Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Pavilion At Brandon Wilde during CMS and state inspections, most recent first.
Incomplete grievance documentation and unresolved resident complaints. The facility did not consistently document grievance dates, findings, or resolution details for multiple residents, and some grievances were not found in the grievance log at all. Family members and a POA reported that concerns about care and staffing had been raised repeatedly without clear resolution, while grievance forms for one resident listed satisfaction without documenting what was discussed or how that conclusion was reached.
Background Check and Reference Check Deficiencies: The facility failed to complete a GCHEXS fingerprint background check before an Administrator’s hire date and failed to complete reference checks for seven of seven new hires, including an ADON, LPNs, an RN, and CNAs. The HRD stated GCHEXS checks were required before the start date, but reference checks were not being completed and only employment verification checks were done. Facility policy required reference checks and criminal history review before an employee started work.
A resident with depression, dementia, and anxiety disorder was started on lorazepam PRN for anxiety, but the record had no documentation that the resident or representative was informed in advance of the medication’s risks, benefits, or alternatives, or that consent was obtained. The DON stated psychotropic meds require informed consent prior to administration, including on admission, and nursing staff are responsible for obtaining it.
Failure to Provide Transfer, Discharge, and Bed-Hold Notifications: The facility failed to communicate transfer information to the hospital and failed to provide written notice to a resident and resident representative about the reason for hospital transfer/discharge and the bed-hold policy, including reserve bed payment. The resident had CHF, atrial fibrillation, a cardiac pacemaker, anxiety disorder, and severe cognitive impairment, and was sent to the hospital for respiratory distress. The DON confirmed the required notifications were not issued, and the facility policy required transfer/discharge documentation and communication to the receiving provider.
A resident was hospitalized, but the facility did not have documented transfer notification, eInteract transfer, or bed hold records. The discharge return anticipated MDS and entry MDS were marked out in error and not completed, and the DON confirmed the discharge return anticipated MDS should have been completed.
MDS Incorrectly Coded Discontinued Antipsychotic Medication: A resident with Alzheimer's disease and dementia with behavioral disturbance had quetiapine discontinued, but the annual MDS still indicated antipsychotic use. The MDS Coordinator confirmed the med was outside the 7-day look-back period and should not have been coded, while the care plan and MAR reflected the discontinuation.
A resident receiving oxygen had no physician order for oxygen in the EMR when staff were observed administering it, and the resident's room lacked an oxygen sign. Humidification and tubing were undated, and no storage bag was present. RN and DON confirmed the missing order and infection control issues, while an RN said she relied on verbal hospice information for the oxygen flow rate instead of the physician order.
A facility failed to ensure personal resident refrigerators were monitored for temperature and spoiled food. Two residents had room refrigerators with missing temperature log entries, and one refrigerator measured 46 degrees F. Staff found peaches with visible mold in one resident’s refrigerator, and the facility policy required daily temperature checks and removal of expired or spoiled items.
A resident with cognitive impairment was left waiting during mealtime due to insufficient staff and space, compromising their dignity. Additionally, a resident with diabetes had their blood glucose tested in a public area, violating privacy protocols. Staff interviews confirmed these practices were against facility policy, highlighting deficiencies in maintaining resident dignity.
A resident with hypertension and atrial fibrillation had their medications withheld by an RN without consulting the physician, despite the absence of parameters for withholding. The RN based the decision on the resident's blood pressure and pulse, but did not notify the physician or obtain parameters for future reference. Interviews revealed inconsistencies in nursing judgment and a lack of standardized guidelines for withholding medications.
A facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate. Two residents were affected: one had medications withheld without physician orders, and another had a medication omitted due to being out of stock. The errors were due to non-compliance with facility policies and lack of physician notification.
A resident with hypertension and atrial fibrillation experienced a medication labeling error during administration. The RN found discrepancies between the pharmacy packet descriptions and the actual medications, leading to difficulty in identifying the correct pills. The pharmacist confirmed the error, which was attributed to outdated descriptions not matching the medications, highlighting a need for process improvements.
A facility failed to maintain infection control during medication administration, as a nurse used an ungloved fingernail to remove medications from a cup and placed a glucometer on an unclean surface. An overflowing sharps container and an open beverage on the medication cart were also noted, indicating lapses in infection control protocols.
Incomplete grievance documentation and unresolved resident complaints
Penalty
Summary
The facility failed to ensure grievances were promptly resolved for five residents, including R9, R23, R35, R50, and R61, out of 22 sampled residents. The deficiency centered on grievance documentation that was incomplete or missing, including failures to date grievances, summarize findings, and document corrective action taken in response to complaints. Review of the facility grievance records showed no documentation of grievances filed on behalf of R61 or R50 in the grievance log for the review period, despite concerns being raised by family members and a POA that grievances had not been addressed or resolved. For R35, the record showed six grievances filed on behalf of the resident, but the grievance forms listed the family member as the person notified of resolution without documenting what was discussed or the family member’s response, and one resident council concern form lacked a departmental signature, date returned to the administrator, and any response from the complainant. R23’s quarterly MDS showed an admission date of 08/26/25, kidney insufficiency, and a BIMS score of 14, indicating no cognitive impairment. R61’s MDS showed an admission date of 12/17/25, cancer, heart failure, stroke, depression, and a BIMS score of 9, indicating moderate cognitive impairment. R50’s MDS showed an admission date of 12/29/21, coronary artery disease, hypertension, diabetes, anxiety disorder, depression, asthma, and a BIMS score of 13. R35’s MDS showed an admission date of 04/18/24, chronic kidney disease, heart disease, stroke, and a BIMS score of 10. The SSD stated the documentation should be more in-depth and should include specific concerns and how satisfaction was determined, and the Administrator confirmed follow-up for resident council concerns had been inconsistent.
Background Check and Reference Check Deficiencies
Penalty
Summary
The facility failed to ensure a Georgia Criminal History Check System (GCHEXS) fingerprint background check was completed before the hire date for the Administrator. Record review showed the Administrator was hired on 12/01/25, and the required GCHEXS fingerprint background check was completed on 12/02/25. During interview, the Human Resources Director stated GCHEXS background checks are completed for all employees except nurses and are required to be completed prior to the start date, and also stated the Administrator is not a facility employee but a corporate employee based out of Iowa. The facility also failed to complete reference checks for seven of seven new hire employees, including the Administrator, Assistant DON, LPN 1, LPN 3, RN 1, CNA 1, and CNA 3. The Human Resources Director stated the facility did not complete reference checks and only performed employment verification checks through the company that performed the background checks, and further stated that the corporate office had directed the facility to resume completing reference checks. Facility policy titled Resident Abuse Prevention Program stated that prior to a new employee starting a work schedule, the community will initiate a reference check from previous employer(s) and obtain a limited criminal history for nurse aides and other unlicensed employees. The Hiring Process policy stated job offers would only be extended after clearance from Human Resources based on acceptable references, review of criminal history, licensure/certification verification, and fingerprint records check as required for the position.
Failure to Obtain Informed Consent Before Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed of the benefits, risks, and alternatives before psychotropic medication was started. R42 was admitted with diagnoses including depression, dementia, and anxiety disorder, and the admission MDS showed the resident was unable to complete a BIMS and was assessed as severely cognitively impaired. The MDS also indicated the resident received antianxiety medications. Review of the MAR and physician orders showed R42 received lorazepam 0.5 mg every eight hours as needed for anxiety, with the order originating on 01/16/26. The medical record contained no documentation that the resident or the resident's representative was provided information in advance about the medication's risks and benefits, treatment alternatives, or other options, and no documentation of consent or refusal was found. During interview, the DON stated psychotropic medications require informed consent prior to administration, including upon admission, and that nursing staff are responsible for obtaining consent, but was unable to provide documentation of consent prior to lorazepam administration.
Failure to Provide Transfer, Discharge, and Bed-Hold Notifications
Penalty
Summary
The facility failed to convey information to the hospital at the time of transfer, failed to notify the resident and resident representative in writing of the reason for the transfer/discharge to the hospital, and failed to notify the resident or resident representative of the facility bed-hold policy including reserve bed payment for one of three residents reviewed for hospitalization, identified as R7. R7 was admitted to the facility with diagnoses including diastolic congestive heart failure, atrial fibrillation, presence of a cardiac pacemaker, and anxiety disorder, and the annual MDS dated 02/17/26 coded R7 with a BIMS score of 4 out of 15, indicating severe cognitive impairment. Review of the medical record showed that R7 was sent to the hospital for respiratory distress on 02/09/26. The record contained no documented evidence that the facility communicated information to the receiving hospital at the time of transfer, provided written notice to R7 or the resident representative explaining the reason for the transfer/discharge, or notified them of the facility's bed-hold policy including reserve bed payment. During interview, the DON stated that written notification of transfer to the hospital, written notification of the reason for transfer, and bed-hold policy notification were not issued when R7 was emergently transferred to the hospital. The facility's Transfer or Discharge policy required documentation in the medical record and communication to the receiving provider, including the basis for transfer or discharge and notice to the resident and/or legal representative, but the policy did not specify information regarding bed-hold policy notification.
Incomplete transfer documentation and MDS completion
Penalty
Summary
The facility failed to ensure the Discharge Return Anticipated MDS was completed for one resident who was hospitalized. Record review showed no evidence of a documented transfer notification, eInteract transfer, or bed hold on 02/09/26. The discharge MDS was marked out in error and not completed on 02/09/26, and the entry MDS was also marked out in error and not completed on 02/10/26. During interview, the DON stated she was unable to locate the transfer notice to the hospital, the transfer notification to the resident or resident representative, or the bed hold notice, and confirmed the discharge return anticipated MDS should have been completed.
MDS Incorrectly Coded Discontinued Antipsychotic Medication
Penalty
Summary
The facility failed to ensure the comprehensive assessment accurately reflected a discontinued antipsychotic medication for one resident, R22, who was reviewed for unnecessary medications. R22 was admitted with diagnoses of Alzheimer's disease and dementia with behavioral disturbance. Review of the record showed that quetiapine 25 mg daily was discontinued on 03/05/26, with the last dose administered on 03/04/26, and the care plan also reflected that the Seroquel antipsychotic medication had been discontinued starting 03/05/26. Despite this, R22's annual MDS with an ARD of 03/12/26 indicated that the resident received antipsychotics. During interview, the MDS Coordinator confirmed the MDS has a seven-day look-back period and stated the antipsychotic should not have been coded for R22 because the medication had been discontinued 8 days earlier. The facility policy stated that comprehensive assessments are conducted in accordance with criteria and timeframes established in the RAI User Manual.
Oxygen Provided Without Order and Supplies Not Properly Labeled
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who was admitted with a diagnosis of pneumonitis due to inhalation of food and vomit. Review of the electronic medical record showed the resident was not care planned for oxygen, and progress notes documented oxygen administration on multiple occasions before a physician's order for oxygen was present in the record. The order summary showed no physician's order for oxygen as of the review date, and the medication administration record did not contain an oxygen order until later in the survey process. During observations, the resident was found in the room with an oxygen concentrator running through nasal cannula at 5 liters per minute, and later at 7 liters per minute. Humidification was present with no date, the oxygen tubing was not dated, and no storage bag was present. On one observation, no oxygen sign was posted outside the resident's door. The resident stated she was on oxygen because without it her oxygen level bottoms out. RN2 and the DON both observed the resident receiving oxygen and confirmed that the humidification and tubing were not dated, that a storage bag should be present for infection control purposes, and that an oxygen sign should be outside the door. RN2 also confirmed there was no physician's order for oxygen in the EMR at the time of review. RN3 stated she relied on verbal information from hospice about the oxygen flow rate rather than the physician's order, and the ADON confirmed there was no oxygen order in the hospital discharge paperwork and that the EMR did not contain a signed order until later.
Personal Refrigerators Not Monitored for Temperature or Spoiled Food
Penalty
Summary
The facility failed to ensure that personal resident refrigerators were maintained to prevent potential food borne illness for two residents who had refrigerators in their rooms. R33, who had severe cognitive impairment with a BIMS score of 3 and a diagnosis of high blood pressure, had a personal refrigerator near the door in the room. During observation, the refrigerator temperature log had no recorded temperatures for two days, and the thermometer inside the refrigerator read 46 degrees Fahrenheit. Inside the refrigerator was a melamine cup containing peaches with thick yellow, white, and black fuzzy material that appeared to be mold, and the lid on the cup was not dated. R50, who had a BIMS score of 13 and diagnoses including coronary artery disease, high blood pressure, diabetes, anxiety disorder, depression, and asthma, also had a personal refrigerator near the door in the room. The refrigerator temperature log had no recorded temperatures on multiple days. Staff interviews confirmed that the peaches in R33's refrigerator had mold and needed to be discarded. The Administrator stated that residents' personal refrigerators were to be checked daily during rounds by assigned staff, including temperature checks and removal of outdated or spoiled food, and the facility policy required personal refrigerators to maintain temperatures at or below 41 degrees Fahrenheit with daily monitoring and removal of expired, spoiled, or improperly stored items.
Deficiencies in Resident Dignity During Mealtime and Medical Procedures
Penalty
Summary
The facility failed to uphold the dignity of a resident during mealtime. A resident with severe cognitive impairment and malnutrition was observed sitting off to the side of the dining room, watching other residents eat for over 30 minutes due to insufficient dining table space and staff availability. Despite the resident's attempts to gain attention, they were not provided a meal until a staffing coordinator arrived and assisted them. Interviews with staff revealed that this was a common occurrence due to a lack of staff and space, resulting in residents having to wait for assistance with meals. Another deficiency was noted during the medication administration process for a resident with diabetes mellitus. The resident's blood glucose testing was conducted in a public area, the therapy gym, rather than in a private setting. This was done in the presence of other residents and staff, compromising the resident's privacy and dignity. Staff interviews confirmed that blood glucose testing should be conducted in the resident's room to maintain privacy, and performing such procedures in public areas was against the facility's policy. The Director of Nursing and the Administrator both expressed that residents should be treated with dignity at all times, including during dining and medical procedures. However, the observations and staff interviews indicated that the facility's practices did not align with these expectations, leading to the noted deficiencies in resident care and dignity.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with accepted professional standards during a medication administration for a resident with hypertension, atrial fibrillation, and heart disease. The resident, identified as having moderate cognitive impairment, was observed during a medication pass where the RN withheld physician-ordered medications without consulting the physician. The medications withheld were amlodipine besylate-valsartan and Cardizem, both prescribed for the resident's conditions, and there were no parameters in the orders for withholding these medications. The RN decided to hold the medications based on the resident's blood pressure reading of 107/61 and a pulse of 48 beats per minute, documenting the action on the Medication Administration Record (MAR) with a code indicating vital signs outside of parameter. However, the RN did not notify the physician of the decision to withhold the medications or obtain orders for parameters for withholding them. Interviews with other nursing staff revealed that they would typically contact the physician if there were no parameters for withholding medication, but the RN in question did not follow this protocol. The Director of Nursing (DON) and the Medical Director both expressed expectations that nurses should notify physicians when withholding medications and obtain parameters for future reference. The facility's policies did not specify blood pressure parameters for withholding medications, leading to inconsistencies in nursing judgment. The DON acknowledged that every nurse might have a different idea of what constitutes low blood pressure, highlighting a lack of standardized guidelines within the facility.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12.9% error rate during a medication administration observation. This deficiency involved two residents, R55 and R29, out of three observed. For R55, the Registered Nurse (RN) held two medications, amlodipine besylate-valsartan and Cardizem, without physician orders or parameters for withholding. The RN based her decision on the resident's blood pressure and pulse readings, but did not notify the physician or document the withholding of medications, leading to two medication errors. R55 had a medical history of essential hypertension, atrial fibrillation, and heart disease, with moderate cognitive impairment. The resident's care plan required antihypertensive medications to be administered as ordered and monitored for effectiveness. However, the RN held the medications due to low blood pressure and pulse, without consulting the physician, which was against the facility's policy and expectations. For R29, the RN failed to measure polyethylene glycol accurately and omitted a cholecalciferol tablet during medication administration. R29 had a history of anxiety and cognitive communication deficit, with intact cognition and required total assistance with activities of daily living. The omission of the cholecalciferol tablet was due to the medication being out of stock, which was not addressed prior to the medication pass. These actions contributed to the facility's medication error rate exceeding the acceptable threshold.
Medication Labeling Error During Administration
Penalty
Summary
The facility failed to ensure medications were accurately labeled for a resident during medication administration. The resident, who had a medical history of essential hypertension, atrial fibrillation, and heart disease, was observed during a medication pass. The registered nurse (RN) checked the resident's blood pressure and pulse, which were 107/61 and 48 beats per minute, respectively. Due to the low blood pressure reading, the RN decided to hold the administration of amlodipine besylate-valsartan and Cardizem extended-release. However, the RN encountered difficulty identifying the medications because the descriptions on the pharmacy packets did not match the actual medications inside. The RN attempted to remove the specific medications from the cup but had to refer to a strip of the next day's medications to identify the Cardizem, as the pharmacy descriptions were outdated. The RN noted that manufacturers sometimes changed the appearance of medications, and the pharmacy did not update the packets accordingly, making it challenging for nurses to verify medications without additional resources. The RN ultimately removed and destroyed the two medications due to the labeling issue. The Director of Nursing (DON) and the pharmacist confirmed the discrepancy in medication labeling. The pharmacist identified that the amlodipine besylate-valsartan had an incorrect description on the packet, which was a pharmacy error that should have been caught in their quality assurance process. The pharmacist acknowledged the need for a process change to prevent such errors in the future. The DON and the facility administrator expressed their expectations for nurses to follow the medication administration policy and regulations.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, as observed with one of the medication carts. A registered nurse was seen attempting to remove medications from a medication cup using an ungloved fingernail for a resident, which is against the facility's infection control policy. Additionally, the nurse had an open personal beverage on the medication cart and did not replace an overflowing sharps container, which was acknowledged but not addressed over several days. Another incident involved the same nurse performing a blood glucose test for a resident without disinfecting the bedside table or placing a barrier before placing the glucometer on it. This action was contrary to infection control protocols, as the glucometer was placed directly on an unclean surface. The nurse did disinfect the glucometer after returning to the medication cart, but the initial lapse in protocol posed a risk of contamination. The facility's policy on infection prevention and control emphasizes the importance of educating staff and ensuring adherence to proper techniques. However, interviews with other nursing staff revealed that the observed nurse did not follow the expected procedures, such as wearing gloves or using a medicine spoon to remove medications from a cup. The Director of Nursing and the Administrator both expressed expectations for adherence to infection control practices, but the observed deficiencies indicate a failure to meet these standards.
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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 Evans
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Evans, Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Harrington Park Health And Rehabilitation | 3 mi | ★★★★★ | 8 | 0 |
| Harborview Health Center Of Augusta | 3.1 mi | ★★★★★ | 0 | 0 |
| Place At Martinez, The | 3.1 mi | ★★★★★ | 17 | 0 |
| Pruitthealth - Richmond, Llc | 3.4 mi | ★★★★★ | 1 | 0 |
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