Below 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 Cordele Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment and storage areas, including the walk-in refrigerator, ovens, and fryer, were not kept clean or sanitary as required by facility policy. Despite established cleaning schedules, observations confirmed persistent food debris, stains, and rust, with the Dietary Manager and Administrator acknowledging the deficiencies. This had the potential to affect the majority of residents receiving food from the kitchen.
Three resident rooms were found with heavily soiled PTAC air filters, covered in dust and debris, due to a lack of regular cleaning as required by facility protocols. Housekeeping staff cleaned only the grills, while maintenance staff, responsible for the filters, did not perform the necessary cleaning, resulting in compromised room cleanliness and comfort.
Two residents receiving oxygen therapy did not have their care plans properly developed or followed. One resident with COPD had a care plan that was not checked or implemented by nursing staff, while another had no care plan in place for oxygen use despite a physician's order. Staff interviews and record reviews confirmed these deficiencies in care planning and implementation.
An unsecured oxygen cylinder was found standing upright in a resident's room, contrary to facility policy requiring all O2 tanks to be properly secured or stored. The resident had multiple medical conditions, including dependence on supplemental oxygen. Staff interviews confirmed that O2 cylinders should not be left unsecured in resident rooms and must be stored in designated areas or attached to mobility devices when in use.
The facility did not consistently follow physician orders for oxygen therapy, failed to label and date oxygen tubing, and did not maintain oxygen concentrators in a clean and sanitary condition for several residents with complex medical needs. Staff did not always adhere to care plans or facility policies regarding respiratory care, resulting in deficiencies in both the administration of oxygen and the maintenance of related equipment.
An LPN did not adhere to infection control protocols by failing to change gloves and perform hand hygiene between medication preparation and administration for two residents. The LPN used the same gloves while handling injections, oral medications, and assisting with personal care, only sanitizing hands after all tasks were completed. Both the LPN and DON confirmed that proper hand hygiene and glove changes were required but not performed.
A resident with venous ulcers did not receive consistent wound care as ordered by the physician, with treatments not documented as provided on multiple occasions. The resident, with a BIMS score indicating little to no cognitive impairment, had specific orders for wound care every shift, but the TARs showed gaps in administration, particularly on weekends and night shifts. Interviews with staff confirmed the inconsistency in care, placing the resident at risk for adverse consequences.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness and sanitation in key kitchen areas, including the walk-in refrigerator, ovens, and fryer. During an initial walkthrough with the Dietary Manager, both ovens were found with burnt food stains, the fryer contained debris and dark-colored oil, and the side of the stove had built-up dirt and grease. The walk-in refrigerator was noted to be very dirty, with food debris on the floor and rusted shelving. These conditions were acknowledged by the Dietary Manager at the time of observation. A follow-up walkthrough confirmed that the unsanitary conditions persisted, with no improvement in the cleanliness of the kitchen equipment and storage areas. Interviews with the Dietary Manager and the facility Administrator revealed that there were established cleaning schedules and expectations for daily and weekly cleaning of kitchen equipment and storage areas. However, the observed conditions indicated that these cleaning protocols were not being followed, potentially affecting 56 of 62 residents who receive food from the kitchen.
Failure to Maintain Clean PTAC Air Filters in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and comfortable environment in three of thirteen resident rooms, as evidenced by heavily soiled PTAC (Packaged Terminal Air Conditioner) air filters. Observations revealed that the air filters in these rooms were covered with a thick accumulation of dust, dirt, and debris, turning the originally white filters dark gray and releasing visible dust clouds when handled. The facility's own PTAC Preventative Maintenance Guide and HVAC cleaning procedures require regular cleaning or replacement of air filters and vent screens, but these protocols were not followed for the affected rooms. Interviews with housekeeping staff indicated that while they cleaned the PTAC grills daily, they did not clean the air filters themselves. The Director of Housekeeping and the Director of Maintenance confirmed that maintenance staff were responsible for cleaning the air filters, but only cleaned the grills as needed. This lack of adherence to established cleaning protocols resulted in the accumulation of contaminants in the PTAC units, compromising the cleanliness and comfort of the resident environment.
Failure to Develop and Implement Complete Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to follow and implement complete care plans for two residents with oxygen therapy needs. For one resident with emphysema/COPD, the care plan included an intervention for oxygen settings as ordered, but staff did not check or follow the care plan as required. The nurse responsible did not verify the care plan or ensure it was followed according to the physician's order for continuous oxygen at 2L/min, as confirmed by staff interviews and record review. The DON stated that her expectation was for nurses to follow doctor's orders, regulate oxygen or medication as ordered, and update the care plan to reflect any changes. For another resident, an unsecured oxygen tank was observed in the room, with no nasal cannula or nebulizer attached, despite a physician's order for oxygen therapy. Review of the care plan revealed that no care plan was in place for this resident's oxygen use. The MDS Director confirmed that the resident was ordered for oxygen at 2L/min and expected the care plan to contain accurate, resident-centered information. These findings indicate that the facility did not ensure care plans were developed and implemented to address all the residents' oxygen therapy needs.
Unsecured Oxygen Cylinder Found in Resident Room
Penalty
Summary
A deficiency was identified when an unsecured oxygen (O2) tank was observed in a resident's room, standing upright in front of the dresser drawers and not attached to any medical device. The facility's policy on Medical Gas Cylinder Storage requires all freestanding O2 cylinders to be secured in a rack, on a cart, in a portable holder, in a storage cabinet, or with a chain. The resident involved had multiple diagnoses, including dependence on supplemental oxygen, dyspnea, recurrent pneumonia, Alzheimer's disease, COPD, type 2 diabetes mellitus, and dementia. The resident's assessment indicated intact cognition and a need for supervision to partial assistance with activities of daily living. Staff interviews confirmed that O2 cylinders should not be stored unsecured in resident rooms and should be kept in the supply room or properly attached to a wheelchair when in use. The Certified Nurse Aide (CNA) and the Director of Nursing (DON) both stated that extra cylinders should not be present in resident rooms and must be stored according to policy. The observation of the unsecured O2 tank in the resident's room was not in compliance with the facility's established procedures for safe storage of medical gas cylinders.
Failure to Ensure Safe and Appropriate Oxygen Therapy and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy, as evidenced by multiple deficiencies in following physician orders and maintaining equipment cleanliness. For one resident with diagnoses including anemia, heart failure, and multiple sclerosis, the oxygen flow rate was not consistently maintained as ordered by the physician. Observations showed the oxygen was set at the correct rate at times, but at other times it was set lower than ordered. Additionally, the oxygen tubing was not labeled or dated to indicate when it had been changed, contrary to facility expectations and policy. Another resident with a complex medical history, including COPD and congestive heart failure, was observed using an oxygen concentrator that was visibly dirty, with a fluffy brown, gray, and white substance covering the filter area and the machine itself over several days. The facility's policy required weekly cleaning of the concentrator's exterior by housekeeping and regular maintenance by the oxygen provider, but these procedures were not followed, resulting in unsanitary equipment use. A third resident with COPD and other chronic conditions had inconsistent oxygen orders and administration. The care plan indicated the resident sometimes removed the nasal cannula and changed the oxygen setting independently. Observations and interviews revealed that nursing staff did not consistently follow the care plan or physician orders regarding oxygen flow rates and documentation. The DON confirmed expectations for staff to follow orders, label and date tubing and humidification bottles, and ensure proper administration, but these practices were not consistently implemented.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
A deficiency was identified when an LPN failed to follow proper infection prevention and control procedures during medication administration for two residents. During observation, the LPN drew up heparin and prepared insulin for one resident without changing gloves or sanitizing hands between tasks, despite handling multiple medications and equipment. The same gloves were used throughout the process, contrary to the facility's hand hygiene policy, which requires hand sanitization and glove changes to prevent contamination. In a separate instance, the LPN assisted another resident in the bathroom, handled an oxygen tank and tubing, and then administered nasal and oral medications without removing gloves or performing hand hygiene between these activities. The LPN only removed gloves and sanitized hands after completing all tasks. Both the LPN and the DON acknowledged during interviews that hand hygiene and glove changes should have occurred between different care activities and medication routes to prevent cross-contamination.
Inconsistent Wound Care Administration for Resident with Venous Ulcers
Penalty
Summary
The facility failed to provide wound care as ordered by the physician for a resident with venous ulcers, leading to a deficiency in care. The resident, who had a BIMS score indicating little to no cognitive impairment, was admitted with multiple diagnoses including paroxysmal atrial fibrillation, chronic heart failure, COPD, Parkinson's disease, and hypertension. The physician's orders required specific wound care treatments to be administered every shift, including cleaning the wounds with acetic acid-soaked gauze, applying gentamycin ointment, and using a non-adherent dressing followed by a dry dressing. However, the Treatment Administration Records (TARs) revealed that these treatments were not consistently documented as provided. In December 2024, January 2025, and February 2025, there were multiple instances where the wound care was not recorded as administered on both day and night shifts. Interviews with the Wound Care LPN and the Director of Nursing confirmed the inconsistency in treatment administration, particularly on weekends and night shifts, depending on staff availability. This lack of adherence to the prescribed wound care regimen placed the resident at risk for adverse consequences.
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Illustrative
What surveyors actually found near you
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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 Cordele
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crisp Regional Nsg & Rehab Ctr | 0.4 mi | ★★★★★ | 14 | 0 |
| 4angels Of Byromville Healthcare Center | 17.3 mi | ★★★★★ | 15 | 0 |
| Crossview Care Center | 18.9 mi | ★★★★★ | 7 | 0 |
| Pruitthealth - Ashburn | 20.6 mi | ★★★★★ | 5 | 0 |
| Montezuma Health And Rehabilitation | 26.3 mi | ★★★★★ | 2 | 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.