Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Eatonton Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed that several insulin medications were not properly stored or labeled, including unopened insulin pens and vials that were not refrigerated as required and opened pens lacking expiration or first-used dates. Nursing staff and the ADON confirmed that these practices did not meet facility policy or pharmacy labeling requirements.
Two residents were allowed to keep and self-administer medications at their bedside without documented assessments or care plans supporting their ability to do so. One resident with Alzheimer's and other conditions had multiple pills left unattended, while another had prescription eye drops and antacids in their room, with staff confirming no proper assessment or orders were in place.
A resident who was cognitively intact and required minimal ADL assistance reported dissatisfaction with food quality and lack of menu information to multiple staff, including the SW, DON, and Administrator. Although the resident's concerns were discussed in person, the facility did not document the grievance or provide a written resolution as required by policy, and the grievance was not entered into the facility's log.
A resident with hereditary and idiopathic neuropathy was transferred to the hospital twice for altered mental status, and the facility did not provide the resident or their representative with written notice specifying the daily bed-hold rate as required by policy. Staff interviews revealed inconsistent practices and lack of documentation regarding the notification process.
Three dependent residents with cognitive impairment and significant ADL needs did not receive scheduled showers as required, with documentation showing missed showers and no consistent record of refusals. Residents and their POAs reported missed care, and staff confirmed that lack of documentation indicated showers were not provided. The DON acknowledged missing documentation and the absence of a related policy.
A resident with left upper extremity paralysis did not consistently receive prescribed splint application as outlined in her restorative care plan. Documentation and staff interviews revealed irregular and insufficient splint use, with staff often unaware of the care plan requirements. The resident and her POA reported inconsistent application, and the facility failed to ensure proper documentation and communication regarding the splint schedule.
Discontinued medications, including topical ointments, powders, insulin pens, and oral tablets, were found improperly stored in a medication room drawer and not disposed of according to facility policy. Nursing staff and the ADON confirmed that these medications were neither documented on the required inventory and destruction log nor destroyed in the authorized collection receptacle, resulting in a lack of control and accountability.
A resident with Alzheimer's disease who required substantial assistance with bathing had a care plan specifying only female CNAs should provide showers. On one occasion, a female CNA provided the shower, but due to EMR assignment restrictions, a male CNA who did not deliver the care documented it instead. Staff interviews confirmed the documentation did not accurately reflect who provided the care, resulting in an inaccurate medical record.
Improper Storage and Labeling of Insulin Medications
Penalty
Summary
Facility staff failed to ensure that medications, specifically various types of insulin, were properly stored according to both facility policy and pharmacy labeling. During an observation of the medication storage room, it was found that several insulin pens and vials were either not labeled with the required expiration or first-used dates, or were not refrigerated as required prior to being opened. For example, one resident's NovoLog FlexPen was opened without an expiration date, and another insulin pen lacked both a first-used date and expiration date. Additional unopened insulin products for other residents were found unrefrigerated, despite pharmacy labels indicating they should be kept refrigerated until opened. Interviews with nursing staff and the Assistant Director of Nursing confirmed that the facility's expectation was for all medications requiring refrigeration, such as insulin, to be refrigerated upon delivery and properly labeled when opened. The staff acknowledged that the observed medications were not stored in accordance with these requirements, and that this was inconsistent with both facility policy and accepted professional standards for medication storage.
Failure to Assess Residents for Medication Self-Administration
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications before allowing them to keep unsecured medications at their bedside. For one resident with diagnoses including Alzheimer's disease, psychotic disorder, and dysphagia, there was no care plan or assessment for self-administration of medication. Observations showed that this resident had a cup containing eight pills left on her overbed table while she was asleep, and staff confirmed that medications were sometimes left with the resident until she woke up, without a formal assessment or documentation supporting her ability to self-administer. For another resident, there was also no care plan or assessment for self-administration, yet prescription eye drops and antacid tablets were found unsecured in the room. The resident reported self-administering the eye drops and taking antacid tablets as desired, with staff confirming that the eye drops should not have been left in the room and that the resident did not have an order for the antacid tablets. The DON confirmed that this resident was not appropriate for self-administration and lacked the necessary assessment, and the Regional Nurse Consultant noted that the antacid tablets had been brought in by the family.
Failure to Document and Resolve Resident Grievance Regarding Food Service
Penalty
Summary
The facility failed to document and resolve a resident's grievance regarding food service, as required by its own policy. A cognitively intact resident, who required minimal assistance with activities of daily living, reported to multiple staff members—including the kitchen staff, Social Worker (SW), Director of Nursing (DON), and Administrator—that he was dissatisfied with the palatability of the food and the lack of information about daily menus and alternate food options. The resident stated that he had filed a grievance about these concerns and that the four staff members met with him to discuss the issue. However, he was not provided with a written grievance form nor a written response or resolution to his complaint. Review of the facility's grievance log showed no documentation of the resident's reported grievance. The SW, who served as the grievance coordinator, confirmed awareness of the complaint and acknowledged that the standard process was to complete a grievance form and provide a written resolution within three days. Despite this, the SW admitted that the grievance was neither documented nor resolved in writing, and the resident did not receive the required follow-up. The Administrator also confirmed that grievances should be documented and responded to within three days, which did not occur in this case.
Failure to Provide Required Bed-Hold Rate Notification During Hospitalization
Penalty
Summary
The facility failed to provide a resident or their representative with written notice specifying the duration and daily rate of the bed-hold policy during two separate hospitalizations. According to the facility's own policy, a bed-hold letter should be sent to the resident or their designee, clearly stating the amount to be paid per day for a private bed hold. However, review of the documentation for the resident's transfers to the hospital revealed that the notices sent did not include the specific daily bed-hold rate, only general information about the policy and a statement that the rate would be communicated later. Interviews with staff indicated a lack of clarity and consistency regarding the process for notifying residents or their representatives about the bed-hold rate. The LPN stated that no paperwork was sent by the charge nurse to the family, and the DON was unsure if the notification included the required rate or where documentation of the mailing was kept. The social worker reported that she no longer documented when the bed-hold notification was sent and was unaware that the specific charge needed to be included in the notice. The resident involved had a primary diagnosis of hereditary and idiopathic neuropathy and was transferred to the hospital on two occasions for altered mental status.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide scheduled showers to three dependent residents who required assistance with activities of daily living (ADLs), specifically bathing. Review of the electronic medical records (EMR) and interviews revealed that one resident with Alzheimer's disease, who was moderately cognitively impaired and required substantial assistance, only received two showers in a month despite being scheduled for three showers per week. The resident expressed missing her baths, and staff confirmed her scheduled shower days and the documentation process. Another resident with hereditary and idiopathic neuropathy, also with moderate cognitive impairment and requiring partial to moderate assistance, did not consistently receive showers according to her three-times-weekly schedule. Documentation showed significant gaps in shower provision, and both the resident and her Power of Attorney (POA) reported that showers were often missed and refusals were inaccurately documented. The resident stated she rarely refused showers and often requested them without staff following through. A third resident with chronic atrial fibrillation and moderate cognitive impairment, requiring substantial to maximum assistance, received very few showers over several months, with documentation indicating almost no showers and no refusals. The resident and her POA were unaware of her bathing schedule, and the resident reported rarely being showered and not having her hair washed since admission. Staff interviews confirmed that if showers or refusals were not documented, the care was not provided. The Director of Nursing acknowledged the lack of documentation and the absence of a facility policy related to showering and ADL care.
Failure to Consistently Apply and Document Splint Use for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a history of stroke and left upper extremity paralysis consistently received splint application as outlined in her restorative care plan. The care plan required daily application of a palmar grip splint to the resident's left hand for two to four hours, with the goal of maintaining range of motion and preventing contractures. Documentation showed that the splint was applied inconsistently, with recorded application times significantly less than the prescribed duration and on an irregular schedule. Observations revealed that the resident was not wearing the splint during several visits, and both the resident and her Power of Attorney reported that the splint was not applied consistently. The resident was unsure of the splint schedule, and her Power of Attorney, who visited almost daily, stated he rarely saw the splint in use and was not informed of a schedule. Staff interviews confirmed a lack of awareness regarding the splint application, with some staff unaware of the need for the splint and others unable to recall seeing it applied until prompted by the survey. Further review indicated that although the facility's policy required documentation of restorative care interventions in the electronic medical record, this was not consistently done. The Director of Nursing and other staff members acknowledged gaps in communication and responsibility for splint application, with uncertainty about which staff were responsible for the task. The resident's occupational therapy notes emphasized the importance of regular splint use to prevent further contracture, but this was not consistently implemented by the nursing staff.
Failure to Properly Store and Dispose of Discontinued Medications
Penalty
Summary
The facility failed to ensure discontinued medications were stored and disposed of according to its policy, which requires that expired, discontinued, or unneeded medications be promptly removed from active stock, inventoried by two licensed nurses, and destroyed in an authorized collection receptacle within three business days. Observations revealed that multiple discontinued medications for five sampled residents were found improperly stored in a medication room drawer, including topical ointments, powders, insulin pens, and oral tablets. These medications were not recorded on the Certificate of Inventory and Destruction (CID) log, nor were they disposed of in the authorized collection receptacle as required. Interviews with nursing staff and the Assistant Director of Nurses (ADON) confirmed that discontinued medications were not properly discarded or documented for the affected residents. In some cases, medications belonging to deceased or discharged residents remained in the facility instead of being returned to families or destroyed. The ADON acknowledged that the medications found were not listed on the medication log and had not been disposed of according to policy, confirming a lapse in control and accountability for discontinued medications.
Inaccurate Documentation of ADL Care Due to Assignment Restrictions in EMR
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident by not ensuring that the staff member who delivered care was the same individual who documented the care in the electronic medical record (EMR). According to the facility's policy, all pertinent observations and services performed should be recorded in the patient's medical record by the person providing the care. In this case, a resident with Alzheimer's disease and moderate cognitive impairment required substantial assistance with bathing and had a care plan specifying that only female CNAs should provide shower assistance. On a specific date, the EMR indicated that a male CNA documented providing the resident's shower, despite the resident's preference and care plan intervention. Interviews with staff revealed that the female CNA actually provided the shower, but was unable to document this in the EMR because she was not assigned to the resident. Instead, the male CNA, who was not assigned to the resident and did not provide the care, documented the shower as completed. The Assistant Director of Nursing confirmed that only assigned staff could document care in the EMR, and if another staff member provided care, the assigned person would have to be notified to record it. This process resulted in inaccurate documentation of care provided to the resident.
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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 Eatonton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium Health Navicent Baldwin | 17.5 mi | ★★★★★ | 0 | 0 |
| Madison Health And Rehab | 19.4 mi | ★★★★★ | 0 | 0 |
| Chaplinwood Nursing Home | 19.7 mi | ★★★★★ | 0 | 0 |
| Green Acres Health And Rehabilitation | 19.7 mi | ★★★★★ | 2 | 0 |
| Legacy Health And Rehabilitation | 19.7 mi | — | 0 | 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.