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 Camellia Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe contractures, blindness, and total dependence on staff for ADL care was provided in-bed care by a CNA using only one-person assistance, contrary to the care plan's requirement for two-person assistance. During this care, the resident fell from the bed, sustained a head injury, and was later pronounced deceased. Staff interviews revealed confusion and inconsistency in following care plan requirements for assistance levels.
A resident with severe contractures, blindness, and total dependence on staff for ADLs was not provided with the required two-person assistance for bed mobility. Instead, a CNA performed care alone, during which the resident rolled off the bed, sustained a head injury, and was later pronounced deceased. Staff interviews revealed inconsistent adherence to care plans specifying assistance levels.
The facility did not maintain an effective pest control program, resulting in widespread roach infestations in resident rooms, a guest bathroom, and the kitchen. Staff interviews revealed that pest control was not called for additional visits despite ongoing issues, and the pest control technician faced barriers to accessing needed areas. A resident reported finding bugs in food and using bug spray, while staff confirmed the persistent problem.
Three residents with mobility and skin integrity risks were found using wheelchairs with torn or missing armrests and backs, despite facility records indicating regular inspections. Staff, including an LPN and CNA, confirmed the poor condition of the wheelchairs and acknowledged the potential for skin tears. The maintenance staff later admitted that inspection documentation was inaccurate, and the deficiencies were not identified or addressed.
A resident with severe malnutrition and anemia experienced a significant change in condition, including low oxygen levels, but the family was not notified as per facility policy. The resident's daughter, distressed by the lack of communication, requested hospital transfer, where the resident later passed away. Interviews confirmed the lapse in communication by the nursing staff.
Failure to Follow Care Plan for Dependent Resident Results in Fatal Fall
Penalty
Summary
A deficiency occurred when the facility failed to follow the care plan for a resident who was totally dependent on staff for activities of daily living (ADL) care, including bed mobility and transfers. The resident had significant medical needs, including contractures in multiple joints, blindness, immobility, impaired cognition, muscle weakness, and an inability to care for herself. The resident's care plan and Minimum Data Set (MDS) assessment specified that she required two-person assistance for bed mobility, bathing, and transfers. Despite these documented requirements, a Certified Nursing Assistant (CNA) provided care to the resident with only one-person assistance while giving a bed bath and changing linens. During this process, the resident rolled out of bed, fell to the floor, and sustained a head injury. The CNA called a Registered Nurse (RN), who assessed the resident and found a laceration on her head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. Interviews with staff revealed inconsistencies in understanding and following the plan of care, with some staff relying on memory or assumptions rather than verifying the required level of assistance in the care plan. Some staff believed that only one person was needed for certain in-bed care tasks, despite the care plan's requirement for two-person assistance. The failure to adhere to the care plan directly resulted in the resident's fall and subsequent death.
Removal Plan
- R1 is no longer at the facility.
- Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care and the support staff needed for ADL care by the DON. Validation of staff education and competency was completed by the DON.
- In-service education was initiated for all nursing staff regarding adhering to the plan of care and the support staff needed for ADL care. Education included how to access the level of care required on the POCs, bed mobility, plan of care, and residents' alerts. DON, ADON, and nurse managers provided education to all RN, LPNs, CNAs, CMAs, and RAI coordinator. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
- 100% audits of the resident plan of care and ADL plan of care were completed to reflect that all residents who require assistance with bed mobility were accurate. Audit was completed by Don, Adon, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
- The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
- Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and Charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1, then monthly for two months, and/or when compliance is achieved or maintained.
- An Adhoc Quality Assurance Process Improvement (QAPI) meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F656. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. The Administrator, DON, Medical Director, Director of Regulatory and Quality Services, ADON, Resident Care Coordinator, Social Service Director, Activity Director, Healthcare Navigator, Human Resource partner, Rehab Director, Schedule Coordinator, and housekeeping supervisor were in attendance.
- All corrective actions were completed. The facility alleges that the IJ was removed.
Failure to Provide Required Bed Mobility Assistance Resulting in Resident Fall and Harm
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, chronic pain, muscle weakness, severe contractures, lack of coordination, and blindness was not provided with adequate bed mobility assistance. The resident was completely dependent on staff for all activities of daily living and required two-person assistance for bed mobility, as documented in the care plan and the ADL plan of care. Despite this, a Certified Nursing Assistant (CNA) provided care with only one-person assistance while changing linens after bathing the resident. During this process, the CNA was on the opposite side of the bed, pulling sheets and pads, and observed the resident roll off the bed. Following the fall, a Registered Nurse (RN) was called to assess the resident and found a laceration on the top of the resident's head and was unable to obtain vital signs. Emergency Medical Services were called, and the resident was pronounced deceased upon their arrival. The incident was reported to the State Survey Agency by the Director of Nursing (DON), who also conducted an internal investigation, collected statements from involved staff, and reviewed the care plan and staff education records. Interviews with facility staff revealed inconsistencies in understanding and following the required level of assistance for bed mobility. Some staff referenced the plan of care for guidance, while others relied on their experience or knowledge of the residents. The care plan and ADL documentation clearly indicated the need for two-person assistance, but this was not followed at the time of the incident, resulting in a fall and subsequent harm to the resident.
Removal Plan
- R1 is no longer at the facility.
- Investigation initiated and the associate providing care to R1 was removed from the schedule. The associate received education regarding adhering to the plan of care with repositioning patients and the support staff needed for ADL care by the DON. Validation of associate education and competency was completed by the DON.
- In-service education was initiated for all nursing staff and was completed regarding falls management, adhering to the plan of care with repositioning patients and the support staff needed. Education included how to access the level of care required on the POCs and turning and repositioning, bed mobility, plan of care, and residents' alerts. The facility's fall management program was reviewed. Education was provided by the Administrator, DON, ADON, and nurse managers. All RN, LPN, CNAs, CMAs, and RAI coordinator have been in-service, which totals 100%. No nursing staff shall work until they have completed in-service education. Newly hired associates will be educated upon hire.
- Audit was completed by DON, ADON, and nurse managers on residents with falls to ensure the plan of care is being followed. No revisions needed after review.
- 100% audit completed of residents' plan of care by DON, ADON, and nurse managers to ensure each resident had the appropriate level of assistance needed for bed mobility. All levels of assistance are noted to be accurate.
- The facility's plan of care and ADL plan of care policy were reviewed by the administrator and medical director, with no changes required at this time.
- Audits of staff providing care by the residents' plan of care are being monitored weekly by DON, ADON, Nurse Managers, and charge nurses and will continue weekly for six weeks across all shifts to include the associate involved in providing direct care to R1.
- An ADHOC QAPI meeting led by the administrator was held and a performance improvement plan was developed and re-evaluated for F689. A root cause analysis was conducted, and no trends were identified; it was determined to be an isolated incident. CNA followed the plan of care. The interventions implemented included the PIP review, a review of the fall Program with no changes, and a process for adhering to the plan of care, which involved repositioning patients and the support staff needed.
- All corrective actions were completed. The facility alleges that the IJ was removed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as evidenced by widespread observations of roaches in multiple resident rooms, a guest bathroom, and the kitchen. Direct observations included roaches emerging from behind and inside an oxygen concentrator, inside a nightstand drawer, on windowsills, and on the walls and floors of several rooms. In the kitchen, roaches were seen in the room with the refrigerators. Review of the pest control maintenance log showed that routine pest control visits were scheduled, but there were gaps in addressing ongoing infestations. Interviews with staff and residents revealed ongoing issues with roaches for several months. The Maintenance Director and Administrator both acknowledged that it was the Administrator's responsibility to call pest control for additional visits, but this had not been done. The Pest Control Technician reported being unable to access certain areas due to locked doors or staff reluctance to move residents, and noted a persistent leak in the kitchen that contributed to the infestation. A resident reported finding bugs in her food and keeping bug spray to kill roaches, while a housekeeping aide confirmed the ongoing problem.
Failure to Maintain Wheelchairs in Good Repair for Multiple Residents
Penalty
Summary
The facility failed to maintain wheelchairs in good repair for three out of four residents observed, resulting in wheelchair armrests and backs that were missing, torn, or tattered. Observations during the initial tour revealed that one resident's wheelchair had a tattered and torn right armrest and back cover, with the back cushion cover not connected and missing a screw. Two additional wheelchairs, found in the hallway near resident rooms, were observed to have discolored tape, missing armrests, and tattered or torn back cushions and armrests. These deficiencies were confirmed by staff, including an LPN and a CNA, who acknowledged that the damaged areas could potentially cause skin tears. Record reviews indicated that the affected residents had diagnoses such as difficulty in walking, neuropathy, peripheral vascular disease, radiculopathy, arthritis, and type 2 diabetes. Their care plans identified them as being at risk for skin impairment, skin breakdown, and skin tears due to their medical conditions and fragile skin. Each resident's care plan also documented the use of a wheelchair as special equipment, further emphasizing the importance of properly maintained mobility devices. Interviews with staff revealed inconsistencies in the facility's equipment inspection and maintenance practices. The Director of Nursing stated that wheelchairs were checked before each use and that CNAs were responsible for notifying maintenance of any issues. However, the Maintenance Assistant/Floor Technician later admitted that the documentation of monthly wheelchair inspections was incorrect, despite records indicating that inspections had been marked as completed. The observed deficiencies in wheelchair condition were not identified or addressed through the facility's documented inspection process.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition, which was a deficiency identified during the survey. The resident, who had multiple diagnoses including severe protein calorie malnutrition and iron deficiency anemia, was admitted to the facility and was under hospice care. On a particular day, the resident was noted to be very weak with low oxygen saturation levels, prompting the application of supplemental oxygen. Despite the facility's policy requiring notification of significant changes in a resident's condition, the resident's daughter was not informed of these changes by the nursing staff. Interviews with the resident's daughter and facility staff revealed that the daughter was distressed over not being notified, as she had been in the past. The LPN who applied the oxygen reported informing the nursing supervisor, who was supposed to notify the family but did not. The Director of Nursing acknowledged that the family should have been notified. The resident's daughter eventually requested hospital transfer due to the low oxygen levels, and the resident passed away the following day at the hospital.
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Illustrative
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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 Claxton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tattnall Healthcare Center | 13.7 mi | ★★★★★ | 10 | 0 |
| Glenvue Health & Rehab | 15.4 mi | ★★★★★ | 0 | 0 |
| Orchard Health And Rehabilitation | 16 mi | ★★★★★ | 0 | 0 |
| Pleasant View Nursing Center | 18.7 mi | ★★★★★ | 6 | 0 |
| Azalea Health And Rehabilitation | 19.1 mi | ★★★★★ | 8 | 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.