them to become lethargic and hard to arouse. Both residents were transferred to the emergency room and treated with Narcan to reverse the opioid overdose. One resident was admitted to the hospital with a diagnosis of somnolence, while the other returned to the facility after declining hospital admission. The deficiency was identified through observations, staff interviews, and record reviews. The facility's Medication Administration Guidelines were not followed, leading to the administration of oxycodone at incorrect intervals. For one resident, oxycodone was administered two hours after the previous dose, and for the other resident, it was administered three hours after the previous dose. This resulted in both residents receiving multiple doses of oxycodone within a short period, leading to their lethargic state and subsequent emergency treatment. Interviews with the Director of Nursing (DON) revealed that the nurse responsible for administering the medication, LPN AA, was inconsistent in documenting the effectiveness of pain medication and signing off on the Medication Administration Record (MAR). Despite previous education on medication administration, LPN AA continued to be inconsistent, leading to the overdose incident. The DON suspended LPN AA pending an investigation, and the nurse was eventually terminated for not adhering to the facility's medication administration policies.
Significant Medication Errors Lead to Harm
Penalty
Summary
The facility failed to ensure that two residents, R1 and R2, were free from significant medication errors. Both residents were administered pain medication with sedative effects, which led to lethargy and difficulty in arousing them. R1 received oxycodone 5 mg doses at 4:00 pm and 6:00 pm on the same day, while R2 received oxycodone 10 mg doses at 3:00 pm and 6:00 pm. These doses were administered without proper review of the Medication Administration Record (MAR), resulting in both residents being transferred to the emergency room and treated with Narcan to reverse the opioid overdose effects. R1 was admitted to the hospital with a diagnosis of somnolence, while R2 returned to the facility after declining hospital admission despite being diagnosed with sepsis and rhabdomyolysis at the ER. The report reveals that LPN AA, who was responsible for administering the medications, did not review the MAR before giving the medications to see if the residents had been previously medicated. This resulted in the administration of multiple doses of oxycodone within a short period. LPN AA had a history of disciplinary actions, including not completing wound care and administering PRN pain medication without a pain assessment. The DON confirmed that LPN AA had been working the night shift full-time since November or December 2023 and had clocked in late on the day of the incident, signing the narcotic sheet for an earlier time. The DON acknowledged that there was no documented narcotic audit being conducted at the time of the incident. Following the incident, the DON began performing daily narcotic audits of PRN medications. The nursing staff was also educated on medication administration. The report highlights the failure in medication administration practices and the lack of proper review and monitoring, which led to significant medication errors and harm to 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 Statesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eagle Health & Rehabilitation | 0.3 mi | ★★★★★ | 0 | 0 |
| Westwood Healthcare And Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Heritage Inn Health And Rehabilitation | 1.5 mi | ★★★★★ | 0 | 0 |
| Orchard Health And Rehabilitation | 10.9 mi | ★★★★★ | 0 | 0 |
| Pleasant View Nursing Center | 15.9 mi | ★★★★★ | 6 | 0 |
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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.