Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Parkside Center For Nursing And Rehab At Ellijay during CMS and state inspections, most recent first.
Improper Insulin Pen Administration: An LPN failed to prime an insulin pen before giving NovoLog to a resident with DM2 and immediately removed the needle after injection. The resident had an order for sliding-scale insulin based on blood glucose, and the facility policy required priming the pen and holding it in place for several seconds to ensure the full dose was delivered.
A resident with pneumonia, pleural effusions, acute respiratory failure, COPD, and CHF received O2 at a higher flow rate than ordered. The physician ordered 2 LPM via NC, but surveyors observed the concentrator set at 3.5 LPM on multiple occasions. An LPN confirmed the incorrect setting and said she did not know who changed it; the DON stated oxygen is a medication and must be given per the physician’s order.
Medication administration errors exceeded the allowed rate when surveyors identified 2 errors in 31 observed opportunities. An LPN gave a 6:00 AM Protonix dose that had already been documented as administered and did not give ordered calcium carbonate 600 mg because only a 500 mg strength was available; the MAR also lacked documentation that the medication issue had been addressed. The DON stated nurses are expected to give medications as ordered and contact the provider if the correct dose is not available.
A resident received a roommate’s bedtime meds during the PM med pass, including insulin, melatonin, sertraline, ferrous sulfate, gabapentin, hydroxyzine, metoprolol, oxybutynin, and ranolazine. The resident had multiple chronic conditions, including HF, Afib, HTN, asthma, and cognitive communication deficit, with a BIMS of 13. The facility’s policy required photo identification in the MAR and verification of the six rights, but the wrong resident was medicated.
Failure to follow EBP and disinfect shared equipment occurred during medication passes when an LPN entered a resident’s room, donned a gown after reading EBP signage, but did not sanitize a blood pressure machine after use. The same LPN later used an unclean glucometer for two residents without disinfecting it between checks. In a separate observation, an RN administered meds via a PEG tube to a resident with EBP signage posted but did not wear PPE and stated she was unsure why the sign was present or whether PPE was needed.
The facility failed to provide written transfer notices to three residents and/or their representatives during emergent hospital transfers. The residents, with varying medical conditions and cognitive statuses, were transferred without receiving documentation explaining the reason for transfer. Staff interviews confirmed that discharge summaries were not provided in a language the residents or their representatives could understand.
A resident with hypoxemia and shortness of breath requiring intermittent oxygen therapy was admitted, but the facility failed to include oxygen use in the comprehensive care plan. Interviews with an LPN, MDS Coordinator, and DON confirmed the oversight, acknowledging that the care plan should have detailed the oxygen use to inform staff of the resident's needs.
A resident did not receive most of her prescribed medications due to a delay in pharmacy delivery and a lack of timely action by the facility staff. The resident, with multiple health conditions, was admitted without her medications being entered into the system in time for delivery. The facility had options to access medications from an emergency kit or request a stat delivery, but these were not utilized. Communication issues also contributed to the delay, as medications were delivered to the wrong unit.
A facility failed to document target behaviors for a resident prescribed lorazepam for anxiety, potentially leading to unnecessary medication use. Despite the facility's policy requiring documentation of psychotropic drug use, there was no evidence of monitoring the resident's behaviors to justify the medication. Staff interviews confirmed the lack of expected documentation.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure professional standards were followed when preparing and administering insulin for one resident receiving NovoLog by insulin pen. The resident had diagnoses including type 2 diabetes mellitus and an order for NovoLog subcutaneously with meals using a sliding scale based on blood glucose readings. During an observed medication pass, the LPN checked the resident’s blood sugar at 195 mg/dL and prepared 14 units of insulin, attached the pen needle, and dialed the ordered dose. The LPN did not prime the insulin pen before administration, despite the facility policy requiring priming prior to each use. She administered the insulin in the resident’s right arm and immediately removed the needle from the skin after fully depressing the plunger. In a follow-up interview, the LPN stated she was not aware the pen should be wasted prior to administration or that the needle should remain in the skin for several seconds after injection. The DON stated nurses were expected to follow the facility’s insulin pen policy and hold the pen against the skin for five to 10 seconds after pressing the injection button to ensure the full dose is delivered.
Oxygen Flow Rate Not Set Per Physician Order
Penalty
Summary
Oxygen therapy was not administered according to the physician’s order for one resident receiving O2. The resident was admitted with diagnoses including pneumonia, pleural effusion, acute respiratory failure, COPD, and CHF. The admission MDS documented a BIMS score of 14 and indicated the resident was on oxygen therapy. The care plan for COPD included administering oxygen as ordered, and the physician order dated 03/03/2026 directed O2 at 2 LPM via nasal cannula. Observations on 03/03/2025 at 10:37 AM, 2:53 PM, and 03/04/2025 at 9:45 AM showed the oxygen concentrator set at 3.5 LPM via nasal cannula. The assigned LPN confirmed the flow rate was 3.5 LPM and then verified the order was for 2 LPM, stating she did not know who had adjusted it. The DON stated oxygen is considered a medication and must be administered according to the physician’s order, and that nurses are responsible for ensuring physician orders and care plans are followed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. During observations, record review, staff interviews, and review of the facility’s Medication Administration policy, surveyors identified 2 medication errors out of 31 opportunities observed, resulting in a 6.45 percent medication error rate. The policy required staff to follow the six rights of medication administration, including the right dosage and right time, and to compare the medication source with the EMAR to verify the resident name, medication name, form, dose, route, and time. An LPN was observed administering 9:00 AM medications to a resident and included a 6:00 AM dose of Protonix from the blister pack even though it had already been documented as administered in the EMR. The LPN stated she did not realize it had already been given and assumed it was due because it appeared as an AM medication on the blister pack card. The same LPN also did not administer calcium carbonate 600 mg because only calcium carbonate 500 mg was available and she could not locate the correct strength. Later review showed the calcium carbonate had still not been documented as administered, and there was no documentation that the pharmacy had been contacted or the physician notified. The DON stated nurses are expected to administer medications as ordered, and if the correct dosage is not available, the provider should be contacted for further instructions.
Medication Admin Error: Resident Received Roommate’s Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when the resident received another resident’s bedtime medications during the 9:00 PM medication pass. The medications mistakenly administered included Tresiba insulin 8 units subcutaneously, Humalog insulin per sliding scale with 4 units given, melatonin 3 mg two tablets, sertraline 50 mg, ferrous sulfate 325 mg, gabapentin 300 mg, hydroxyzine 25 mg, metoprolol succinate ER 25 mg one-half tablet, oxybutynin 2.5 mg, and ranolazine ER 500 mg. The error involved medications intended for the resident’s roommate and was identified as a self-reported incident. The affected resident had diagnoses including rheumatoid arthritis, hypertension, heart failure, atrial fibrillation, pulmonary hypertension, asthma, peripheral vascular disease, lymphedema, morbid obesity, generalized weakness, and cognitive communication deficit. The quarterly MDS indicated adequate hearing, ability to make self understood, ability to understand others, and a BIMS score of 13, indicating little to no cognitive impairment. The resident’s active medication profile included multiple medications such as anticoagulants, antibiotics, diuretics, inhalers, and other routine therapies, but no reference to insulin in the resident’s high-risk medication section. The facility’s policy required staff to identify residents by photo in the MAR, follow the six rights of medication administration, and compare the medication source with the EMAR to verify the resident’s name, medication name, form, dose, route, and time. The nurse involved in the incident was identified by the facility as RN FF, who recognized the error immediately and reported it to the physician and family. The physician evaluated the resident the next day, and the record noted that the resident’s blood glucose remained stable with no documented hypoglycemia.
Failure to Follow EBP and Disinfect Shared Equipment
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) and failed to sanitize shared medical equipment between resident uses during medication administration observations. Review of the facility policies showed that reusable, non-critical equipment such as blood pressure machines and glucometers were to be cleaned and disinfected after each use, and that EBP was required for residents with wounds or indwelling medical devices during high-contact care activities, including device care or use. During an observation with an LPN, the nurse entered a resident’s room to check blood pressure after reading the EBP sign, donned a gown, and stated she believed she was required to gown every time she entered the room. She brought a blood pressure machine into the room, obtained the resident’s blood pressure, and left without sanitizing the machine. When questioned, she stated she did not think cleaning was necessary because she was unsure what condition the resident had and believed the roommate, not the resident she was caring for, likely had the condition; she then acknowledged the blood pressure machine should have been cleaned. The same LPN later checked one resident’s blood sugar, placed the glucometer on the resident’s bed, exited the room to obtain insulin, and returned the glucometer to the medication cart without sanitizing it. She then used the same unclean glucometer for another resident’s blood sugar check and again returned it to the cart without cleaning it. In a separate observation, an RN administered medications via a PEG tube to a resident with EBP signage posted on the door, performed hand hygiene, but did not wear PPE during the procedure. The RN stated she was not sure why the signage was present and was unsure whether PPE should have been used for PEG tube medication administration. The IC Nurse and DON stated that staff were expected to sanitize shared equipment between residents and follow EBP practices.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide written transfer notices containing all required information to three residents and/or their representatives during emergent hospital transfers. This deficiency was identified through record reviews, resident and staff interviews, and facility policy review. The facility's policy on transfer and discharge was not followed, as it required providing orientation for transfer or discharge in a manner the resident could understand and sending copies of notices for emergency transfers to the Ombudsman. However, for the residents in question, there was no documentation of a written notice of transfer provided to them or their representatives. Resident 8, with a diagnosis of gastrointestinal hemorrhage and moderately impaired cognition, was transferred to the emergency department due to dyspnea and blood in stool without receiving a written notice. Resident 18, with little or no cognitive deficit, was transferred due to fecal impaction without a written notice. Resident 91, with multiple diagnoses including dementia and heart failure, was transferred after the resident's daughter called 911, and no written notice was provided. Interviews with the Administrator, Unit Manager, and Director of Nursing confirmed that discharge summaries were not provided in a language the residents or their representatives could understand, and a separate discharge sheet indicating the reason for discharge was not available.
Oxygen Use Omitted from Resident's Care Plan
Penalty
Summary
The facility failed to include the use of oxygen in the comprehensive care plan for one resident, identified as R20, who was part of a sample of 23 residents reviewed for care planning. The resident was admitted with diagnoses including hypoxemia and shortness of breath, requiring intermittent oxygen therapy. Despite these needs, the care plan initiated on 12/16/24 did not document the use of oxygen, which is essential for communicating the resident's care requirements to the staff. Interviews with facility staff, including an LPN, the MDS Coordinator, and the Director of Nursing, confirmed that oxygen should have been included in the care plan to ensure all nursing staff were aware of the resident's needs and how to properly administer care. The omission was acknowledged as an oversight, with staff indicating that the care plan should detail whether oxygen is used continuously or as needed (PRN).
Failure to Administer Medications Timely Due to Pharmacy Delivery Issues
Penalty
Summary
The facility failed to ensure timely administration of medications for a resident, identified as R91, due to a delay in receiving medications from the pharmacy. R91, who was admitted with multiple diagnoses including nonrheumatic aortic valve stenosis, idiopathic pulmonary fibrosis, and chronic respiratory failure, did not receive most of her prescribed medications ordered on 09/21/24. The medications were delivered to the facility on 09/20/24 but were not administered to the resident. The Director of Nursing (DON) confirmed that the orders were not entered prior to the resident's admission, and the pharmacy did not deliver medications on Sundays, which contributed to the delay. Interviews with the DON and nursing staff revealed that the facility had procedures in place to access medications from an emergency kit or request a stat delivery from the pharmacy, but these options were not utilized. The DON acknowledged that the charge nurse could have administered Lasix from the emergency kit, as it was available in the correct dosage. Additionally, there was a communication breakdown, as RN4 was not informed about the pending medication delivery, and medications intended for the rehabilitation side were mistakenly delivered to the long-term care side of the facility. The Medical Director expected nurses to access the emergency kit or contact the pharmacy for immediate delivery if necessary.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to identify and document target behaviors for monitoring the effectiveness of antipsychotic medication for one resident, leading to potential unnecessary use of lorazepam. The facility's policy requires that psychotropic drugs are only given when necessary to treat a specific condition, with documented evidence of the medication's benefit to the resident. However, for Resident 48, there was no documentation of monitoring moods and behavioral symptoms to evaluate the need for lorazepam, which was prescribed for anxiety. Resident 48 was admitted with diagnoses including a history of falls, multiple fractures, panic attacks, anxiety, and major depression disorder. Despite having a BIMS score indicating little or no cognitive deficit, there was no evidence in the medical records of monitoring the resident's behaviors to justify the administration of lorazepam. Interviews with staff revealed that the expected documentation of behaviors in the Medication Administration Records was not present, and the Director of Nursing confirmed that behaviors should be documented with each administration of the medication.
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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 Ellijay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jasper Point Of Journey Llc | 13.5 mi | ★★★★★ | 14 | 0 |
| Pruitthealth - Jasper | 14.5 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Blue Ridge | 15.7 mi | ★★★★★ | 0 | 0 |
| Wildwood Health And Rehab | 16.1 mi | ★★★★★ | 2 | 0 |
| Murray Woods Of Journey Llc | 18 mi | ★★★★★ | 22 | 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 July 2026) and official state health department websites.