Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Nancy Hart Operation Llc during CMS and state inspections, most recent first.
Hand hygiene was not consistently performed when a laundry aide entered and exited resident rooms while delivering clothing and placing items in closets, and the aide confirmed she was unsure when hand hygiene should occur and had not received refresher training since hire. The facility also had not implemented EBP for residents with catheters or pressure ulcers, had no staff training or PPE competency check-offs for EBP, and had no formal water management program or Legionella monitoring; water testing was limited to lead, copper, and coliform.
A facility failed to maintain a safe, clean, and homelike environment in seven of 26 resident rooms. Surveyors observed holes in a resident room wall and bathroom door, chipped and peeling paint, fuzzy buildup on ceiling vents, jagged closet edges, soiled baseboards, and scuffed walls in multiple rooms. The Maintenance Director verified the concerns and stated repairs were delayed due to supply issues and limited maintenance staffing.
Failure to Implement Diabetes Care Plan Interventions: A resident with DM and CKD had a care plan calling for insulin administration and monitoring for hypo- and hyperglycemia, but the scheduled insulin glargine was missed on most dates reviewed and there was no documentation of blood sugar-related monitoring. Staff interviews showed an LPN was unaware the resident was diabetic, another LPN was unsure of the diagnosis, and the DON acknowledged the monitoring was overlooked because it was not listed on the MAR.
Oxygen therapy was not provided as ordered for two residents, and respiratory circuits were not cleaned as ordered for two residents. One resident with CHF and chronic respiratory failure was observed receiving oxygen at 3 LPM instead of the ordered 2 LPM, and an RN UM confirmed the incorrect setting. Another resident with COPD and severe cognitive impairment was observed with oxygen set at 3 LPM, later found with the concentrator turned off, and staff confirmed the tubing was overdue for weekly replacement. The facility also failed to ensure respiratory circuits were cleaned as ordered for two residents.
A resident with DM and CKD was ordered nightly insulin glargine, but the MAR showed multiple missed doses over several days. Notes indicated the medication was "awaiting pharmacy" on some dates, while an LPN said she kept reordering it without contacting the pharmacy or physician, and the pharmacist said there was no prescription on file. The DON stated staff were expected to follow physician orders and communicate medication issues promptly.
A resident with moderate cognitive impairment and a history of wandering exited the facility unsupervised through an unsecured exit door. Staff interviews and record reviews revealed that the resident was known to check doors and attempt to leave, but the exit door was not properly secured, and supervision was insufficient to prevent the elopement. The resident was later found by the roadside after a fall and transported to the hospital.
Hand Hygiene, EBP, and Water Management Program Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed during resident room entry and exit. Observations on 7/23/2025 and 7/24/2025 showed Laundry Aide MM entering and exiting multiple resident rooms while delivering clean clothing and placing items in residents’ closets without performing hand hygiene at any point during the process. In interview, Laundry Aide MM confirmed she did not perform hand hygiene after entering and exiting each resident room and stated she was uncertain about the exact moments hand hygiene should be performed. She reported receiving hand hygiene training when hired in 2020 and said she had not received any refresher training since then. The facility also failed to implement Enhanced Barrier Precautions (EBP) and failed to establish a water management program. Review of the MDS Resident Matrix showed three residents with indwelling urinary catheters and two residents with pressure ulcers, and the facility’s CNA Skills Checklist did not include EBP. A CNA stated she did not wear a gown for any resident and only performed hand hygiene before entering resident rooms, not after, and said she had not been required to demonstrate PPE competency check-offs. The DON stated EBP had not been implemented, no staff training had been conducted, and no procedures, policies, or protocols were in place. In addition, review of infection surveillance records found no documentation of a water management program or Legionella monitoring, and the Maintenance Director stated the facility had not implemented a formal Water Management Program. Environmental Management Services confirmed water testing was limited to lead, copper, and coliform, with no Legionella monitoring and no risk assessment or control measures in place.
Unsafe and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable homelike environment in seven of 26 resident rooms. Observation of one resident room revealed a two-inch hole in the wall behind the resident's door and a two-inch hole in the bathroom door. Additional observations of Rooms 108, 200, 201, 202, 203, 204, and 205 showed chipped and peeling paint near the residents' beds and window areas, fuzzy material buildup covering the ceiling ventilation slats, jagged closet edges, soiled baseboards, and scuffed walls. The Maintenance Director later verified these concerns during a walk-through and stated the rooms had ongoing cosmetic and structural issues, with repairs delayed due to supply delays and because he was the only maintenance staff member at the time.
Failure to Implement Diabetes Care Plan Interventions
Penalty
Summary
Care plan interventions were not implemented for a resident with type 2 diabetes mellitus and stage 3 chronic kidney disease. The resident’s admission MDS documented diabetes as an active diagnosis and insulin use, and the care plan included a goal for the resident to remain free from signs or symptoms of hyperglycemia or hypoglycemia, with interventions to administer diabetes medication as ordered and monitor for side effects and signs of hyperglycemia and hypoglycemia. The physician ordered insulin glargine 16 units subcutaneously at bedtime for diabetes. Review of the July 2025 MAR showed the scheduled nightly insulin glargine was not administered on 16 of 19 dates, and there was no documentation of monitoring for signs of hypoglycemia or hyperglycemia. Staff interviews confirmed that an LPN regularly caring for the resident was unaware the resident was diabetic, had not administered diabetes medication, and had not monitored for signs or symptoms of hypo- or hyperglycemia. Another LPN stated she was unsure whether the resident was diabetic and had not monitored the resident or administered the insulin as ordered. The DON stated nurses were expected to review and implement care plans and acknowledged that monitoring for hypoglycemia had been overlooked because it was not included on the MAR.
Oxygen Therapy and Respiratory Circuit Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for two residents with oxygen orders. R69 had diagnoses including acute chronic diastolic congestive heart failure and chronic respiratory failure with hypoxia, and had a physician order for oxygen at 2 liters per minute via nasal cannula as needed. On multiple observations, R69 was found in bed receiving oxygen via nasal cannula from a concentrator set at 3 LPM, and an RN Unit Manager confirmed the resident was receiving oxygen at 3 LPM and acknowledged the ordered rate was 2 LPM. The facility also failed to ensure respiratory circuits were cleaned as ordered for two residents with respiratory circuits. R46 had diagnoses including COPD with acute exacerbation, hypertension, anemia, and a history of venous thromboembolism, and an MDS assessment documented severe cognitive impairment with a BIMS score of 4 and that the resident received oxygen. R46 had an order for oxygen via nasal cannula at 2 LPM continuous, but observations showed the concentrator set at 3 LPM, the oxygen tubing dated 7/7/2025, and later the concentrator turned off with the resident not receiving oxygen. Staff confirmed the incorrect flow rate, the turned-off concentrator, and that the tubing was overdue for weekly replacement. R48 was also identified as having respiratory circuits that were not cleaned as ordered.
Missed Insulin Doses Due to Failure to Obtain Ordered Medication
Penalty
Summary
The facility failed to ensure that a resident with type 2 DM and stage 3 CKD received prescribed insulin glargine as ordered. The resident was admitted with an active diagnosis of diabetes mellitus, and the physician ordered insulin glargine 16 units subcutaneously at bedtime for DM. The MAR for July 2025 showed the insulin was scheduled nightly at 9:00 pm, but it was not administered on multiple dates. Several entries were marked with code 9, and some were marked as drug refused or absent from home with meds, while progress notes on some dates stated, "Awaiting pharmacy." There was no documentation for the other missed doses. During interview, the LPN stated the insulin was not given because it had not been received from the pharmacy and that she kept reordering it, but she had not called the pharmacy or notified the physician for further instructions and assumed it would eventually arrive. The pharmacist stated the insulin glargine had not been ordered and there was no prescription on file. The DON, UM, and MDS Coordinator stated that nurses were expected to follow physician orders as written, communicate medication issues promptly to the pharmacy, contact the physician if medication was unavailable, and use emergency kits if needed; the DON stated she could not explain why the nurse did not follow through with obtaining the insulin.
Failure to Prevent Elopement Due to Inadequate Supervision and Exit Door Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure the proper functioning of an exit door, resulting in a resident eloping from the premises. The facility's policy on elopement protocols requires all staff to report any resident attempting to leave or suspected of being missing, and defines elopement as leaving the grounds of the nursing home. Despite this, a resident with a history of cerebral infarct, altered mental status, cognitive impairment, and daily wandering behaviors was able to exit the facility unsupervised. The resident's care plan identified him as an elopement risk due to disorientation and impaired safety awareness, with documented behaviors of attempting to leave the facility and trying to use door codes. On the day of the incident, staff last observed the resident in the hallway in the morning, but he was later found missing when a nurse went to administer medications. Staff searched for the resident, who was eventually found by the roadside by members of the public after he had fallen. The resident was transported to the hospital and later reported that he had left to go to a store, though he did not recall the incident during a subsequent interview. Interviews with staff revealed that the exit door at the end of the hallway, which the resident used, was not properly secured at the time of the incident. The maintenance director stated that he regularly checked the doors and changed codes, but acknowledged that residents observed staff entering codes and shared this information. Multiple staff members confirmed that the resident frequently checked doors to see if they were open, and housekeeping staff were instructed to ensure doors were locked when taking out the trash. The failure to provide adequate supervision and ensure the exit door was functioning properly directly contributed to the resident's elopement.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Elberton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heardmont Health And Rehabilitation | 4.3 mi | ★★★★★ | 10 | 0 |
| Pruitthealth - Spring Valley | 8.9 mi | ★★★★★ | 1 | 0 |
| Comer Health And Rehabilitation | 18.7 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Washington | 19.9 mi | ★★★★★ | 2 | 0 |
| Iva Post-acute | 21.3 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Nancy Hart Operation Llc.
100% money-back within 48 hours.
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.