Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Emanuel County Nursing Home during CMS and state inspections, most recent first.
Food items in the kitchen were found improperly labeled, dated, and discarded, including prepared fruit parfait cups kept past the allowed time, a pudding pan missing dates, flour with outdated labeling, and opened pantry items missing open dates. A Dietary Aide was also observed preparing food with facial hair not fully covered by a beard guard, and the DM confirmed the labeling, storage, and hair coverage deficiencies.
A facility failed to ensure two residents did not have unsecured medications at bedside. One resident with intact cognition had an OTC medication in a dresser drawer within arm's reach, despite no self-administration assessment or order to keep meds at bedside; the resident said a family member brought it in and she planned to give it to nursing when needed. Staff confirmed no residents were authorized for bedside meds. Another resident with vascular dementia and allergic rhinitis also had no order for bedside meds, and the facility policy stated meds should not be left at bedside unless specifically ordered by a physician.
Unattended unlocked computer screens at the medication cart displayed the personal and medical information of two residents. One resident had COPD and CHF with a BIMS score of 13, and the other had hypertensive heart and CKD with dementia and a BIMS score of 12. RN BB confirmed the screens were unlocked and visible to the public, and the DON and Administrator stated that resident information must not be displayed when the screens are unattended.
A resident with depression, bipolar disorder, anxiety, moderate cognitive impairment, and behavioral symptoms was not referred for a PASRR Level II assessment on admission or within 30 days of a new diagnosis. The EMR, care plan, and medication profile reflected serious mental health needs, and both the Admissions Coordinator and DON confirmed that a Level II should have been completed rather than relying only on the hospital's PASRR Level I review.
Failure to Follow Oxygen Care Plan: A resident with COPD and paroxysmal atrial fibrillation had an order for humidified O2 at 2 L/min via N/C continuously, and the care plan directed staff to administer oxygen as ordered. However, observations showed the resident receiving O2 at 3 L/min via N/C, and the RN/MDS Coordinator confirmed staff were expected to follow the care plan as directed.
Failure to follow O2 orders and clean O2 concentrators: A resident with COPD and AFib was observed receiving O2 at a higher flow than ordered from a dirty concentrator, and two other residents receiving O2 therapy were also observed using dirty concentrators covered with dust and debris. The DON and an RN confirmed the dirty equipment and that one resident’s O2 setting did not match the physician order.
The facility's water management program was found to be inadequate and not in compliance with ASHRAE guidelines, lacking detailed descriptions and control measures to prevent Legionella growth. Interviews revealed that while the Maintenance Director conducted some testing, there was no formal water management plan in place, as confirmed by the DON.
The facility failed to monitor antipsychotic medications for three residents, leading to a deficiency in medication management. Despite policies requiring documentation of behaviors, side effects, and efficacy, the facility did not adhere to these guidelines. Residents were prescribed psychiatric medications, but specific behavior monitoring and adverse reaction documentation were lacking. Interviews with staff confirmed the absence of precise monitoring practices.
A facility failed to ensure medications administered to a resident with COPD and heart failure were not expired. During a medication pass, a nurse identified expired fluticasone propionate spray and Refresh Tears, contrary to facility policies requiring expiration checks. The DON acknowledged the risk of infection from expired medications.
A facility failed to offer a resident the opportunity to receive updated pneumococcal vaccinations in line with CDC guidelines. The resident's records showed previous vaccinations, but there was no indication of being offered the newer PCV20 or PCV21 vaccines. The facility's reliance on a state system lacking updated CDC guidance contributed to this oversight, as acknowledged by the DON and Administrator.
Food Storage and Dietary Hair Coverage Deficiencies
Penalty
Summary
Food items in the kitchen were not properly discarded, labeled, or dated during a surveyor observation of the walk-in cooler and pantry. Fruit parfait cups prepared with fresh ingredients were dated 07/06/2026 with a discard date of 07/10/2026, which exceeded the three-day time limit. A pudding pan in a water pan was missing both a preparation date and an expiration date. Flour in a bin had an expiration date of 06/08/2026 and a use-by date of 07/08/2026, and the Dietary Manager reported that staff had placed the flour in the bin the day before and forgot to put a new label on it. In the pantry, an opened bag of creamy potatoes and an opened bag of cake mix were both sealed with plastic wrap but were missing open dates. During observation of food preparation, a Dietary Aide was seen preparing a mixture of baked beans while wearing a thick mustache and beard that were not covered with a beard guard. The Dietary Aide stated he was unaware of the regulation that male staff facial hair should be covered. The Dietary Manager confirmed the findings related to food not being discarded within three days, food not being properly dated, and dietary staff not ensuring all hair was completely covered in a beard guard, and stated that staff were expected to follow all policies relating to food items.
Unauthorized Medications Left at Bedside
Penalty
Summary
The facility failed to ensure that two sampled residents, R25 and R30, did not have unauthorized and unsecured medications at the bedside. The facility policy titled, Medications-Administration and Preparation, stated that medication should not be left at bedside unless specifically ordered by a physician, and the record review showed no orders for either resident to self-administer medications or to keep OTC medications at bedside. For R25, the EHR showed diagnoses including disorder of the skin and subcutaneous tissue and dry eye syndrome of bilateral lacrimal glands. R25 had a BIMS score of 15 and required varying levels of assistance with toileting, personal hygiene, and bathing. A Self-Administration Assessment Form had not been completed. During observation, R25 was sitting in her room with a bottle of OTC medication in a slightly open dresser drawer within arm's reach. R25 stated that a family member brought the medication in and that she planned to keep it in her room and give it to the nurses when the medication cart ran out. R25 also stated that she did not self-administer her medications. RN AA and RN BB stated that no residents had been assessed for medication self-administration and that no residents had been authorized to keep medications at bedside. RN AA confirmed the medication in the drawer and stated the family should have given it to the nurse instead of leaving it in the room. For R30, the EMR showed diagnoses including vascular dementia and allergic rhinitis, with a BIMS score of 13 and orders for ipratropium-albuterol nebulizer solution twice a day.
Unattended Unlocked Computer Screens Exposed Resident Information
Penalty
Summary
The facility failed to keep residents' personal and medical records private and confidential for two of 24 sampled residents, R14 and R16. Review of the facility policy titled, Resident's Federal and State Rights, stated that residents have a right to privacy and confidentiality in personal, medical, and bodily care, and that case discussion, consultation, examination, treatment, and care must be confidential and conducted in privacy. R14 was admitted with diagnoses including chronic obstructive pulmonary disease and chronic diastolic congestive heart failure, and had a BIMS score of 13, indicating cognitive intactness. R16 was admitted with diagnoses including hypertensive heart and chronic kidney disease with heart failure and unspecified dementia, and had a BIMS score of 12, indicating moderate cognitive impairment. On 07/10/2026 at 7:35 AM, observation showed no staff member present at the medication cart while two computer screens were open and unlocked, displaying R14's and R16's personal and medical information. Continued monitoring showed RN BB returning to the cart while both screens remained unlocked and visible, and then walking away again, leaving the confidential information exposed. During interview and observation at 7:55 AM, RN BB confirmed the screens were unlocked and that residents' medical information was visible to the public, and acknowledged that resident medical information must be protected at all times and that computer screens should be locked before walking away. The DON and Administrator later stated that all computer screens must be locked and must not display residents' personal or medical information when unattended.
Failure to Complete PASRR Level II for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that one resident with serious mental health diagnoses was referred for a PASRR Level II assessment on admission or within 30 days of a new diagnosis. R6 was admitted with diagnoses including depression, other bipolar disorder, and anxiety disorder, and the record also showed a quarterly MDS with a BIMS score of 11, indicating moderate cognitive impairment. Physician orders included chlordiazepoxide, Depakote ER for bipolar disorder, and olanzapine. The care plan documented behavioral symptoms, including verbal aggression toward others, and noted the resident had a history of traumatic brain injury, poor short-term memory, and needed assistance with activities of daily living and mobility. Review of the facility policy showed that residents with suspected serious mental illness were to receive the appropriate PASRR screening and, when indicated, a Level II evaluation. Interviews confirmed the omission: the Admissions Coordinator stated that R6 should have had a PASRR Level II completed due to the diagnoses and that she had not looked closely enough at the diagnoses when entering the resident into the facility system. The DON, in the presence of the Administrator, also confirmed that a PASRR Level II should have been submitted and stated the facility should not have relied solely on the hospital's PASRR Level I review.
Failure to Follow Oxygen Care Plan
Penalty
Summary
The facility failed to follow the care plan for oxygen administration for one resident with diagnoses including COPD and paroxysmal atrial fibrillation. The resident’s EMR showed a physician order for humidified oxygen at 2 liters per minute via nasal cannula continuously every shift, and the care plan dated 03/02/2026 identified that the resident required oxygen therapy related to COPD with an intervention to administer oxygen as ordered. Observations on 07/10/2026 at 9:16 AM and again at 11:50 AM showed the resident receiving oxygen at 3 liters per minute via nasal cannula from the oxygen concentrator, which did not match the ordered 2 liters per minute. The resident’s MDS also documented moderate cognitive impairment, shortness of breath when lying flat, and oxygen therapy while a resident. During interview, the RN/MDS Coordinator confirmed she was responsible for ensuring residents had care plans and stated her expectation was that staff follow care plans as directed.
Failure to Follow Oxygen Orders and Clean Oxygen Concentrators
Penalty
Summary
The facility failed to follow a physician’s order for oxygen administration for one resident and failed to prevent the spread of infections by not cleaning oxygen concentrators for three residents receiving O2 therapy. The facility’s policy titled, Respiratory Devices Nebulizer Treatments, stated that all equipment should be thoroughly cleaned before sterilizing or disinfecting weekly and as needed, and that small-volume medication nebulizers should be disinfected, rinsed, and air dried between treatments on the same patient. One resident with diagnoses including COPD and paroxysmal atrial fibrillation had an order for humidified O2 at 2 L/min via nasal cannula continuous every shift, but observations showed the resident receiving O2 at 3 L/min via nasal cannula from a dirty concentrator covered with dust and debris. Two other residents with diagnoses including CHF and COPD, and another resident with allergic rhinitis, also had physician orders for O2 therapy and were observed receiving O2 from dirty concentrators covered with dust and debris. The DON and RN AA confirmed that the concentrators were dirty and that one resident’s oxygen was set at 2.5 L/min instead of the ordered 2 L/min.
Inadequate Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement an adequate water management program, which is essential for preventing the growth and spread of Legionella bacteria, a serious health risk in healthcare settings. The facility's water management program was found to be incomplete and not aligned with the current ASHRAE guidelines. Specifically, the program did not include a detailed description or flow diagrams of the building's water systems, which are necessary to identify potential areas where Legionella could grow and spread. Additionally, the program lacked control measures and monitoring procedures to ensure the effectiveness of the water management plan. During interviews, the Maintenance Director mentioned that the facility conducted Legionella testing and risk assessments, and monitored water temperatures in resident rooms weekly. However, the Director of Nursing acknowledged the absence of a formal water management plan and expressed an expectation to follow CDC guidance. The deficiency was identified through observations, staff interviews, and a review of relevant guidelines and facility documents, highlighting the potential risk of Legionella exposure to residents.
Failure to Monitor Antipsychotic Medications
Penalty
Summary
The facility failed to ensure proper monitoring of antipsychotic medications for three residents, R17, R21, and R40, leading to a deficiency in medication management. The facility's policy required that each resident's medication administration record (MAR) include documentation of behaviors, side effects, and efficacy of antipsychotic medications. However, the facility did not adhere to this policy, as evidenced by the lack of specific targeted behavior monitoring and side effect documentation for these residents. Resident R17, who was severely cognitively impaired, was prescribed Zyprexa for depression. Despite the care plan indicating the need to monitor for adverse side effects and efficacy, there was no evidence of specific behavior monitoring related to the use of Zyprexa. Similarly, Resident R21, who was cognitively intact, was prescribed multiple psychiatric medications, including Geodon for schizophrenia. The facility monitored general behaviors but failed to document specific behaviors or adverse reactions related to each medication. Resident R40, also severely cognitively impaired, was prescribed several antidepressants. The facility's monitoring was not specific to the medications ordered, and there was no documentation of adverse effects or efficacy. Interviews with the Director of Nursing and the Pharmacist confirmed the lack of precise monitoring for behaviors, side effects, and efficacy specific to the medications. The Registered Nurse also indicated uncertainty about where to document such observations, highlighting a systemic issue in the facility's medication monitoring practices.
Expired Medications Found During Medication Pass
Penalty
Summary
The facility failed to ensure that medications administered to a resident were not expired, as observed during a medication pass. Specifically, two medications for a resident with chronic obstructive pulmonary disease (COPD) and unspecified systolic heart failure were found to be expired. The medications included fluticasone propionate spray, which was dispensed and began use without an open date or expiration date, and Refresh Tears, which was dispensed on a specific date and expired shortly thereafter. This oversight was confirmed by a registered nurse during the medication pass. The facility's policies, revised and approved in April 2024, require nurses to check medication labels for expiration dates during each medication pass and to remove any expired drugs from the medication chart. However, these procedures were not followed, as evidenced by the expired medications found on the medication cart. The Director of Nursing acknowledged that expired nasal and ophthalmic drops could increase the risk of infections, indicating a failure to adhere to the facility's medication management policies.
Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer a resident, identified as R28, the opportunity to receive flu and pneumonia vaccinations in accordance with nationally recognized standards. The facility's policy on immunizations, dated May 22, 2024, was not updated to reflect the current CDC recommendations. The CDC guidelines indicated that adults of a certain age have the option to receive Prevnar 20 (PCV20) or PCV21, or to not receive additional pneumococcal vaccines, depending on their vaccination history. However, R28's electronic medical record did not show any indication of being offered the PCV20 or PCV21 vaccine after receiving previous pneumococcal vaccinations, specifically Pneumovax 23 in 2010 and PCV13 in 2015. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility relied on a state online system for immunization records, which did not have updated CDC guidance. The DON acknowledged the importance of following CDC recommendations, while the Administrator admitted that the facility failed to identify and apply the current CDC recommendations to their policy. This oversight had the potential to place R28 at risk of contracting pneumonia and other residents at risk of not being offered immunizations based on current guidelines.
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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 Swainsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Swainsboro | 7.7 mi | ★★★★★ | 6 | 0 |
| Twin City Trails Of Journey Llc | 10.8 mi | ★★★★★ | 12 | 0 |
| Scott Health & Rehabilitation | 14.6 mi | ★★★★★ | 0 | 0 |
| Comfort Creek Nursing And Rehabilitation Center | 18.9 mi | ★★★★★ | 10 | 0 |
| Treutlen County Health And Rehabilitation | 20.1 mi | ★★★★★ | 3 | 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 October 2026) and official state health department websites.