Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Pureed diet items were prepared without standardized, dietitian-approved recipes. The Dietary Manager made pureed beans and pureed spaghetti using beans and bean liquid, and tomato paste as a thinning agent, without measuring ingredients or following recipes. The Dietary Manager confirmed she does not use recipes for pureed foods, and the Administrator stated she was unaware dietary staff were not using standardized recipes.
Food items in the walk-in cooler were found improperly labeled and dated, including raw bacon, a gallon of water, and chicken salad past its expiration date. The DM confirmed the findings and stated she was responsible for ensuring food items were labeled with open dates and use-by dates.
Failure to respect a resident's dignity occurred when an RN/WCN referred to the resident's incontinence brief as a diaper during wound care. The resident had severely impaired cognition and a stage four sacral pressure ulcer, and the RN/WCN acknowledged that using the term diaper for an adult resident could make the resident feel inferior. The LPN supervisor and DON stated that briefs should be used instead of diapers because the term diaper is associated with babies and can affect dignity.
Call lights were not kept within reach for two residents. One resident with moderately impaired cognition and ADL dependence had a call light hanging on the bed rail and could not reach it, and another resident with hemiplegia had a call light hanging on a roommate’s bed and out of reach. The CNA confirmed both call lights were inaccessible, and the DON and LPN stated call lights were expected to be within residents’ reach at all times.
A resident's discharge MDS assessment was not transmitted within the required timeframe after discharge. Record review showed the assessment was not completed until months later, and the MDS Care Plan Coordinator stated it was not entered into the system and was not present or completed.
A resident with no cognitive impairment had CPAP listed on the MDS and a physician order for CPAP care, but the care plan did not include CPAP interventions. The MDS Coordinator confirmed the CPAP needs were not added to the care plan until later, and the DON stated CPAP should have been included and staff were expected to review care plans for interventions.
An unattended medication cart on a hallway had a pair of scissors left on top of it while residents were ambulating nearby. An LPN confirmed she left the cart to get medication items and that the scissors were out of her view, and the LPNS and DON stated scissors should be secured in the cart because a resident could take them and cause harm.
A resident’s CPAP mask was observed unbagged on multiple occasions when not in use. Facility policy required respiratory equipment to be stored clean and bagged, and an LPN, the DON, and an administrator all confirmed that CPAP masks should be clean and bagged when stored.
Staff failed to follow infection control practices during resident care and medication administration. A CNA did not clean or disinfect an overbed table after catheter care for a resident with an indwelling catheter, an LPN handled a dropped carvedilol tablet with bare hands before giving it to a resident with HTN and CHF, and another LPN placed a blood glucose meter on the medication cart without disinfecting it between resident uses. Facility policy required cleaning and disinfecting glucometers between uses and maintaining infection control precautions.
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.
Pureed Diets Prepared Without Standardized Recipes
Penalty
Summary
The facility failed to ensure pureed foods were prepared according to standardized recipes and professional food service standards for residents requiring texture-modified diets. The deficiency involved pureed diet preparation and was identified through observations, staff interviews, and review of the facility policy titled, Pureed Diet Preparation and Services. The policy required all pureed diet items to be based on standardized, dietitian-approved recipes and to include ingredient lists, preparation instructions, and yield information, and the facility was also required to maintain standardized pureed recipes. During observation, the Dietary Manager prepared pureed beans and pureed spaghetti without using standardized recipes. The pureed beans were made using beans and bean liquid, and tomato paste was used as a thinning agent for the pureed spaghetti. Measuring tools were not used to measure ingredients during preparation. The Dietary Manager confirmed that she does not use recipes when preparing pureed foods. The Administrator stated she was unaware that dietary staff were not using standardized recipes for pureed food preparation and said her expectation was that all dietary staff use standardized recipes when preparing meals, including pureed diets.
Improper Food Labeling and Dating in Walk-In Cooler
Penalty
Summary
Food items were not properly labeled, dated, or maintained in sanitary conditions in the dietary area. During a tour with the Dietary Manager, surveyors observed a box of raw bacon in the walk-in cooler that was not labeled or dated correctly, a gallon of water that was not dated or labeled, and a pan of chicken salad with an expiration date of 06/10/2026. The facility policy titled Safe Food Handling stated that all food items shall be labeled and dated. The Dietary Manager confirmed the observations and stated she was responsible for ensuring food items were labeled with open dates and use-by dates to promote food safety.
Failure to Respect Resident Dignity During Care
Penalty
Summary
The facility failed to respect the dignity of one resident by referring to the resident's incontinence product as a "diaper" during wound care. The resident was admitted with diagnoses including a pressure ulcer of the sacrum, had severely impaired cognition with a BIMS score of 07, and had one unhealed pressure ulcer noted on the MDS. The care plan documented a stage four pressure ulcer with an intervention to clean the sacrum, and a physician's order directed cleansing the sacrum with normal saline, applying Mesalt to the wound bed, and covering it with a dry dressing every other day and as needed. During observation of wound care, the RN/WCN told the resident that she and a CNA were going to assist with turning the resident onto her side and putting on a diaper. The RN/WCN confirmed she used the term diaper when referring to the resident's brief and stated that the product packaging identified the items as diapers. She acknowledged that babies wear diapers and that using that term for a resident's brief could cause the resident to feel inferior. The LPN supervisor stated staff should refer to incontinence products as briefs rather than diapers because diapers are associated with babies and could affect dignity, and the DON stated that calling briefs diapers was a dignity concern and could cause residents to feel ashamed, upset, or depressed.
Call Lights Not Kept Within Reach of Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs by not keeping call lights within reach for two sampled residents, R18 and R39. The facility policy titled, Resident Call Light Response Policy, stated residents were to have access to a functioning call light at all times while in bed, seated in a chair, or in the bathroom, and staff were to verify accessibility during each shift and after every transfer or repositioning. R18 was admitted with diagnoses including malaise and hypoxemia, had a BIMS score of 12 indicating moderately impaired cognition, and was dependent on staff for ADL care. Her care plan identified fall risk related to impaired physical mobility and included an intervention to provide a working and reachable call light. Observations on multiple occasions showed R18 lying in bed with the call light hanging on the back of the bed rail and not accessible to her. During interview, R18 stated she did not know where the call light was and could not reach it, and the CNA confirmed she was unable to access it. R39 was admitted with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting the right dominant side, had a BIMS score of 15, and was dependent on staff for toileting. Her care plan also identified fall risk related to impaired physical mobility with an intervention to provide a working and reachable call light. Observations showed R39 lying in bed with the call light hanging on her roommate's bed and out of her reach, and the CNA confirmed the call light was not accessible to R39.
Late Transmission of Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure that a discharge MDS assessment for one resident was transmitted within 14 days of discharge to the CMS system. Record review showed the resident was discharged from the facility on 03/05/2026, but the discharge MDS assessment was not completed until 06/13/2026. During an interview on 06/13/2026 at 4:23 PM, the MDS Care Plan Coordinator stated the resident's discharge assessment was not completed and was not entered into the system, and that discharge assessments typically appeared in the system, but this assessment was not present or completed.
Incomplete Care Plan for CPAP Needs
Penalty
Summary
Failure to develop a comprehensive, person-centered care plan was identified for one resident who had a BIMS score of 15 on the quarterly MDS, indicating no cognitive impairment, and who had CPAP listed as a special treatment or program. The resident also had a physician order for CPAP with instructions to change the face or nasal mask every 3 months, change the water chamber every 6 months, and use CPAP settings at 13. Review of the resident’s care plan dated 12/30/2023 showed that CPAP care was not included. During interview, the MDS Coordinator confirmed that the resident’s CPAP needs were not included in the care plan until 06/13/2026 and stated that CPAP use should have been assessed and implemented into the care plan. The DON also confirmed that a resident’s CPAP should be part of the care plan and stated that staff were expected to review care plans to determine interventions.
Unattended Scissors Left on Medication Cart
Penalty
Summary
The facility failed to ensure the environment was free of accident hazards when one pair of scissors was left on top of an unattended medication cart on the 200 hallway. Observations at 8:10 AM, 9:15 AM, and 10:16 AM on 06/13/2026 showed the medication cart unattended with no nurse present, while residents were observed ambulating in the hallway. During interview, the LPN confirmed she had left the cart to get items for medication administration and that the scissors were left on top of the cart while it was out of her view. She stated the scissors should have been locked in the cart because residents could take them and cut themselves or another resident. The LPNS and DON also confirmed scissors should not be left on top of medication carts and described the situation as a safety issue.
CPAP Mask Left Unbagged When Not in Use
Penalty
Summary
The facility failed to maintain respiratory equipment consistent with professional standards for one resident, R47, by not bagging the resident’s CPAP mask when it was not in use. The facility policy titled, Respiratory care equipment storage and respiratory supply bag policy, stated that respiratory equipment and supplies are to be stored, maintained, cleaned, and transported according to manufacturer recommendations, infection prevention standards, and facility policies, and that respiratory supply bags shall remain closed when not in use. R47’s quarterly MDS documented a BIMS score of 15, indicating no cognitive impairment, and identified CPAP use in Section O. A physician order dated 05/28/2026 directed CPAP use at settings of 13 and specified that the face or nasal mask be changed every 3 months and the water chamber every 6 months. Survey observations on 06/12/2026 at 10:49 AM, 06/13/2026 at 12:03 PM, and 06/13/2026 at 2:51 PM showed that R47’s CPAP mask was not bagged. An LPN confirmed on 06/13/2026 at 2:56 PM that the mask was not bagged and stated it should be cleaned and bagged after every use. The DON later confirmed that CPAP masks should be clean and bagged when stored, and the administrator from the sister facility stated that staff are expected to bag and date all respiratory masks to prevent infection.
Failure to Follow Infection Control Practices During Care and Medication Administration
Penalty
Summary
The facility failed to implement infection control practices during resident care and medication administration. Review of facility policies showed requirements for cleaning and disinfecting glucometers between resident uses, maintaining hand hygiene, and cleaning surfaces after catheter care. During observations, staff were seen not following these practices in multiple instances, including handling a medication tablet with bare hands, placing an uncleaned blood glucose meter on the medication cart, and leaving a bedside table uncleaned after catheter care. R50 had severely impaired cognition and an indwelling catheter. During catheter care, a CNA provided the procedure and then removed supplies from the overbed table without cleaning or disinfecting the table afterward. The CNA stated the table should have been cleaned and disinfected because the wash basin and towel used during the procedure were placed on it, and acknowledged that meal trays are later placed on the same surface. R87 had diagnoses including hypertension and congestive heart failure and was ordered carvedilol 6.25 mg twice daily. During medication administration, an LPN dropped a carvedilol tablet onto the bare surface of the medication cart, picked it up with bare hands, and placed it in the medication cup for administration. In a separate observation, another LPN removed a blood glucose meter from a resident's room and placed it directly on the medication cart without cleaning or disinfecting it first, and stated the meter was only cleaned at the end of the shift rather than between resident uses.
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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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.
Illustrative
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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 | ★★★★★ | 0 | 0 |
| Montezuma Health And Rehabilitation | 26.3 mi | ★★★★★ | 2 | 0 |
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