Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Hospital Authority Of Brooks County, Georgia, The during CMS and state inspections, most recent first.
Expired and unlabeled food items were found in the dry pantry, walk-in cooler, and unit refrigerators/freezers. Surveyors observed expired red cooking wine, expired ice cream, and multiple containers of tomatoes, lettuce, and other items that were either past their use-by dates or not labeled/dated. The ADON and Assistant Director of Food Service confirmed the findings and stated staff were responsible for removing expired items and labeling/dating stored food.
Unsecured and Improperly Stored Medications at Bedside: The facility failed to keep medications properly secured for residents who were not approved for self-administration and failed to store approved self-administered creams correctly. A resident had a labeled topical medication left in the room after nurse application without a self-administration assessment, another resident had OTC meds at the bedside without approval to self-administer, and a third resident’s prescribed creams were found hanging in the bathroom instead of being stored in the bedside drawer.
Dirty Resident Room Vents: Surveyors found dust and grime buildup, including black substance on vent grates and slats, in eight resident rooms on two halls. Facility interviews showed staff were unsure when the vents were last cleaned, and the Mnt Supervisor admitted the vents were dirty, that summer months were worse, and that he had not increased cleaning or monitoring.
The facility failed to develop and implement comprehensive, person-centered care plans for three residents. One resident with COPD and chronic respiratory failure had an oxygen order for 2 LPM, but staff observed the oxygen set below the ordered rate. Another resident receiving O2 had no care plan for oxygen use, humidification, or signage, despite physician orders for O2 and humidifier changes. A third resident who independently used prescription cream had no care plan for self-administration of medication, and staff confirmed the resident had not been assessed or care planned for that ability.
Unsafe smoking supervision and ash tray handling were observed for two residents. One resident with dementia, hemiplegia, COPD, and nicotine dependence was seen smoking in the designated area next to an uncovered ash tray that was overflowing with cigarette butts and trash, while staff were unsure who was responsible for maintaining the ash trays. Another resident with Parkinson’s disease and severe cognitive impairment was observed carrying extinguished cigar butts in an N-95 mask hanging from his rollator after being told only to turn in his cigars and lighter.
Oxygen therapy orders, signage, and humidification not followed. Surveyors found that one resident's O2 concentrator was set below the ordered flow rate, two residents receiving O2 had no oxygen-in-use signage posted, one resident had no O2 order despite receiving oxygen, and one resident receiving O2 at 3 LPM did not have humidification in place. The DON and other staff confirmed the incorrect settings, missing signage, and lack of an O2 order during observations and record review.
A resident with multiple chronic conditions alleged that a CNA shoved a neck pillow behind her head. Despite the facility's policy requiring immediate suspension of staff accused of abuse, the CNA continued to work and remained assigned to the resident during the investigation. The Administrator did not initially consider the incident as abuse and only reassigned the CNA after further inquiry, resulting in a failure to follow the facility's abuse prevention policy.
A resident with multiple chronic conditions reported that a CNA had shoved a pillow behind her head. The incident was initially reported to the DON as rough handling and was not reported to the state agency until the following day, after the Ombudsman intervened. Law enforcement was also contacted at the resident's request. This delay in reporting did not comply with the facility's abuse reporting policy.
Expired and Unlabeled Food Items Found in Kitchen and Unit Refrigerators
Penalty
Summary
The facility failed to discard expired foods and failed to ensure food items were properly labeled and dated in the dry pantry, walk-in cooler, and unit refrigerators/freezers. Review of the facility policy titled Food Receiving and Storage showed that dry foods stored in bins are to be labeled and dated and rotated using a first-in, first-out system, and refrigerated foods are to be labeled, dated, monitored, and used by their use-by date, frozen, or discarded. During a kitchen tour with the Assistant Director of Food Service, surveyors observed four one-gallon containers of red cooking wine in the dry pantry with an expiration date of 8/4/2025. In the walk-in cooler, surveyors observed a green plastic container labeled tomatoes with a use-by date of 8/22/2025, a blue plastic container labeled lettuce with a use-by date of 8/23/2025, a red plastic container labeled tomatoes with a use-by date of 8/24/2025, and a foam container wrapped in plastic wrap labeled EL and dated 6/26/2025. In Unit A refrigerator, a sandwich covered in plastic wrap was not labeled or dated. In Unit B refrigerator/freezer, surveyors observed one gallon of chocolate ice cream with an expiration date of 3/29/2025 and two plastic containers that were unlabeled and undated. The Assistant Director of Food Service confirmed these concerns and stated there should not have been any expired food or any items not labeled or dated in the dry storage area, walk-in cooler, or hall refrigerators/freezers. The ADON also stated kitchen staff were responsible for removing expired food items and ensuring food items were labeled and dated on unit refrigerators/freezers.
Unsecured and Improperly Stored Medications at Bedside
Penalty
Summary
The facility failed to ensure that residents who were not approved for self-administration did not have unsecured medications at bedside, and it also failed to ensure that authorized self-administered medications were securely stored. The survey identified three residents involved in the deficiency, including residents with cognitive communication deficits and BIMS scores indicating little to no cognitive impairment. The facility’s policy stated that residents may self-administer medications only after the interdisciplinary team determines it is safe and the resident is able to accurately self-administer, with periodic re-evaluation based on status changes. For one resident, a tube of zinc oxide paste topical ointment labeled with the resident’s name was observed lying on the dresser in the room. The resident stated that an unidentified nurse had applied the medication and left it in the room. The record did not contain a completed assessment showing whether the resident was capable of self-administering medications. RN AA confirmed the medication was at the bedside and that the resident had not been assessed for independent self-administration, and LPN BB also confirmed the resident had not been assessed. For another resident, a bottle of cold medicine and a bottle of Tums were observed on the bedside table. RN AA confirmed the medications were in the room and that the resident had not been assessed to administer medications. For a third resident, two tubes of prescription medicated creams were observed hanging on a bathroom grab bar rather than being stored in the bedside drawer. The resident stated she used the cream independently for a rash, while RN AA confirmed the creams were openly hanging in the bathroom and not properly stored. The DON later confirmed that the resident was approved to self-administer medicated creams, but the creams should not have been stored in the bathroom.
Dirty Resident Room Vents
Penalty
Summary
The facility failed to ensure resident room vents were free from dust and grime buildup in eight rooms on two halls, A and B, despite its Environmental Services Policy requiring routine inspections of resident rooms and common areas, weekly rounds by environmental services supervisors, and communication of concerns identified during nursing or administrative rounds within 24 hours. Survey observations on 8/26/2025 and 8/27/2025 found dirty vent grates and grilles with black substance on the front slats in Rooms 37, 38, 39, 40, 68, 66, 70, and 71. Additional observations described air vents and slats covered in a black substance with dust buildup in multiple rooms. During interviews, Maintenance II said the vents in resident rooms may have been cleaned in May 2025 but he was unsure. The Lead Engineering Assistant said staff clean vent grates and slats about every six months, while the Maintenance Supervisor said they are cleaned about every two months but he was unsure when they were last cleaned. He stated summer months were worse but admitted he did not increase cleaning or monitoring of the vents. He confirmed the vents were covered in dust and grime and said the facility started cleaning the vents on A hall the night of 8/26/2025 after receiving a text and picture from an employee that the surveyor was taking pictures of the vents. On 8/28/2025, the Environmental Supervisor confirmed that all of the identified vents were dirty.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and Self-Administration
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans for three residents. The report states that the facility did not implement the care plan for oxygen therapy for one resident, did not develop a care plan for oxygen use, water humidification, and signage for another resident, and did not develop a care plan for self-administration of medication for a third resident. The facility policies reviewed required comprehensive care plans with measurable objectives and timetables, and required that ability to self-administer medications be documented in the care plan. One resident had diagnoses including COPD and chronic respiratory failure with hypoxia, and a physician order for oxygen at 2 LPM via nasal cannula continuously. The resident’s care plan included an intervention to administer oxygen as prescribed or per standing order, but observations on multiple occasions showed the oxygen setting at 1 to 1.5 LPM instead of 2 LPM. The ADON confirmed the order was for 2 LPM and confirmed the oxygen was not set at that rate, stating nurses were expected to check oxygen settings during medication pass. Another resident had diagnoses including Alzheimer’s disease, dementia, psychotic disorder with delusions, major depressive disorder, and anxiety disorder, and had physician orders for oxygen at 2 to 4 LPM via nasal cannula to keep saturations above 90% and to change the oxygen tubing and humidifier bottle every Sunday. The resident was observed receiving oxygen at 2 LPM, but there was no sign posted on the door or inside the room indicating oxygen was in use, and the care plan had no problem, goal, or interventions for oxygen use. A third resident with a BIMS score of 15 was observed keeping prescription medicated creams hanging in the bathroom and stated she used the cream herself daily for a rash; RN AA confirmed the cream was not properly stored and said the resident had not been assessed to administer the cream. The care plan had no focus area for self-administration of medications, and the DON and MDS Coordinator confirmed the care plan had not been created until after the issue was identified during the survey.
Unsafe Smoking Area Supervision and Ash Tray Management
Penalty
Summary
The facility failed to ensure that precautions were in place for the safety of two residents during smoke breaks. Review of the facility’s Smoking Policy showed it was intended to evaluate a resident’s ability to safely hold, light, smoke, and extinguish cigarettes. The deficiency involved designated smoking areas where residents were observed smoking with inadequate safety oversight and unsafe handling of smoking materials. R118 was admitted with diagnoses including sequelae of cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, dementia with agitation, COPD, and nicotine dependence. His MDS showed mild cognitive impairment, behavioral symptoms, and functional limitations requiring supervision for all ADLs. His care plan identified him as a smoker and directed that cigarettes and lighters be kept in the medication room and dispensed by the nurse, with smoking safety evaluation and education on the tobacco/smoking policy. During observation, R118 was smoking in the designated area outside unit E near the flagpole, where a fire blanket, fire extinguisher, and two ash trays were present. One uncovered ash tray contained cigarette butts and trash overflowing from it. Staff interviewed after the observation were unsure who was responsible for maintaining the ash trays. R58 was admitted with Parkinson’s disease with dyskinesia and dementia. His MDS showed severe cognitive impairment and a need for supervision or touching assistance with mobility. His care plan also identified him as a smoker with cigarettes and a lighter to be kept in the medication room and dispensed by the nurse, along with smoking safety evaluation and education. His smoking safety assessment noted balance problems while sitting and standing. During observation, after being told he could smoke, he stated that the only instruction he received was to turn in his cigars and lighter, and he was seen walking in with extinguished cigar butts placed in an N-95 mask hanging from his rollator. Staff later stated that residents needing supervision should smoke with a nurse or CNA, and that housekeeping was responsible for checking the ash trays twice a day.
Oxygen therapy orders, signage, and humidification not followed
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy. Review of the facility policy titled Oxygen Administration showed that oxygen administration required a physician's order, an oxygen-in-use sign outside the room entrance, and a humidifier bottle as part of the equipment and supplies. Survey observations and record reviews identified multiple residents receiving oxygen without the required conditions being met. For R59, diagnoses included COPD and chronic respiratory failure with hypoxia. The physician ordered oxygen at 2 LPM via nasal cannula continuously, but observations on multiple occasions showed the oxygen concentrator set at 1 to 1.5 LPM instead of 2 LPM. The ADON confirmed the order and the incorrect setting, and the DON stated that oxygen should be set as ordered. For R101, diagnoses included Alzheimer's disease, dementia, psychotic disorder with delusions, major depressive disorder, and anxiety disorder. Although physician orders included oxygen at 2 to 4 LPM via nasal cannula to keep saturations above 90%, observations showed the resident receiving oxygen at 2 LPM with no oxygen-in-use sign posted on the door or inside the room. For R145, diagnoses included COPD, dependence on supplemental oxygen, and interstitial pulmonary disease. The resident had an order for oxygen at 3 LPM via nasal cannula and for tubing and humidifier changes on Sundays, but observations showed oxygen in use with no humidification and no oxygen signage posted. For R11, diagnoses included heart failure and morbid obesity, and the MDS showed severe cognitive impairment. The resident was observed receiving oxygen at 1 LPM, but the record review found no oxygen order, and no oxygen sign was posted inside or outside the room. RN staff confirmed the resident did not have an oxygen order, and the DON confirmed the lack of oxygen signage and the absence of supporting diagnoses or orders for oxygen.
Failure to Suspend Staff After Alleged Abuse
Penalty
Summary
The facility failed to protect a resident from alleged abuse by staff, as required by its Abuse/Neglect Prevention Program policy. According to the policy, any staff member accused of abuse is to be immediately suspended pending investigation. However, after a resident with multiple diagnoses, including emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia, hemiparesis, dementia, and hypertension, alleged that a CNA shoved a neck pillow behind her head, the accused CNA continued to work and was not suspended. Documentation showed that the CNA worked the same day as the alleged incident and even completed a double shift the following day. Further, law enforcement records indicated that the CNA was still assigned to the resident nearly a month later. Interviews revealed that the CNA was aware of the resident's accusation and had another CNA accompany her when providing care to the resident. The Administrator stated that she did not initially consider the incident to be abuse and believed that the facility policy only required reassignment, not suspension, of the accused staff member. This series of actions and inactions resulted in the facility not following its own policy for handling abuse allegations, thereby failing to ensure the resident was protected from potential further abuse during the investigation.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required timeframe for one resident. According to the facility's policy, all personnel are required to promptly report any incident or suspected incident of resident abuse, including injuries of unknown source. In this case, a resident with multiple diagnoses, including emphysema, chronic pulmonary edema, chronic obstructive pulmonary disease, hemiplegia, dementia, and hypertension, reported that a CNA had shoved a pillow behind her head. The incident occurred on 1/27/2025 but was not reported to the state agency until 1/28/2025. The Director of Nursing (DON) acknowledged responsibility for state reportables and stated that the incident was initially reported to her as rough handling. The Ombudsman visited the facility the following day and informed the Administrator that the incident should be reported as abuse. Law enforcement was also involved after the resident requested to make an assault charge. The delay in reporting the incident to the SSA did not comply with the facility's abuse reporting policy.
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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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How nearby facilities compare on the same public inspection record.
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| Pruitthealth - Lakehaven, Llc | 18.1 mi | ★★★★★ | 0 | 0 |
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| Archbold Living Thomasville | 21.3 mi | ★★★★★ | 7 | 0 |
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