Above 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 Colquitt Regional Senior Care & Rehabilitation during CMS and state inspections, most recent first.
Failure to Document Informed Consent for Psychotropic Medications: The facility did not document that two residents were informed of the risks, benefits, and alternatives before psychotropic meds were started or increased. One resident with depression and insomnia received eszopiclone and hydroxyzine, and another resident with depression and pseudobulbar affect had an order for hydroxyzine PRN for anxiety; the records contained no consent documentation. The DON confirmed consent forms could not be located, and the pharmacist confirmed hydroxyzine is a psychotropic when used for anxiety.
Missing GCHEXS Background Check for FSS: The facility failed to ensure a GCHEXS fingerprint background check was completed for the FSS, whose record did not contain the required clearance letter. The Assistant Administrator, Administrator, and HRA stated food service and environmental services staff were not getting fingerprint checks because they were not considered direct care staff, even though facility policy stated all associates would be screened prior to hire with a criminal background check.
A resident with COPD, DM2, and CKD had an active order to avoid all NSAIDs, but a later PRN order for ibuprofen 800 mg was entered and the conflicting orders were not reconciled before the medication was administered. The MAR showed the resident received ibuprofen on multiple occasions, and the ADON, DON, and NP confirmed the orders conflicted and that the earlier NSAID-avoidance order should have taken precedence.
A CNA failed to wear required gown and gloves while transferring a resident on EBP and providing incontinent care, despite the resident’s care plan and posted EBP status. In a separate event, a WCRN performing wound care for a resident with a stage 3 sacral pressure ulcer placed clean supplies on a bedside table where items touched the surface and changed gloves without hand hygiene before continuing care; the DON stated hand hygiene was expected before wound care and with each glove change.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to the prescription of antibiotics without proper diagnostic testing or symptom documentation. Over several months, multiple residents were prescribed antibiotics despite not meeting McGreer's criteria for infection. The Infection Preventionist and Director of Nursing confirmed the lack of interventions for these cases, and the facility's ASP data collection was inconsistent.
The facility failed to provide required transfer notices to three residents and their representatives before transferring them to the ER, as well as failed to notify the State LTC Ombudsman of these transfers. The transfer forms lacked information on appeal rights and Ombudsman contact details. The facility's administrator confirmed that prior to May 2024, transfer notices were not sent to the Ombudsman, and some transfers were omitted from the lists sent thereafter.
The facility failed to implement care plans for monitoring psychotropic medications for two residents. One resident was prescribed Aripiprazole and Escitalopram Oxalate without monitoring for side effects or behaviors, despite a care plan indicating such interventions. Another resident was prescribed Celexa, but monitoring for side effects and efficacy was not conducted until months later. The DON confirmed these oversights during interviews.
A facility failed to document discharge needs and assessment for a resident discharged home with a femur fracture. Despite being cognitively intact, there was no record of discharge needs or assessment in the progress notes. Discharge instructions lacked prior assessment documentation. Staff interviews revealed gaps in communication and documentation, with expectations for discharge documentation not being met.
A facility failed to document pressure ulcer dressing changes for a resident, leading to a lack of communication among staff. The facility's policy requires detailed documentation of treatments, but a review of the resident's progress notes showed only one entry over a two-month period. Interviews with the WN/RN and DON confirmed that documentation was inconsistent, despite instructions to record each dressing change.
A facility failed to document and collaborate effectively for a resident requiring dialysis care. The resident, with end-stage renal disease, had incomplete documentation on the Dialysis Transfer Form, missing vital signs, assessments, and signatures. Staff interviews confirmed these deficiencies, highlighting a lack of communication between the facility and the dialysis center.
The facility failed to accurately post daily nurse staffing information, as required by their policy, leading to outdated and incomplete data being displayed. The staffing document did not include certain CNAs, and the responsibility for posting was divided between the DON and RN Supervisor. This resulted in potential misinformation about the nursing staff available to care for the 54 residents.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were informed of the benefits, risks, and alternatives of psychotropic medications before those medications were started or increased. One resident was admitted with diagnoses including major depressive disorder and insomnia, had a BIMS score of 14 indicating little to no cognitive impairment, and received eszopiclone 3 mg at bedtime for insomnia and hydroxyzine 25 mg daily. The record review found no documentation that the resident or representative had been provided information in advance about the risks and benefits of the medications, treatment alternatives, or other options, and no documentation of consent to receive the medications. A second resident was admitted with diagnoses including major depressive disorder and pseudobulbar affect and had a BIMS score of 9 indicating moderate cognitive impairment. This resident had an order for hydroxyzine 25 mg every 12 hours as needed for anxiety, but the medication was not administered during the reviewed period and behavior monitoring documented no anxious behaviors. The record also contained no documentation that the resident or representative had been informed in advance of the risks and benefits of the medication, treatment alternatives, or other options, or had consented to receive it. During interviews, the DON stated psychotropics were usually prescribed by psychiatry and confirmed she could not locate consent forms or documentation of consent for the increase in Lunesta or the initiation of the other medications.
Missing GCHEXS Background Check for Food Service Supervisor
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Based on record review, interviews, and facility policy, the facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed for the Food Service Supervisor (FSS). Review of the FSS employee record showed he was hired on 09/07/2022, and the required GCHEXS fingerprint background check clearance letter was not located in the file. During interviews, the Assistant Administrator stated the FSS did not have a GCHEXS background check completed upon hire. The Administrator stated Human Resources did not complete fingerprint background checks for staff who did not have direct care with residents. The Human Resources Assistant stated environmental services and food services staff would not have direct contact with residents and did not have fingerprint background checks completed. Review of the facility policy titled, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property, stated all associates will be screened prior to being hired by having a criminal background check performed. The facility's Employee Recruitment policy stated Human Resources would be responsible for maintaining applicant records and screening applicants in comparison to the established requirements for the available position.
Conflicting NSAID Orders Were Not Reconciled Before Ibuprofen Was Given
Penalty
Summary
R50, admitted on 08/05/2024, had diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and chronic kidney disease. The medical record showed a physician order dated 03/19/2025 directing staff to avoid all NSAIDs at all times. Despite that order remaining active, a subsequent physician order dated 05/29/2025 was entered for ibuprofen 800 mg by mouth every six hours as needed for pain, and the conflicting orders were not reconciled, clarified, or discontinued before the ibuprofen was administered. The MAR documented that R50 received ibuprofen on 06/08/2025, 07/07/2025, and 07/08/2025 after the order to avoid NSAIDs was already in effect. During interview, the ADON confirmed the avoid-NSAIDs order and the later PRN ibuprofen order. The Administrator and DON stated staff were expected to follow physician orders as written. The NP stated the avoid-NSAIDs order should have taken precedence unless risks and benefits were reviewed and acknowledged, and that if a prior order existed to avoid NSAIDs, the PRN ibuprofen order should not have been written.
Infection Control Lapses During EBP and Wound Care
Penalty
Summary
The facility failed to ensure staff followed standard infection control practices during Enhanced Barrier Precautions for R12 and during wound care for R9. R12 was admitted with diagnoses including colostomy status, type 2 diabetes mellitus, and overactive bladder, and had an order for colostomy care and a care plan placing the resident on Enhanced Barrier Precautions. During observation, a CNA transferred R12 from a wheelchair to bed and later provided incontinent care without wearing the required gown and gloves. The CNA confirmed she did not wear the required PPE, and the Infection Preventionist and DON stated staff were required to wear PPE and follow hand hygiene protocols for high-contact care. For R9, who was admitted with diagnoses including hemiplegia, diabetes mellitus, and peripheral vascular disease, had a BIMS score of 9, and had a stage 3 sacral pressure ulcer with wound care treatments, the Wound Care RN performed wound care with supplies placed on the bedside table in a way that allowed clean and unopened items to touch the table. During the procedure, the RN changed gloves without performing hand hygiene before continuing wound cleansing and dressing application. The RN confirmed she did not use hand sanitizer when changing gloves, and the DON stated hand hygiene was expected before wound care, after removing the old dressing, before applying the new dressing, and with each glove change.
Deficient Antibiotic Stewardship Program in LTC Facility
Penalty
Summary
The facility failed to develop an effective Antibiotic Stewardship Program (ASP) to monitor antibiotic use, as evidenced by the prescription and administration of antibiotics to residents without appropriate diagnostic testing or documented symptomology. The facility's policy on Antibiotic Stewardship, dated September 2022, required antibiotics to be prescribed and administered under the guidance of the ASP and Quality Assurance and Performance Improvement (QAPI) Committee. However, the facility's ASP data collection was inconsistent, with missing data for February 2024 and no interventions documented for residents whose symptoms did not meet McGreer's criteria for infection. Throughout the months from December 2023 to July 2024, multiple instances were noted where residents were prescribed antibiotics despite their symptoms not meeting McGreer's criteria. For example, in December 2023, three residents were prescribed antibiotics without meeting the criteria, and similar patterns were observed in subsequent months. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that there was no evidence of interventions for these cases, and the facility's ASP was not in place prior to December 2023. Interviews with the IP/DON revealed that the facility used McGreer's criteria to guide the ASP, but there was a lack of evidence for interventions or corrective actions for infections that did not meet the criteria. The IP/DON acknowledged the absence of ASP data for February 2024 and confirmed that no additional interventions were implemented beyond a June 2024 inservice on hand hygiene and perineal care. This deficiency in the ASP has the potential to affect all residents in the facility, with a census of 54 residents.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written transfer or discharge notice with the required content to three residents and their representatives before transferring them to the emergency room. The facility's policy on transfer or discharge documentation mandates that appropriate notice be documented in the medical record when a resident is transferred. However, for three residents, there was no documentation in their electronic medical records indicating that they or their representatives were provided with the necessary transfer notice. These residents were transferred to the emergency room due to various medical conditions, including vomiting, abdominal pain, fever, and pneumonia, but the facility did not document the provision of transfer notices. Additionally, the facility did not notify the State LTC Ombudsman office of the transfers or discharges of these residents. The transfer forms provided to the residents' representatives lacked essential information, such as the residents' appeal rights and the contact details of the State Ombudsman office. The facility's administrator confirmed that prior to May 2024, the facility was not sending transfer notices to the State LTC Ombudsman. Although the facility began sending lists of transfers and discharges to the Ombudsman in May 2024, some transfers, including those of the residents in question, were not included in these lists.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement a care plan for monitoring the use of psychotropic medications for two residents, R154 and R31. For R154, the facility's policy on antipsychotic medication use was not followed, as there was no monitoring of side effects or behaviors related to the psychotropic medications prescribed, including Aripiprazole and Escitalopram Oxalate. Despite having a care plan that included interventions for mood issues, the Medication Administration Record (MAR) for August 2024 showed no evidence of monitoring for side effects or worsening behaviors. The Director of Nursing (DON) confirmed the lack of monitoring during an interview. Similarly, for R31, the facility did not monitor the side effects or efficacy of the antidepressant Celexa, which was prescribed to manage anxiety and depression. Although the care plan included monitoring for side effects and effectiveness, the MARs for May, June, and July 2024 showed no evidence of such monitoring. It was only on August 12, 2024, that monitoring was initiated. The DON acknowledged that the orders and MAR did not include monitoring conditions for Celexa, confirming the oversight during an interview.
Failure to Document Discharge Needs and Assessment
Penalty
Summary
The facility failed to document discharge needs and assessment for a resident, identified as R44, who was discharged home. R44 was admitted with a diagnosis of a fracture of the right femur and was cognitively intact with a BIMS score of 15 out of 15. However, there was no documentation in the progress notes regarding the discharge needs or assessment for R44, nor was there a record of the discharge date. The discharge instructions provided were dated and included information about medical equipment and a home health company, but lacked documentation of an assessment prior to discharge. Interviews with facility staff revealed gaps in the discharge process. The Social Services Director mentioned discussing equipment needs with R44's husband and faxing a referral to a home health agency, but there was no documentation confirming the agency received the referral. The LPN confirmed the absence of a discharge assessment in the progress notes. The DON and Administrator both expressed expectations for discharge documentation, including details about the resident's condition, medications, and equipment needs, which were not met in this case.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to document pressure ulcer dressing changes for a resident, identified as R49, which resulted in a lack of communication among staff involved in the resident's care. The facility's policy on Charting and Documentation requires detailed documentation of procedures and treatments, including the date and time, the name and title of the caregiver, assessment data, and the resident's response to treatment. However, a review of R49's progress notes from June 2024 to August 12, 2024, revealed only one entry on August 3, 2024, indicating that the wound was cleaned and bandaged per physician orders, with no further documentation of wound care. Interviews with the Wound Nurse/Registered Nurse (WN/RN) and the Director of Nursing (DON) confirmed that a progress note should be made each time a wound care dressing is performed, detailing the wound's appearance, drainage, odor, size, and improvement or deterioration. The WN/RN admitted to sometimes forgetting to document in both the Treatment Administration Record (TAR) and the progress notes. The DON stated that she had instructed the wound care nurse to make a progress note for each dressing change a couple of months prior, but this was not consistently followed, leading to the deficiency in documentation.
Incomplete Dialysis Documentation and Collaboration
Penalty
Summary
The facility failed to provide complete documentation and collaboration for a resident requiring dialysis care. The resident, identified as R9, was readmitted with diagnoses of end-stage renal disease and chronic kidney disease. The facility's policy and the dialysis contract required comprehensive documentation of dialysis services, including laboratory values, vital signs, medications, and any changes in the resident's medical status. However, the review of R9's Dialysis Transfer Form revealed incomplete documentation, with missing pre and post-dialysis assessments, signatures, dates, and times. The dialysis center also failed to complete sections of the form that were their responsibility. Interviews with staff, including an LPN and the DON, confirmed the deficiencies in documentation. The LPN acknowledged that the nurse should fill out vital signs and any changes in the resident's condition to inform the dialysis center. The DON confirmed that all areas of the pre and post-dialysis assessments should be completed by the nurse and that any missing documentation from the dialysis center should be addressed by contacting them and having the form completed. This lack of documentation and communication resulted in a deficiency in the care provided to R9.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was accurately posted to reflect the actual staff hours available to care for the 54 residents. The facility's policy required that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift within two hours of the beginning of each shift. However, an observation on 8/11/2024 revealed that the posted staffing information was outdated, showing the date of 8/9/2024 and indicating 52 residents instead of the current 54. This discrepancy was noted during a survey, and it was found that the document was not updated as required. Interviews with the Administrator revealed that the responsibility for posting the staffing information was assigned to the Director of Nursing (DON) during weekdays and the RN Supervisor on weekends. However, the daily nurse staffing document did not include certain CNAs, such as the rehabilitation CNA, the bath CNA, and the multipurpose CNA. The Administrator admitted that these CNAs were not included in the nursing schedule to prevent other CNAs from perceiving there were extra staff and potentially calling off. This omission led to inaccurate staffing information being posted, which could misinform residents, family members, or visitors about the available nursing staff.
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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 Moultrie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Moultrie | 0.7 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Magnolia Manor | 1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Sunrise | 1.1 mi | ★★★★★ | 0 | 0 |
| Southwell Health And Rehabilitation | 20.3 mi | ★★★★★ | 5 | 0 |
| Thomasville Vistas Of Journey Llc | 21.5 mi | ★★★★★ | 25 | 0 |
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