Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Haralson Nsg & Rehab Center during CMS and state inspections, most recent first.
A resident with multiple diagnoses, including CVA-related dysarthria, paraplegia, adult failure to thrive, and MDD, was transferred to another SNF after repeated behaviors. The record showed the transfer was facility-initiated, but there was no documented prior discussion, no 30-day discharge notice, and no notification to the Ombudsman, despite the resident having a BIMS score of 14 and little to no cognitive impairment.
Incomplete MAR Documentation for PRN Acetaminophen: The facility failed to accurately document PRN acetaminophen administration for two residents. One resident with multiple chronic conditions and a pain-management care plan received Tylenol from an LPN, but there was no MAR entry or progress note documenting the dose. Another resident with CHF, chronic respiratory failure, Parkinson's disease, and a pain-risk care plan had acetaminophen administered, but the MAR was left blank. The DON stated that standing-order medications must be entered into the MAR before administration.
Medication administration errors were observed involving an RN and two residents. One resident with DMII received Lantus without the insulin pen being primed and had leakage at the injection site, while Metformin ER doses were missed when the medication was unavailable and later a formulation mismatch occurred between the order and the MAR. Another resident received Biotin 5,000 mcg instead of 1 mg, and Psyllium was repeatedly unavailable and not administered as ordered.
Ice Machine Not Kept Clean and Sanitary: The kitchen ice machine was observed with brown substance buildup in the inside door corners and crevices, and the buildup wiped off with a paper towel. The DM confirmed the condition, and the Maintenance Director stated he cleaned the machine on a schedule, with the last documented cleaning noted in the log. The facility policy required daily cleaning and sanitizing of ice equipment.
Infection control practices were not followed during soiled item disposal, laundry handling, and meal tray delivery. A CNA transported soiled linen and trash while wearing gloves, touched a keypad with the gloves, removed them, and did not perform hand hygiene. In the laundry room, clean clothing was stored on the dirty side and a clean-linen folding table was cluttered with food, drinks, a microwave, binders, and office supplies. CNAs also delivered meal trays between resident rooms without sanitizing their hands, and they confirmed they were not aware hand hygiene was required between rooms.
Dining Practices Did Not Support Resident Dignity: Two residents who were independent with eating were observed eating directly from serving trays left on the tables with plate warmers under the dishes during meals. One resident with BIMS 15 said she had never been asked if she preferred the tray and disliked the tray/warmer setup, while another resident with BIMS 9 said she preferred a tray-free dining experience. Staff, including an LPN, Activities staff, the Activities Director, and the DON, confirmed the trays were always used and left in place as a routine practice.
Hazardous Items Found in Resident Rooms: The facility failed to keep three resident rooms on the 100 Hall free from hazards when surveyors found manual razors, alcohol wipes, and aerosol spray in resident rooms. An UM/LPN confirmed the razors were supposed to be kept on nursing carts or in the shower room and that the alcohol wipes and aerosol spray should not have been in the rooms; the DON also confirmed the items should not have been there.
Resident Served Regular Meal Instead of Ordered Pureed Diet: A resident with DM, Alzheimer's disease, CVA, hemiplegia, and hemiparesis had a physician order for a reduced concentrated sweets, no added salt, pureed, nectar-thick diet, but was observed being served a regular consistency lunch tray. The CNA confirmed the tray was regular consistency, the dietary aide acknowledged the tray check error, and the FSM stated the tray did not match the resident's diet order.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
Surveyors found that shower rooms on two halls were not maintained in a clean condition, with dark brown to black fuzzy and slimy substances present on the walls near cracks in grout and caulking, and a musty odor detected. Facility policy required monthly deep cleaning with bleach, but these procedures were not effectively carried out, as confirmed by staff interviews.
A resident with a history of metabolic encephalopathy, diabetes, and an unstageable pressure ulcer did not have complete documentation of wound care treatments in the medical record. The TAR lacked entries for several days, and an LPN admitted to performing but not documenting a treatment due to distraction, despite being trained to do so. The administrator confirmed that all treatments are expected to be documented after completion.
The facility failed to ensure adequate nursing staff for its 104 residents, resulting in a One-Star Staffing Rating for Quarter 1 of 2024. High turnover and reliance on agency staff contributed to the deficiency, as revealed by interviews with the HR Director and Administrator.
The facility failed to maintain safe water temperatures, with readings above 110 degrees Fahrenheit in 27 resident rooms and the shower room. Additionally, a resident reported that bed linens were not changed after showers, as required by facility policy. These deficiencies were confirmed through staff interviews and record reviews.
The facility failed to administer O2 therapy as ordered for a resident with multiple diagnoses, including heart failure and sleep apnea. Observations revealed the O2 concentrator was set at 3 LPM instead of the prescribed 2 LPM. Staff interviews confirmed the resident sometimes adjusted the O2 settings herself, and nursing staff did not consistently monitor and adjust the O2 levels as ordered.
Failure to Provide Required 30-Day Transfer Notice
Penalty
Summary
The facility failed to provide a 30-day notice to one resident, R14, before a facility-initiated transfer to another skilled nursing facility. The facility policy titled, Transfer or Discharge, Preparing a Resident For, stated that a notice of transfer or discharge and/or bed-hold shall be provided to the resident or representative prior to or at discharge or as soon as practicable. Review of R14’s record showed the resident was admitted with diagnoses including dysarthria following cerebral infarction, paraplegia, adult failure to thrive, poly osteoarthritis, insomnia, major depressive disorder, constipation, and gastro-esophageal reflux disease. The quarterly MDS with an ARD of 11/07/2025 indicated a BIMS score of 14, showing little to no cognitive impairment. A progress note dated 11/07/2025 documented that, due to repeated behaviors, the facility initiated a discharge/transfer to another SNF, that the resident was informed and agreed to the transfer, that the resident was accepted at another healthcare facility, and that discharge would occur that day with facility transport. However, review of the record found no prior documented conversation between the SW and the resident about the transfer and no evidence that a 30-day discharge notice was provided. During interviews, the Administrator stated the discharge notice process was initiated after the resident was discussed in the morning meeting and that the SW completed the process in her absence. The Ombudsman stated she was not informed of R14’s discharge and had no record of notification, and the SW confirmed that no 30-day discharge notice was issued and that the Ombudsman was not notified.
Incomplete MAR Documentation for PRN Acetaminophen
Penalty
Summary
The facility failed to ensure medication administration was accurately documented in the MAR for two residents during medication administration. The facility policy titled, Administering Medications, stated that the individual administering the medication should document the administration on the eMAR, and the Standing Orders-Medication Protocols included an order for acetaminophen 325 mg, two tablets every six hours as needed for pain for seven days, but did not include instructions for transcription into the electronic MAR prior to administration. One resident, admitted with multiple diagnoses including tubulo-interstitial nephritis, CHF, Parkinson's disease, type 2 diabetes mellitus, aphasia, polyneuropathy, atrial fibrillation, spinal stenosis, failure to thrive, obesity, and a history of MI and lung cancer, had a BIMS score of 13 and was cognitively intact. The resident's care plan addressed pain management related to muscle relaxant use, anticonvulsant use, and spinal stenosis. Review of the EMR for 05/05/2026 through 05/07/2026 showed no progress note documenting acetaminophen administration and no corresponding MAR entry, although the resident told surveyors she had been given Tylenol around 11:30 AM and the LPN stated she administered Tylenol 325 mg, two tablets, from the standing orders list. A second resident, admitted with diagnoses including nonrheumatic aortic valve stenosis, pericardial effusion, chronic respiratory failure with hypoxia, acute on chronic diastolic heart failure, Parkinson's disease, and a cardiac pacemaker, had a BIMS score of 12 and a care plan for risk for pain related to osteoarthritis and age-related factors. Review of the EMR showed acetaminophen 325 mg, two tablets, was administered on 04/30/2026, but the MAR entry for that date was left blank with no documentation that the medication had been given. The DON stated that medications on the standing orders list must be entered into the MAR prior to administration and that accurate MAR documentation was necessary to maintain medication tracking and reduce the risk of duplicate administration or medication errors.
Medication Administration Errors and Missed Doses
Penalty
Summary
Medication administration errors occurred during observation and record review for two residents, resulting in a 16 percent error rate across 25 observed medication administration opportunities. For one resident with DMII and an order for Lantus SoloStar 50 units subcutaneously every 12 hours, an RN dialed the dose but did not prime the insulin pen before injection and removed the pen after about three seconds, with medication leakage observed at the injection site. The RN stated she did not know the meaning of priming in relation to insulin pens. The same resident had an order for Metformin HCl ER 500 mg, two tablets by mouth twice daily, but the medication was not available in the medication cart at the scheduled time and was not administered. The MAR review showed the morning and evening doses were missed on 05/05/2026. Review of the MAR and pharmacy information also showed a discrepancy between the physician order, the MAR, and the dispensed medication, with Metformin ER later supplied while the MAR reflected Metformin HCl 500 mg, and the resident received Metformin ER twice daily on 05/06/2026 despite the revised order for non-ER Metformin. For another resident, an RN administered Biotin 5,000 mcg instead of the ordered 1 mg dose, which was five times greater than prescribed. The resident also had an order for Psyllium 3.4-gram packet daily, but it was not available in the medication cart and was not administered; the MAR showed repeated coded unavailability on multiple days, indicating multiple missed or interrupted administrations. The DON stated nursing staff were expected to monitor supply levels and reorder medications before stock became low, and later confirmed that insulin pens required priming and holding in place for 5 to 10 seconds after administration.
Ice Machine Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to ensure the ice machine in the kitchen was maintained in a clean and sanitary condition. Review of the facility policy titled Ice Machines and Ice Storage Chests stated that ice machines and ice storage/distribution containers are to be used and maintained to assure a safe and sanitary supply of ice, and that ice chests and ice scoops are to be cleaned and sanitized daily. A facility-provided Ice Machine Cleaning Log showed documented cleanings on 6/3/2025, 7/8/2025, and 8/22/2025. During an observation on 9/9/2025 at 10:10 AM, the ice machine in the kitchen was observed with the Dietary Manager present, and the inside door left and right corners and crevices had a brown substance buildup that wiped off with a white paper towel. The Dietary Manager confirmed the buildup and stated the Maintenance Director cleaned the ice machine. In a later interview, the Maintenance Director stated he cleaned the ice machine according to a schedule and confirmed the last documented cleaning was 8/22/2025.
Infection Control Lapses During Soiled Item Disposal, Laundry Handling, and Meal Tray Delivery
Penalty
Summary
Infection prevention and control practices were not followed during disposal of soiled items when a CNA transported soiled linen and trash in bags through the hallway while wearing gloves, used the gloved hand to punch in a keypad code to enter the soiled utility room, removed the gloves, and did not perform hand hygiene. The CNA confirmed she wore gloves while transporting the soiled bags, touched the keypad with the soiled gloves, and did not perform hand hygiene after discarding the bags and removing the gloves. In the laundry room, more than nine open boxes of clean clothing were observed stacked on the dirty side of the room against a wall, with the clothing overflowing from the boxes and in direct contact with the wall. A folding table designated for clean linens was cluttered with binders, food, a microwave, drinks, and office supplies, with visible food crumbs and clean linens in contact with those items. During meal tray delivery, CNAs were observed passing trays between resident rooms without performing hand hygiene, and the CNAs confirmed they did not sanitize their hands between rooms and were not aware they should.
Dining Practices Did Not Support Resident Dignity
Penalty
Summary
Dining practices failed to support resident dignity and person-centered preferences for two sampled residents, R43 and R53. Facility policies for Resident Rights, Dining and Meal Service, and Quality of Life-Dignity stated that residents should be treated with respect, kindness, and dignity, and that dining should be person-centered and supportive of individual needs. R43’s quarterly MDS dated 7/7/2025 documented a BIMS score of 15 and that she was independent with eating. R53’s quarterly MDS dated 7/1/2025 documented a BIMS score of 9 and that she was independent with eating. Observations on 9/10/2025 during lunch and dinner in the main dining room showed all residents eating directly from serving trays placed on the tables, with plate warmers remaining under the dishes throughout the meals. R43 stated that trays had been used in the dining room for some time, that she did not care for the tray or plate warmer, and that food gets caught between the plate and the warmer; she also stated she had never been asked if she preferred the tray. R53 stated that she disliked the serving trays and preferred the food plate to be placed directly on the table. Staff interviews confirmed the trays and plate warmers stayed on the tables and were used that way because that was how it had always been done; the Activities Director stated she would not consider it home-like, and the DON was uncertain whether the practice contributed to a home-like environment.
Hazardous Items Found in Resident Rooms
Penalty
Summary
The facility failed to ensure an environment free from hazards in three of 30 rooms on the 100 Hall. During observations, a manual razor was found on a resident's nightstand in one room, alcohol wipes and a manual razor were found on another resident's nightstand with an aerosol spray on the bedside table, and alcohol wipes with an aerosol spray were found on a third resident's nightstand. The facility's policy titled Hazardous Area, Devices, and Equipment identified sharp objects accessible to vulnerable residents and access to toxic chemicals as hazards. During a walking-through observation and interview, the UM/LPN confirmed that manual razors were supposed to be kept on nursing carts or in the shower room, and that alcohol wipes and aerosol sprays should not be in resident rooms. The UM/LPN stated that leadership conducted weekly environmental rounds and nurses and CNAs were expected to round daily. The Administrator and DON later stated that each administration personnel was assigned a room to conduct rounds to ensure hazardous products were not in resident rooms, and confirmed that the identified items should not have been in the rooms.
Resident Served Regular Meal Instead of Ordered Pureed Diet
Penalty
Summary
Therapeutic diets were not consistently served in accordance with physician orders for one resident. R117 was admitted with diagnoses including type 2 diabetes with unspecified complications, Alzheimer's disease, cerebral infarction, hemiplegia, and hemiparesis. The resident's physician ordered a reduced concentrated sweets diet, no added salt, pureed texture, and nectar consistency, and the resident's tray card and the facility's Diet Type Report both identified a pureed diet texture. The facility policy titled Dining and Meal Service stated that residents would be provided meals that meet special dietary needs and that food would be at the proper texture and consistency. On 9/9/2025 at 12:46 pm, R117 was observed being served a regular consistency lunch meal instead of the ordered pureed consistency. During interview, the CNA who delivered the tray confirmed it was a regular consistency meal and should have been pureed. The Dietary Aide stated she was the final checker on the tray preparation line and was responsible for ensuring the tray and meal ticket corresponded, and she acknowledged the error and said she was moving too quickly. The Food Service Manager acknowledged the meal tray did not match the resident's diet order and stated the risk could lead to choking.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain shower rooms in a clean and sanitary condition on two separate halls. Specifically, dark brown to black fuzzy and slimy substances were found on the walls of the shower units near cracks in the grout and caulking. The presence of a musty odor was also noted in these areas. The facility's policy required monthly scrubbing of bathroom ceramic tile floors with a cleanser containing bleach to prevent bacterial growth, but these procedures were not effectively implemented, as evidenced by the unsanitary conditions observed. Interviews with facility staff confirmed the findings. The Maintenance Director acknowledged the presence of the black substance and stated that monthly pressure washing and scrubbing were performed, but was unsure how these areas were missed. The Administrator clarified that nursing staff were responsible for tidying the shower rooms after use, while maintenance was tasked with monthly deep cleaning and inspection. Despite these assigned responsibilities, the required cleaning and inspection did not prevent the accumulation of unsanitary substances in the shower rooms.
Incomplete Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that medical record documentation was completed and accurate for a resident with a pressure ulcer. The resident, who was admitted with metabolic encephalopathy, type 2 diabetes mellitus, and unspecified diarrhea, had an unstageable pressure ulcer present on admission. The care plan required weekly treatment and measurement of all areas of skin breakdown. However, a review of the Treatment Administration Record (TAR) for June showed missing documentation for several days, specifically 6/1, 6/2, 6/4, and 6/9, regarding whether the prescribed wound care was provided. During interviews, an LPN confirmed that she performed the wound treatment on one of the missing dates but did not document it due to being distracted. She acknowledged being trained to document treatments after completion. The facility administrator stated that the expectation was for all treatments to be documented after they are completed. The lack of documentation resulted in incomplete medical records for the resident's pressure ulcer care.
Inadequate Nursing Staff
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of its 104 residents, as evidenced by the PBJ Staffing Data Report for Quarter 1 of 2024. The report indicated a One-Star Staffing Rating due to multiple issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit. Interviews with the HR Director and the Administrator revealed that the facility had a high turnover rate during this period, with several LPNs, Unit Managers, and CNAs resigning. The HR Director, who assumed scheduling responsibilities due to the Scheduler's maternity leave, stated that the facility relied on a mix of full-time staff and agency nurses and CNAs, with a significant portion of the staff being from agencies. The HR Director detailed the scheduling process, which involved notifying the Charge Nurse in case of call-outs and then reaching out to full-time staff or agency staff to fill the shifts. Despite these efforts, the facility struggled to maintain adequate staffing levels, particularly during the night shift. The Administrator acknowledged the high turnover and mentioned that full-time positions were being offered to agency staff, and company recruiters were actively seeking new candidates in local communities. This staffing deficiency had the potential to affect the care provided to all residents in the facility.
Facility Fails to Maintain Safe Water Temperatures and Change Bed Linens
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as required by regulations. Specifically, the water temperatures in one of the facility's wings were found to be above the maximum allowable temperature of 110 degrees Fahrenheit, with temperatures ranging from 115.0 to 121.5 degrees Fahrenheit in 27 resident rooms and the shower room. This issue was identified during an initial tour and confirmed by the Maintenance Director, who admitted that the mixing valve had been problematic for a couple of months. Despite checking temperatures the previous week, the Maintenance Director did not record these checks, and the hot water was subsequently turned off to address the issue temporarily. The Administrator was unaware of the problem until notified by the Maintenance Director and stated that hot water would be sourced from another wing until the part to fix the issue arrived. Additionally, the facility failed to change bed linens for a resident after showers, as required by their policy. The resident, who was cognitively intact, reported that their bed linens were not changed after receiving showers on two consecutive days. Interviews with the Certified Nursing Assistant and the Director of Nursing confirmed that bed linens should be changed on shower days, and failure to do so would result in in-service education and potential employee write-ups. The facility's electronic medical records corroborated the resident's claim, showing that the resident had received showers but did not have their bed linens changed. These deficiencies highlight lapses in the facility's adherence to its policies and procedures, particularly concerning water temperature regulation and bed linen changes. The failure to maintain appropriate water temperatures poses a risk of burns to residents, while not changing bed linens compromises the cleanliness and comfort of the residents' living environment. Both issues were acknowledged by the facility staff during interviews, indicating a need for improved oversight and adherence to established protocols.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen (O2) therapy as ordered for a resident (R21) who was receiving O2 therapy. The resident was admitted with diagnoses including heart failure, morbid obesity, hypertension, transient cerebral ischemic attack, and sleep apnea. The physician's order specified that the resident should receive O2 at 2 liters per minute (LPM) via nasal cannula to maintain O2 levels above 92%. However, observations on multiple occasions revealed that the O2 concentrator was set at 3 LPM instead of the prescribed 2 LPM. Staff interviews confirmed that the resident sometimes adjusted the O2 settings herself, and the nursing staff did not consistently monitor and adjust the O2 levels as ordered by the physician. The facility's policy on oxygen administration did not include procedures for maintaining O2 concentrators, proper storage of O2 devices, or nursing staff responsibilities for ensuring the correct O2 flow. Interviews with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) revealed that the nurses were primarily responsible for checking the O2 settings and monitoring O2 levels every shift. Despite these expectations, the deficiency occurred due to a lack of adherence to the physician's orders and inadequate monitoring of the O2 settings by the nursing staff.
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Illustrative
What surveyors actually found near you
We read the 48 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
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Nursing homes near Bremen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Countryside Post Acute | 6.3 mi | ★★★★★ | 5 | 0 |
| Buchanan Healthcare Center | 6.6 mi | ★★★★★ | 0 | 0 |
| Pine Knoll Path Of Journey Llc | 10 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Carrollton | 11 mi | ★★★★★ | 4 | 0 |
| Carrollton Crossing Of Journey Llc | 13.6 mi | ★★★★★ | 14 | 0 |
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