Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Crisp Regional Nsg & Rehab Ctr during CMS and state inspections, most recent first.
Failure to provide written notice of treatment and advance directive rights: The facility had no documented evidence that two residents, including one with no cognitive impairment and one with moderate cognitive impairment, or their representatives, were informed in writing of their right to accept or decline medical and surgical treatment and to formulate an advance directive. The Administrator confirmed the missing documentation during interview.
Surveyors found missing care plans for several residents with identified needs. One resident with dependence in multiple ADLs had no ADL care plan, two residents with indwelling or external catheters had no catheter care plans, and one resident receiving dialysis had no dialysis care plan. The MDS Coordinator, DON, Unit Manager, and Administrator confirmed the omissions, and the record review showed related orders and MDS findings were present but not reflected in the care plans.
A resident with severely impaired cognition had an external catheter documented, but the EMR lacked a Foley catheter diagnosis, the care plan had no Foley catheter plan, and physician orders did not include an indication for the catheter. The UM, DON, and MDS staff all confirmed the missing documentation and stated nurses would not know why the resident had the catheter or what to monitor without a diagnosis or indication.
An unlocked and unattended medication cart was found on one hall, and multiple medications on another cart had no open dates, including insulin vials, an insulin pen, eye drops, and blood sugar strips. Staff confirmed the cart should have been locked and that open dates were required on insulin, ophthalmic medications, and strips. The affected residents included two residents with DM receiving insulin, two residents with eye drop orders, and one resident with an insulin pen order.
Infection control practices were not followed during Foley catheter care, trach care, and routine hand hygiene. A CNA repeatedly used the same wipe on Foley tubing and the resident’s scrotal area, while an RT placed trach care items on a bare bedside table, changed gloves without hand hygiene, left the room in gown and gloves to get supplies, and then used the same gloves to handle the bed and ventilator controls. An LPN also changed gloves without sanitizing hands while cleaning equipment. Staff interviews confirmed the expected hand hygiene and clean-field practices.
Failure to Provide Written Notice of Treatment and Advance Directive Rights
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed in writing of the right to accept or decline medical and surgical treatments and the right to formulate an advance directive for two residents, R18 and R79. Review of R18’s EMR showed no documented evidence or signed acknowledgment that the resident and representative were provided written information about these rights. R18 was admitted to the facility on [DATE], and the quarterly MDS dated [DATE] showed a BIMS score of 15, indicating no cognitive impairment. Review of R79’s EMR also showed no documented evidence or signed acknowledgment that the resident and representative were informed in writing of the right to accept or decline medical and surgical treatments and to formulate an advance directive. R79 was admitted to the facility on [DATE], and the quarterly MDS dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment. During an interview on 03/25/2026 at 12:25 PM, the Administrator confirmed there was no evidence that R18 or R79, or their representatives, had been provided written information related to these rights on or after admission.
Missing Comprehensive Care Plans for Catheter, Dialysis, and ADL Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for four sampled residents. Review of the facility policy titled LTC Care Plan stated that the interdisciplinary plan of care is to identify priority problems and needs, reflect the resident’s strengths, limitations, and goals, and provide individualized, goal-directed care. Surveyors found that the care plans for R1, R62, R3, and R79 did not include documented plans for identified needs, including Foley catheter care for R1 and R62, dialysis care for R3, and ADL care for R79. R79 was admitted with diagnoses including epilepsy, respiratory failure, and anxiety disorder. The quarterly MDS showed a BIMS score of 12 and dependence for toileting hygiene, showering/bathing, upper body dressing, lower body dressing, and personal hygiene. Review of the care plan showed no ADL care plan, and review of physician orders showed no order with indication for ADL care. The MDS Coordinator confirmed there was no ADL care plan and stated the MDS department was responsible for updating it. R62 was admitted with a quarterly MDS showing a BIMS score of 3 and an external catheter in Section H, but there was no care plan for Foley catheter care and no physician order with indication for a Foley catheter. R1 was admitted and re-admitted with diagnoses including end stage renal disease and kidney transplant status; the MDS showed an indwelling catheter, and physician orders included urinary catheter care, catheter changes, drainage bag changes, and anchor checks, but the care plan did not document catheter care. R3 was admitted with a quarterly MDS showing a BIMS score of 13 and dialysis care in Section O, and physician orders indicated dialysis three days a week, but the care plan did not include dialysis. Interviews with the MDS/Care Plan Coordinator, DON, Unit Manager, and Administrator confirmed the missing care plans.
Missing Foley Catheter Diagnosis and Order
Penalty
Summary
The facility failed to have an order with an indication for a Foley catheter and failed to have a diagnosis for the Foley catheter for one of 12 sampled residents, R62. Review of the EMR showed R62 was admitted with no diagnosis for Foley catheter indication. The Quarterly MDS showed a BIMS score of 03, indicating severely impaired cognition, and identified an external catheter in Section H. Review of the care plan revealed no care plan for Foley catheter, and review of physician orders revealed no order with indication for Foley catheter. During interviews, the Unit Manager confirmed there was no diagnosis and no order with indication for the Foley catheter and stated she could not find documentation of the indication in the EMR or resident file. The DON also confirmed there was no diagnosis or indication documented for the Foley catheter. The MDS Coordinator stated she was responsible for placing the diagnosis in the EMR and it was not done, and MDS staff stated that without a diagnosis or indication, nurses would not know why the resident had a Foley catheter or what signs and symptoms to monitor related to the catheter.
Unlocked Medication Cart and Missing Open Dates on Medications
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted medication storage practices. On 03/25/2026, surveyors observed one medication cart on the 100 hall unlocked and unattended. Registered Nurse CC and Unit Manager DD both confirmed the cart drawers were unlocked and stated the cart should have been locked when not in use. The Director of Nursing later stated medication carts should never be unlocked and unattended. On 03/26/2026, surveyors reviewed the nurses’ medication cart on the Vent Unit and found multiple medications without open dates. These included one multidose bottle of insulin for R66, one multidose vial of insulin glargine for R1, one bottle of Olopatadine Hydrochloride ophthalmic solution for R81, one bottle of Olopatadine 0.1% eye drops for R63, one insulin pen for R90, and one bottle of blood sugar strips. The facility’s policies for medication storage, insulin and insulin pen management, medication open dates, and ophthalmic medications all required medications to be labeled with the date opened and kept in locked storage when not in use. The records reviewed showed R66 and R1 had diagnoses of diabetes mellitus and active insulin orders, R81 and R63 had ophthalmic medication orders, and R90 had an insulin lispro sliding scale order. LPN II confirmed the missing open dates and stated open dates should be on blood sugar strips, insulin vials and pens, and eye drops. UM JJ stated insulin vials and pens were not good after 28 days once opened, and the DON stated nurses were expected to ensure open dates were placed on medications when first opened.
Infection Control Failures During Foley Catheter and Trach Care
Penalty
Summary
The facility failed to ensure adherence to infection control practices during Foley catheter care for a resident with severely impaired cognition and an indwelling urinary catheter. The resident’s EMR showed no diagnosis for Foley catheter indication, the MDS identified an external catheter, and the care plan contained no Foley catheter care plan. Physician’s orders also did not include an indication for the Foley catheter. During observation, a CNA cleaned the Foley catheter tubing by repeatedly wiping up and down the tubing with the same wipe without folding or disposing of it, then used another wipe to clean around the scrotum and used the same wipe again on the Foley catheter tubing. The CNA later confirmed this was how the care was performed. The facility also failed to maintain standard infection control practices during tracheostomy care for a resident with acute and chronic respiratory failure with hypoxia, cardiac arrest, tracheostomy, and ventilator dependence. The resident’s MDS showed the resident was rarely or never understood and received tracheostomy care and invasive mechanical ventilation. During trach care, the RT removed the dressing from the trach site and placed it on the bare bedside table beside an opened sterile trach set, changed gloves without sanitizing hands, removed the inner cannula and placed it on the bare bedside table, and left the room wearing gown and gloves to retrieve wipes from a cart in the hallway before returning to the room in the same gown and gloves. The RT then used the same gloves used during trach care to press the bed controls and reprogram the ventilator. The report also documented hand hygiene failures by nursing staff. An LPN cleaned a blood pressure cuff, removed gloves, donned a new pair of gloves without sanitizing hands, and then cleaned a blood sugar machine before removing the second pair of gloves and going to the medication cart. Interviews with the RT, RN, UM, infection preventionist, and DON confirmed expectations that hand hygiene should occur before glove use, after glove removal, and between glove changes, and that soiled items should not be placed next to sterile or clean fields.
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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) |
|---|---|---|---|---|
| Cordele Health And Rehabilitation | 0.4 mi | ★★★★★ | 0 | 0 |
| 4angels Of Byromville Healthcare Center | 17.6 mi | ★★★★★ | 15 | 0 |
| Crossview Care Center | 18.6 mi | ★★★★★ | 7 | 0 |
| Pruitthealth - Ashburn | 20.3 mi | ★★★★★ | 5 | 0 |
| Montezuma Health And Rehabilitation | 26.6 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.