Below average — CMS composite of the measures below.
The next survey window likely opens 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 Palemon Gaskins Mem Nsg Home during CMS and state inspections, most recent first.
Surveyors found that the facility failed to submit required PASRR Level II evaluations after new qualifying mental illness diagnoses were added for two residents. One resident had PTSD, major depressive disorder, and anxiety disorder documented in the EHR and MDS, along with use of antianxiety and antidepressant medications, but the PASRR Level I did not reflect these mental health conditions and no Level II was submitted. Another resident had schizoaffective disorder, schizophreniform disorder, anxiety, depression, and schizophrenia documented, was receiving antipsychotic, antianxiety, and antidepressant medications, yet the PASRR Level I indicated no mental illness and no Level II was submitted. Both residents were absent from the facility’s list of current Level II PASRR cases, and staff interviews confirmed that the PASRR screenings had not been accurately updated or resubmitted.
Surveyors identified multiple environmental and maintenance deficiencies affecting resident areas, including handrails on two halls with missing caps, exposed screws, and black tape on edges, as well as holes in the floor and an unattached baseboard near a dining room entrance. A resident room sink was repeatedly observed to be clogged or partially clogged, with water draining very slowly over several days. The facility did not provide a policy addressing a safe, clean, homelike environment when requested, and the MDS nurse and Maintenance Director confirmed the ongoing issues with the sink, handrails, flooring, and baseboards.
The facility did not ensure an accurate PASRR Level I screening for a resident with documented schizophrenia, depression, and dementia. Although the resident’s EHR, MDS, and physician orders showed active diagnoses of schizophrenia and depression and ongoing treatment with antidepressant and antipsychotic medications, the PASRR Level I form marked that the resident did not have schizophrenia, anxiety, or depressive disorder, and no Level II PASRR was obtained. The resident was not included on the facility’s Level II PASRR list, and the Administrator confirmed that audits had only reviewed the top three diagnoses on the DMA-6, which excluded the qualifying mental health diagnoses, resulting in the failure to submit an accurate PASRR screening.
A medication security deficiency occurred when an RN unlocked a medication cart, opened the computer to a resident’s MAR, and then walked away to discard an item, leaving the cart and computer screen unattended and unsecured. The RN returned shortly afterward to obtain the resident’s medication but later confirmed in an interview that the cart had been left unlocked and stated she believed it was acceptable because a surveyor was present, while acknowledging she should have locked the cart and closed the screen. The DON reported that her expectation is that nursing staff lock the medication cart before walking away.
The facility’s QAA program did not effectively identify and correct ongoing deficiencies related to maintaining a safe, clean, comfortable, homelike environment and completing required Level I PASRR screenings. Although a PIP had been initiated after prior citations for F644 (coordination of PASRR and assessments) and F645 (PASRR screening for mental illness and developmental disabilities), the Administrator acknowledged that it was not effective for residents who had been in the facility before the earlier survey. As a result, the same residents who previously required PASRR Level II screenings based on their diagnoses were again found to be lacking appropriate PASRR Level II reviews during the current survey.
An LPN was observed during a med pass popping multiple oral medications from blister packs into her bare hand and pouring floor stock pills into her hand before placing them into a medication cup, without performing hand hygiene between handling the pills. Another LPN present at the cart told her that pills should not be popped into the hand due to infection control concerns. In an interview, the LPN acknowledged handling the pills this way, stated she was a new grad working PRN with only one day of orientation, and reported she had been trained to do it that way. The DON later stated her expectation was that staff pop pills directly into a cup rather than into their hands.
A nurse left a med cart unlocked and the computer screen open with a resident's medication list visible while stepping away during med pass. The RN later confirmed the lapse, and the DON stated nurses are expected to black out the screen and lock the cart before walking away.
The facility failed to notify responsible parties of wound progression for several residents, did not maintain a clean and home-like environment, and neglected to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices. Additionally, the facility did not ensure proper Level II Preadmission Screening and Resident Review (PASRR) for residents with qualifying diagnoses. These issues were not addressed in the facility's Quality Assurance Performance Improvement (QAPI) process.
A facility failed to follow infection control policies during wound care and IV antibiotic administration for a resident with pressure ulcers. A nurse did not practice hand hygiene or wear a gown as required by Enhanced Barrier Precautions (EBP). Interviews revealed staff were unaware of EBP guidelines and PPE requirements, indicating a lack of training on infection control practices.
The facility failed to notify the families of two residents about the development and progression of pressure ulcers. One resident's family discovered the wound while assisting with care, and interviews revealed a lack of documentation and communication regarding wound status changes. The facility relied on charge nurses and a visiting wound care nurse, but failed to meet the expectation of timely family notifications.
The facility failed to maintain a clean and homelike environment, with privacy curtains in several rooms found to have dirt and stains, and bathroom ceilings exhibiting a black substance due to condensation. A sink in one room was non-functional, with water turned off to prevent flooding, and leaking pipes were discovered. Staff interviews revealed a lack of awareness and communication regarding maintenance issues, and housekeeping practices were inadequate, with uncertainty about when privacy curtains were last cleaned.
A facility failed to conduct a PASARR Level II evaluation for a resident after new mental illness diagnoses were added. The resident was admitted with anxiety disorder and depression, and later diagnosed with PTSD. Despite these diagnoses, the facility did not submit for a Level II evaluation, as required by their policy. Interviews revealed challenges in obtaining accurate information from discharging facilities and a lack of responsibility taken by behavioral health services to apply for the evaluation.
A facility failed to submit an accurate PASRR Level I application for a resident with schizophrenia and depression prior to admission. The resident's PASRR assessment incorrectly marked the absence of these conditions, and the resident was not listed for a Level II evaluation. Interviews revealed an expectation for accurate PASRRs, but the necessary resubmission was not completed.
The facility failed to ensure accurate wound care documentation, as the dates on the weekly wound report reflected the report completion date rather than the actual wound identification date. This issue was noted for several months, and staff interviews revealed that the problem was identified weeks before the survey but was not documented or incorporated into the QAPI plan. The Administrator acknowledged the concern, highlighting the inability to track wound progression accurately.
Failure to Update PASRR Screenings After New Mental Illness Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to submit required PASRR Level II evaluations after new qualifying mental illness diagnoses were added for two residents. The facility’s PASRR policy dated 1/1/2024 states that all individuals seeking admission to Medicaid-certified nursing facilities must be screened for mental illness or intellectual/developmental disability, that residents will be screened prior to admission using the PASRR process, and that if the screening is positive for possible serious mental illness or intellectual/developmental disability/related condition, a Level II evaluation will be performed. Despite this policy, surveyors found that the facility did not complete or submit PASRR Level II evaluations when new mental health diagnoses were added to residents’ records. For one resident, the EHR showed admission with diagnoses including anxiety disorder, depression, and a primary diagnosis of PTSD. The resident’s MDS reflected severe cognitive impairment with a BIMS score of seven and active diagnoses of anxiety disorder, depression (other than bipolar), and PTSD, and the resident was receiving antianxiety and antidepressant medications. The medical diagnosis list showed that Major Depressive Disorder, PTSD, and anxiety disorder were added over time; however, the resident’s PASRR Level I assessment did not list other mental disorder, anxiety, or depressive disorder. Record review revealed no PASRR Level II submission after these mental illness diagnoses were added, and the resident did not appear on the facility’s list of current Level II PASRR residents. For another resident, the EHR showed admission with schizoaffective disorder, bipolar type, depression, and anxiety disorder, with additional diagnoses of schizophreniform disorder and restlessness and agitation added later. The resident’s MDS indicated they were not considered by the state Level II PASRR process to have serious mental illness or intellectual disability/related condition, showed little to no cognitive impairment with a BIMS score of 13, and listed active diagnoses of anxiety disorder, depression (other than bipolar), and schizophrenia. The resident was receiving antipsychotic, antianxiety, and antidepressant medications. The PASRR Level I assessment indicated the resident did not have a mental illness, and record review showed no PASRR Level II submission after the new mental illness diagnoses were added. The resident’s name was not on the facility’s Level II PASRR list. Staff interviews confirmed that qualifying diagnoses existed and that PASRR Level I screenings had not been accurately updated or resubmitted to trigger Level II review.
Environmental Hazards and Maintenance Failures in Resident Areas
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on two hallways and in certain common and resident-use areas. Surveyors observed that handrails on Hall 1 and Hall 2 had multiple missing end caps, with screws protruding, and some handrails had black tape wrapped around the edges. At the entrance to Hall 1 near the dining room, the flooring by the double doors had six holes remaining from old fire doors that had been replaced, and the baseboard in that same area was unattached to the wall. When the state surveyor requested a policy addressing a safe and clean homelike environment, the facility did not provide one. In a resident room, surveyors observed on multiple occasions that the sink was clogged or partially clogged. On one observation, the sink water was running and draining very slowly while the basin filled quickly. On subsequent observations, the sink remained clogged or partially clogged, with slow drainage persisting over several days. During a concurrent observation and interview, the MDS nurse confirmed that the sink continued to drain slowly and remained partially clogged. In a walking tour, the Maintenance Director confirmed that the handrails on both halls needed cap replacements, that the holes in the floor were from removed fire doors and needed to be filled, that the baseboards needed to be reattached, and that the resident room sink required service due to a clog.
Failure to Accurately Complete PASRR Screening for Resident With Schizophrenia and Depression
Penalty
Summary
The facility failed to ensure that a complete and accurate PASRR Level I screening was submitted prior to or on admission for a resident with documented mental health diagnoses. Facility policy required that all residents be screened prior to admission using the PASRR process, that the facility obtain a copy of the PASRR and approval number, and that a Level II evaluation be performed if the screening was positive for serious mental illness or intellectual/developmental disability. The resident’s electronic health record showed admission with diagnoses including unspecified mild dementia with anxiety, schizophrenia (unspecified), and unspecified depression. The admission MDS documented active diagnoses of non-Alzheimer’s dementia, Parkinson’s disease, and schizophrenia, and indicated the resident received antidepressant medications. Physician orders showed ongoing treatment with escitalopram and mirtazapine for depression and risperidone for schizophrenia. Despite these documented conditions, the resident’s PASRR Level I assessment indicated “No” for diagnoses of schizophrenia, anxiety, or depressive disorder, and the resident was not listed on the facility’s roster of residents with Level II PASRR determinations. During interview, the Administrator confirmed that the Social Services Director was primarily responsible for submitting Level I PASRR screenings and acknowledged that the resident did not have a Level II PASRR, despite having qualifying diagnoses. The Administrator further confirmed that the Level I PASRR screening had not been resubmitted with the qualifying diagnoses and explained that prior PASRR audits only reviewed the top three diagnoses on the DMA-6 form, which did not include the qualifying mental health diagnoses.
Unlocked and Unattended Medication Cart Left Accessible by RN
Penalty
Summary
The deficiency involves failure to ensure medications were securely stored on one of two medication carts when a nurse left the cart unlocked and unattended. On 1/16/2026 at 8:16 AM, observation of the short hall medication cart showed it was unlocked and unattended after RN DD had unlocked the cart, opened the computer screen, and pulled up Resident 5’s list of medications. RN DD then walked away from the cart to throw something away, leaving the cart unlocked with the computer screen open, and returned at 8:17 AM to remove Resident 5’s medication from the cart. In an interview at 8:21 AM, RN DD confirmed she had walked away from the unlocked cart and stated she thought it was acceptable because the surveyor was standing nearby, acknowledging she should have locked the cart and closed the computer screen before leaving. In a separate interview at 10:29 AM, the DON stated it was her expectation that nursing staff lock the medication cart before walking away from it. This deficient practice created the potential for unauthorized entry and diversion of medications, as documented in the survey findings.
Ineffective QAA Program Fails to Correct Ongoing PASRR Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assessment and Assurance (QAA) program that identified and corrected deficiencies related to providing a safe, clean, comfortable, homelike environment and ensuring completion of Level I PASRR screenings. Review of the facility’s QAPI purpose statement showed that the program was intended to monitor and sustain operational performance of clinical and non-clinical systems through self-identification and improvement of opportunities for improvement. However, record review of the Monthly QA/PI meeting agenda showed that although a Performance Improvement Plan (PIP) had been established for previously cited deficiencies involving F644 (Coordination of PASRR & Assessments) and F645 (PASRR Screening for Mental Illness and Developmental Disabilities) from a prior survey, the underlying issues were not effectively resolved. During a post-survey interview, the Administrator reported that the QAPI team had created a PIP in response to a previously identified PASRR system failure, but acknowledged that this PIP was not effective for residents who were already in the facility prior to the earlier survey. The Administrator stated that residents residing in the facility before that survey, whose diagnoses clearly qualified them for PASRR Level II reviews, had not been adequately addressed under the existing PIP. The Administrator confirmed that the same residents who had been identified as needing PASRR Level II screenings during the prior survey were again identified during the current recertification survey, demonstrating that the QAA program did not successfully implement corrective actions to resolve the PASRR-related deficiencies.
Improper Handling of Oral Medications During Med Pass
Penalty
Summary
Surveyors observed that during a morning med pass, LPN BB removed multiple blister-pack medications from the cart and repeatedly popped six pills from six separate blister packs into her bare hand before transferring them into a medication cup, without performing hand hygiene between handling the pills. LPN BB also removed floor stock medication from the cart and poured those pills from the bottle into her hand before placing them into the same medication cup. Another nurse, LPN CC, was present near the medication cart, witnessed the interaction, and verbally told LPN BB that pills should never be popped into the hand because it was an infection control issue. In a subsequent interview, LPN BB confirmed she had popped the pills into her hand, stated that this was how she had been trained, and reported she was a new graduate and new nurse, licensed in November 2025, working PRN with only one day of orientation before passing medications. The DON later stated that her expectation was for nursing staff to pop pills directly into a cup and not into their hands. The deficient practice identified was the failure to follow infection control practices during medication administration for one of three residents observed, specifically by handling oral medications in a manner inconsistent with the facility’s stated expectations for infection prevention and control.
Confidentiality Breach During Medication Administration
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when RN DD left the medication cart unlocked and the computer screen open with R5's medication list visible during medication administration on one nursing unit. During observation, RN DD unlocked the medication cart, opened the computer screen to R5's list of medications, stated she had to throw something away, and walked away from the cart without locking it or closing the screen. RN DD later confirmed she left the cart unlocked and said she thought it was acceptable because the surveyor was standing there, and that she should have locked the cart and closed the computer screen before walking away. The DON stated it was her expectation that nurses black out the computer screen and lock the medication cart before walking away.
Deficiencies in Resident Notification, Environment, and Screening
Penalty
Summary
The facility failed to notify responsible parties and family representatives of wound progression and treatment for four residents. The facility's Quality Assurance Performance Improvement (QAPI) process did not monitor or address the issue of notifying responsible parties about the residents' wound status. Interviews with the Director of Nursing (DON) revealed that the concern of notification was not identified as a problem by the administrative staff and was not being monitored through the QAPI process. The facility did not ensure a clean and home-like living environment for residents. During the survey, privacy curtains were observed to be visibly soiled, unidentified black substances were found on the ceilings and walls of residents' bathrooms, and a nonfunctioning sink was noted in one of the residents' rooms. The Administrator in Training (AIT) mentioned that the facility planned renovations to address these concerns but had not incorporated them into the QAPI program. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and wounds, as staff had not been educated on their use. Additionally, the facility did not ensure that residents requiring Level II Preadmission Screening and Resident Review (PASRR) were properly screened. The AIT, previously the Social Services Director, acknowledged that they struggled to get accurate information from discharging facilities and had not applied for Level II PASRRs when necessary. The facility was in the process of auditing PASRRs for accuracy but had not included this concern in their QAPI monitoring.
Infection Control Deficiencies in Wound Care and IV Therapy
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during wound care and intravenous antibiotic therapy for a resident with pressure ulcers. Specifically, a registered nurse did not practice hand hygiene before, during, or after wound care, despite the facility's policy requiring handwashing at these times. The nurse also failed to wear a gown while administering intravenous antibiotics, as required by the facility's Enhanced Barrier Precautions (EBP) policy for residents at risk of carrying or transmitting multidrug-resistant organisms. Interviews with staff, including the Director of Nursing and other nursing staff, revealed a lack of awareness and understanding of the EBP guidelines and the necessity of wearing personal protective equipment (PPE) during care for residents with indwelling medical devices or wounds. The Director of Nursing and other staff members admitted to not being aware of the requirement to wear PPE, such as gowns, during certain procedures, indicating a gap in training and education on infection control practices within the facility.
Failure to Notify Families of Pressure Ulcer Changes
Penalty
Summary
The facility failed to notify the family representatives of two residents, R13 and RA, about the development and progression of pressure ulcers. R13 was admitted with multiple diagnoses, including a pressure ulcer on the heel. A progress note indicated a change in the condition of R13's sacral area wound, which was not communicated to the family. Similarly, RA, who was admitted with a pressure ulcer in the sacral region, had a documented open wound that was not reported to the family. The family member of RA discovered the wound while assisting with care and expressed that they were not informed by the facility staff about the wound or any changes in RA's condition. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility lacked a dedicated wound care nurse, relying instead on charge nurses and a visiting wound care nurse from a hospital. The DON acknowledged the absence of documentation regarding family notifications and the inability to track wound progression. The Administrator confirmed that staff were expected to notify families of any changes in residents' conditions and document these notifications, which was not done in these cases.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several observations and staff interviews. In three of the 17 residents' rooms, privacy curtains were found to have noticeable dirt and debris, including black and brown stains. Additionally, the bathroom ceilings in some rooms had a black substance, which was identified as being caused by condensation and moisture due to the building's age. The sink in one resident's room was not functioning, as the water was turned off to prevent flooding, and it was later discovered that the pipes were leaking and required repair. Interviews with the facility's staff revealed a lack of awareness and communication regarding the maintenance issues. The Director of Engineering was unaware of the need for repairs in the room with the non-functioning sink, and there was no established timeline for completing repairs. The process for reporting and completing maintenance tasks involved notifying the Administrative Assistant, who would then enter a work order into the system. However, the system did not indicate a timeline for completion, and the Director of Engineering only became aware of the issues during the survey. Housekeeping practices were also found to be inadequate, as the privacy curtains were supposed to be cleaned every two weeks, but the housekeeper was unsure of when they were last cleaned. The Interim Administrator confirmed the observations during walking rounds and acknowledged the need for improvement. The expectation was for resident rooms to be clean and free from debris at all times, in accordance with state laws and regulations.
Failure to Conduct PASARR Level II Evaluation for Resident with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASARR) Level II for a resident after new mental illness diagnoses were added. The resident, identified as R15, was admitted with diagnoses including anxiety disorder and depression. The resident's Annual Minimum Data Set (MDS) indicated severe cognitive impairment and active diagnoses of anxiety disorder, depression, and PTSD. Despite these diagnoses, the facility did not submit for a PASARR Level II evaluation, which is required when a resident has a qualifying mental illness diagnosis. The facility's policy mandates compliance with PASARR requirements, including screening residents prior to admission and performing a Level II evaluation if the screening is positive for serious mental illness (SMI) or intellectual and developmental disabilities (ID/DD). Interviews with the Administrator In Training and the Administrator revealed that the facility struggled to obtain accurate information from discharging facilities and that it was the responsibility of behavioral health services to apply for a Level II evaluation. However, no Level II evaluation was completed for R15, and the resident was not listed among those with Level II PASARR in the facility.
Failure to Submit Accurate PASRR Level I for Resident
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I application, which included a diagnosis of schizophrenia and depression, was submitted prior to or on admission for a resident. This oversight was identified during a review of the facility's policy and the resident's electronic health record (EHR). The resident, who was admitted with diagnoses including unspecified dementia, schizophrenia, and depression, did not have a PASRR Level I assessment that accurately reflected these conditions. The facility's policy mandates that all residents be screened for mental illness or intellectual and developmental disabilities before admission, and if the screening is positive, a Level II evaluation should be conducted. The deficiency was further highlighted by the fact that the resident's PASRR Level I assessment incorrectly marked the absence of schizophrenia, anxiety, or depressive disorder. The facility's list of residents with Level II PASRR did not include this resident, indicating a failure to follow through with the necessary evaluation process. Interviews with the Administrator In Training and the Administrator revealed that there was an expectation for PASRRs to be accurate and complete, and the failure to resubmit the PASRR with the correct diagnoses was acknowledged. The Administrator emphasized the importance of adhering to legal requirements in the PASRR process.
Inaccurate Wound Care Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of wound care for residents receiving such care. Specifically, the documentation on the weekly wound report inaccurately reflected the date wounds were identified, as the date the report was completed was used instead of the actual date the wound or injury occurred. This issue was noted in the facility's Wound and Skin Status Report for the months of March, June, and October 2024, where the same date was recorded for both the completion of the report and the identification of the wound or skin alteration. Interviews with staff revealed that the problem with wound documentation was identified three weeks prior to the surveyors' visit, but there was no documentation confirming a skin sweep conducted by the staff and the DON to ensure no other unidentified wounds existed. Additionally, the concern with wound documentation was not incorporated into the facility's QAPI plan for evaluation and monitoring. The Administrator in Training acknowledged the issue, noting the inability to determine when wounds were identified or if they were progressing or declining. The Administrator expressed an expectation for accurate documentation of resident wounds, but no specific meetings were conducted to address the issue beyond regular morning meetings discussing residents' current conditions.
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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 Ocilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Ocilla | 0.3 mi | ★★★★★ | 7 | 0 |
| Harmony Health And Rehabilitation | 7.6 mi | ★★★★★ | 12 | 0 |
| Pruitthealth - Fitzgerald | 8.7 mi | ★★★★★ | 4 | 0 |
| Harborview Tifton | 17.2 mi | ★★★★★ | 22 | 0 |
| Rehabilitation Center Of South Georgia | 17.4 mi | ★★★★★ | 7 | 0 |
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