Below average — CMS composite of the measures below.
The next survey window likely opens 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 Presbyterian Village - Athens during CMS and state inspections, most recent first.
A resident with a history of sacral fracture and cognitive impairment experienced unmanaged pain during a podiatry procedure. Despite vocal expressions of pain, the podiatrist continued without assessing or administering pain relief, contrary to the care plan. The resident was not given prescribed pain medication before or after the procedure, highlighting a failure in pain management by the facility.
The facility failed to follow care plans for three residents by not properly documenting meal intake and snacks. Residents with conditions such as dementia and Alzheimer's had care plans requiring meal monitoring, but records showed missing documentation for meal intake percentages and snacks over several days. Interviews revealed that CNAs were responsible for documentation, and missing data might be due to agency CNAs unfamiliar with the electronic system.
A resident with moderate cognitive impairment experienced a lack of dignity during a podiatry procedure conducted in a common area. The resident, who has a history of various medical conditions, was in pain during the procedure, which involved toenail cutting and hematoma debridement. The DON intervened and instructed the podiatrist to move the procedure to the resident's room, highlighting a failure to adhere to the facility's policy on resident dignity.
A resident reported being handled roughly by a CNA during a bed transfer, resulting in rib soreness. Despite the facility's policy requiring a thorough investigation, only a statement from the alleged CNA was documented, with no additional witness statements or interview notes. The DON confirmed the lack of comprehensive documentation, indicating an incomplete investigation process.
A facility failed to provide a resident or their representative with written notification of the bed-hold policy upon hospital transfer. The resident, with severe cognitive impairment and multiple health issues, was transferred due to a possible stroke. Interviews revealed confusion among staff about the responsibility for communicating the policy, resulting in no signed documentation of notification.
A facility failed to follow physician orders to offer snacks between meals to a resident with Alzheimer's and other conditions, resulting in inconsistent snack provision. Despite the availability of snacks, staff interviews revealed gaps in distribution, particularly when the Activity Director was absent, and reliance on families during weekends. This led to inadequate nutritional intake and significant weight loss for the resident.
The facility was found to have a medication error rate of eight percent, exceeding the acceptable threshold. Errors included an LPN failing to check vital signs before administering Metoprolol to a resident with hypertension and not administering Polyethylene Glycol to another resident as ordered. The LPN attributed these errors to nervousness during the survey, and the DON confirmed the expectation for medications to be administered as ordered.
An LPN in an LTC facility failed to perform hand hygiene during medication administration for three residents, as observed by a surveyor. Despite claiming to use hand sanitizer, the LPN did not wash hands or use antibacterial hand rub before or after handling medications. The DON acknowledged the expectation for staff to perform hand hygiene and noted the LPN's inexperience and nervousness during the survey.
A resident at the facility was administered an incorrect dosage of lamotrigine for 13 days, leading to a grand mal seizure. The pharmacy dispensed 25 mg tablets instead of the prescribed 250 mg ER tablets. The error was not identified until after the seizure, despite internal audit tools being in place. Interviews revealed lapses in the medication dispensing process and failure to provide audit reports to the survey team.
A resident experienced a grand mal seizure due to a significant medication error at an LTC facility. The resident was prescribed lamotrigine 250 mg ER daily but received only 25 mg for 13 days due to a pharmacy dispensing error. Nursing staff failed to verify the medication against the MAR and bubble pack, leading to the error. Interviews revealed inadequate education and oversight on medication administration.
The facility failed to ensure the dietary department had a certified dietary manager or equivalent, affecting all residents receiving meals. The Dietary Manager lacked certification and had been in the role since April, with plans to enroll in a certification course. The Executive Director was aware of the situation, and the Director of Dining Services was working towards certification.
The facility failed to develop comprehensive care plans for several residents, including those with cognitive impairments and complex medical needs, due to issues with transitioning to a new EMR system. This resulted in missing care plans for critical areas such as pressure ulcer risk, psychotropic drug use, and hospice care, leaving staff without access to essential resident information.
The facility did not comply with its Abuse/Neglect Prevention Program by hiring a Dietary Manager before completing a required criminal background check. The program requires thorough investigation histories and criminal background checks prior to hiring. The Dietary Manager was hired before the Georgia Criminal History Check System (GCHEXS) background screening was received. The Director of Human Resources acknowledged that some employees were hired based on local background screenings before receiving the GCHEXS results.
The facility failed to provide a resident or their representative with written notice of the bed-hold policy upon hospital transfer. The resident, with multiple health conditions, was transferred without receiving information about the bed-hold process. The Social Services Director was unsure of the responsibility for issuing the Bed Hold Letter, and no system was in place to ensure compliance.
Two residents in an LTC facility did not receive necessary assistance with ADL care, specifically facial hair removal. One resident, who was cognitively intact, expressed a desire for help with shaving but was not assisted by staff. Another resident with severe cognitive impairment was observed with facial hair, and staff failed to inquire about or provide assistance with its removal. The DON confirmed that both residents should have received this care on their designated shower days.
Failure in Pain Management During Podiatry Procedure
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R4, during a podiatry procedure. R4, who has a history of a non-displaced fracture of the sacrum, hypertension, mild dementia, anxiety, and depression, was observed yelling in pain while Podiatrist GG performed care in a common area. Despite R4's vocal expressions of pain, the podiatrist continued the procedure without stopping to assess the resident's pain level or administering any pain relief. The care plan for R4 included administering analgesia before treatments when possible, but there was no evidence that pain medication was given before or after the procedure. Interviews with staff revealed that R4 was not provided with pain medication before or after the podiatry care, despite having a physician's order for hydrocodone-acetaminophen for pain management. The Director of Nursing (DON) stated that staff should assess and provide medication for pain if there is an order, and if not, they should contact the physician for an order. The deficiency was identified as actual harm, as the resident experienced unmanaged pain during the procedure, and the facility did not adhere to the care plan or professional standards of practice.
Failure to Document Meal Intake and Snacks for Residents
Penalty
Summary
The facility failed to follow the care plans for three residents regarding the monitoring and recording of meal intake. Resident 1, who was admitted with diagnoses including dementia and major depressive disorder, had a care plan that required monitoring and recording meal intake and providing snacks between meals. However, there were gaps in documentation for meal intake percentages and snacks given over several days in August and September 2024. Resident 2, diagnosed with Alzheimer's disease and severe cognitive impairment, also had a care plan that required monitoring meal intake and providing snacks. Similar to Resident 1, there were missing records for meal intake percentages and snacks given on multiple days in August and September 2024. The care plan for Resident 3, who had a history of cerebral vascular accident and Alzheimer's disease, required similar monitoring and documentation, but there were also missing records for meal intake and snacks on various days. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that Certified Nursing Assistants (CNAs) were responsible for documenting meal intake percentages. The ADON suggested that missing data might be due to agency CNAs not knowing how to use the electronic system. The DON confirmed that CNAs were expected to document meal intake after each meal, and it was her expectation that all staff follow each resident's care plan.
Resident Dignity Compromised During Podiatry Procedure
Penalty
Summary
The facility failed to ensure that a podiatrist provided care in a dignified manner for a resident during a foot care procedure. The incident involved a resident with a history of non-displaced sacrum fracture, hypertension, mild dementia, anxiety, and depression, who had a moderate cognitive impairment as indicated by a BIMS score of 11 out of 15. The podiatrist performed the procedure, which included cutting toenails and debriding a subungual hematoma, in a common area where other residents were present. During the procedure, the resident was observed yelling out in pain, and the podiatrist continued despite the resident's distress. The Director of Nursing (DON) intervened after noticing the resident's discomfort and instructed the podiatrist to move the procedure to the resident's room. The DON later stated that the podiatrist typically sees residents in a clinic or their rooms, and she was unsure why the procedure was conducted in the common area. The facility's policy on resident rights emphasizes the importance of treating residents with dignity and respect, which was not upheld in this instance. Attempts to contact the podiatrist for further clarification were unsuccessful.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation of an abuse allegation involving a resident, identified as R13, who reported being handled roughly by a Certified Nursing Assistant (CNA) during a transfer to bed. The resident, who had a BIMS score indicating no cognitive impairment, reported soreness in her ribs following the incident and expressed a desire not to be assisted by the same CNA again. The facility's policy requires immediate initiation of an investigation upon receipt of any report of abuse, which should include determining the nature, cause, and extent of the reported abuse, as well as an assessment of the resident's current condition and needed actions. However, the investigation conducted by the facility was incomplete, as evidenced by the lack of written statements or interview notes from other staff members or residents involved in the incident, except for a statement from the alleged perpetrator, CNA EE. The Director of Nursing (DON) confirmed the absence of these documents, indicating that the investigation did not fully comply with the facility's policy. This deficiency highlights a failure in the facility's process to adequately address and document allegations of abuse, potentially compromising resident safety and trust.
Failure to Notify Resident of Bed-Hold Policy
Penalty
Summary
The facility failed to provide evidence that notice of the bed-hold policy and return was given to a resident or the resident's representative upon transfer to the hospital. This deficiency was identified for one of the three sampled residents, who was transferred to the hospital following an emergent medical situation. The resident, who had a history of hemiplegia, hemiparesis, mixed receptive-expressive language disorders, hypertension, dementia, and depression, exhibited symptoms of a possible stroke, prompting the transfer. Despite the transfer, there was no documentation in the electronic medical record indicating that the resident or their representative received written notification of the facility's bed-hold policy. Interviews with facility staff revealed a lack of clarity and responsibility regarding the communication of the bed-hold policy. The Social Services Director admitted that the bed-hold notification process was new and that the Bed-Hold Letter was included in the hospital transfer packet but not necessarily communicated directly to the resident or their representative. Furthermore, the Director of Nursing confirmed that it was the Social Services Director's responsibility to ensure the completion and signing of the Bed-Hold Letters, which was not done in this case. The absence of signed Bed-Hold Letters indicated a failure in the facility's process to ensure residents or their representatives were informed of the bed-hold policy upon hospital transfer.
Failure to Provide Snacks as Ordered
Penalty
Summary
The facility failed to adhere to the physician's orders to offer snacks between meals to a resident diagnosed with Alzheimer's disease, dementia, major depressive disorder, GERD, and chronic pain syndrome. The resident, who was unable to complete a mental status assessment, had an active order from late August 2024 to receive snacks between meals. Despite this order, documentation revealed inconsistent snack offerings, with several days showing no record of snacks being provided. The resident's nutritional intake was poor, with only 25-50% of meals consumed, leading to a 12% weight loss over 180 days. Interviews with facility staff highlighted a lack of consistent snack distribution. The Dietary Manager confirmed the availability of various snacks, but the Assistant Director of Nursing noted that the Activity Director, responsible for afternoon snacks, was absent on certain days, resulting in no snacks being offered. Additionally, on weekends, the responsibility for providing snacks fell to families. Certified Nursing Assistants stated they offered snacks when the Activity Director was unavailable, but many residents declined them, having received snacks from their families. This inconsistency in snack provision contributed to the facility's failure to meet the resident's nutritional needs as per the physician's orders.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in an observed error rate of eight percent. This deficiency was identified through observations, record reviews, and staff interviews. Specifically, two medication errors were noted among six residents. For one resident, the LPN administered Metoprolol without checking the resident's blood pressure and pulse as required by the physician's order. The resident had a history of hypertension, and the failure to check vital signs before administering the medication was acknowledged by the LPN, who attributed the oversight to nervousness during the survey. Another error involved a resident with chronic diastolic heart failure and hypertension, where the LPN failed to administer Polyethylene Glycol as ordered. The LPN did not retrieve the medication from the cart, measure the prescribed dosage, or mix it with water as required. The LPN admitted to noticing the absence of the medication in the cart and intended to administer it later, but this was not communicated to the surveyor. The Director of Nursing confirmed that the expectation is for medications to be administered as ordered by the physician, noting that the LPN was new and nervous during the survey.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed with one of two nurses. The Licensed Practical Nurse (LPN) did not perform hand hygiene before or after administering medications to three residents. During the morning medication pass, the LPN was observed preparing and administering medications without washing hands or using antibacterial hand rub (ABHR) for each resident. This was noted for three residents, where the LPN handled medication Kardex, prepared medications, and entered and exited residents' rooms without performing hand hygiene. The LPN was questioned about her hand hygiene practices and claimed to use hand sanitizer after each medication administration, although this was not observed by the surveyor. The Director of Nursing (DON) confirmed that staff are expected to perform hand hygiene before and after resident care. The DON noted that the LPN was new and nervous during the survey, which may have contributed to the oversight in infection control practices.
Medication Dosage Error Leads to Seizure
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the correct dosage of medication was dispensed to a resident, identified as R77, who was prescribed lamotrigine for seizures. The error occurred when the pharmacy dispensed 25 mg tablets instead of the prescribed 250 mg extended-release tablets. This incorrect dosage was administered for 13 days before the error was recognized, leading to a grand mal seizure experienced by the resident on 7/15/2024. The facility's policy, titled Pharmacy Policy & Procedure Guide for Care Centers, outlines the joint responsibility of the nursing center and the pharmacy to ensure accurate medication administration. However, the checks and balances intended to prevent such errors were not followed. The Pharmacy Director admitted that the previous Pharmacy Director was responsible for inputting, filling, and packaging the medication orders, which contributed to the oversight. The error was not identified until after the resident experienced a seizure, despite the presence of internal audit tools like medication cart audits and medication pass observations. Interviews with facility staff, including the Director of Nursing and the Director of Health Services, confirmed the medication error and the subsequent seizure. The Pharmacy Director and the previous Pharmacy Director both acknowledged the lapse in the medication dispensing process. Despite the availability of internal audit tools, the facility did not provide the survey team with the medication cart audit, resident medication audit, or medication pass observation reports, which could have potentially highlighted the error earlier.
Medication Error Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident, identified as R77, was free from significant medication errors, resulting in actual harm. R77 was prescribed lamotrigine 250 mg extended release daily to manage seizures. However, due to a pharmacy dispensing error, the resident was administered only 25 mg per day for 13 days. This subtherapeutic dose led to R77 experiencing a grand mal seizure, which was documented in a Nursing Alert Note. The error was discovered after the seizure occurred, when the Director of Nursing and other staff members reviewed the hospital discharge orders and the resident's electronic medical record, confirming the correct prescription was for 250 mg. The pharmacy had dispensed the incorrect dosage, and the nursing staff failed to verify the medication against the Medication Administration Record (MAR) and the bubble pack, as per the facility's policy. Interviews with staff, including the Director of Nursing and Registered Nurse DD, revealed that the five rights of medication administration were not followed, contributing to the error. Further interviews with nursing staff indicated a lack of consistent education and oversight regarding medication administration. Licensed Practical Nurse FF stated she had not received any education on medication administration, and no one had observed her medication pass. Similarly, LPN EE admitted to not checking the bubble pack with the MAR when administering medications to R77. The facility's policy on medication management was not adequately implemented, as evidenced by the lack of adherence to established procedures and guidelines.
Deficiency in Dietary Department Staffing
Penalty
Summary
The facility failed to ensure that the dietary department had a designated staff member as the director of food and nutrition services who was a certified dietary or food service manager, or had a similar food service management degree. This deficiency was identified through a review of records, the Certifying Board of Dietary Managers, and interviews. The review of the employee file for the Dietary Manager (DM) revealed that the individual was hired on January 29, 2021, but did not possess any certification or educational degree in culinary arts or food service management. This lack of certification or qualification had the potential to affect all 25 residents who received meals at the facility. During an interview conducted on July 22, 2024, the DM admitted to not having the required certification but mentioned plans to enroll in a course to become certified. The DM had been in the position since April 2024, and the Registered Dietitian was only present at the facility once a week. The Executive Director acknowledged awareness of the DM's lack of certification and stated that the DM was not required to be certified at that time according to the Certified Board for Dietary Managers. Additionally, the Director of Dining Services was in the process of obtaining the CDM certification but had not yet completed the coursework.
Incomplete Care Plans Due to EMR Transition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for five residents, leading to unmet care needs. Resident 5, who was admitted with multiple diagnoses including neuropathic bladder and depression, did not have a care plan addressing pressure ulcer risk, psychotropic drug use, functional abilities, or urinary incontinence. Despite being on medication for depression, these critical areas were not included in the care plan, indicating a significant oversight in addressing the resident's comprehensive needs. Resident 15, with severe cognitive impairment and multiple health issues such as COPD and heart failure, also lacked a care plan for cognitive loss, communication, functional abilities, urinary incontinence, and pressure ulcer risk. This omission highlights a failure to address the resident's complex medical and cognitive conditions adequately. Similarly, Resident 19, who was on multiple medications and receiving hospice care, did not have a care plan covering anticoagulant use, pain management, psychotropic drug use, or hospice care, among other needs. The transition to a new electronic medical record (EMR) system contributed to these deficiencies, as care plans were not properly migrated, leaving staff without access to essential resident information. Interviews with staff, including the MDS Coordinator and the Assistant Director of Nursing, revealed confusion and lack of access to previous care plans, further exacerbating the issue. Resident 20 and Resident 12 also suffered from incomplete care plans, with missing focus areas on psychotropic drug use, functional abilities, and cognitive conditions, underscoring systemic issues in care plan management during the EMR transition.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its Abuse/Neglect Prevention Program by not ensuring that a criminal background check was completed prior to hiring a Dietary Manager. The program, dated 9/29/2023, mandates an aggressive abuse prevention strategy, including thorough investigation histories and criminal background checks for potential hires. However, the Dietary Manager was hired on 1/28/2021, but the Georgia Criminal History Check System (GCHEXS) background screening was not received until 5/18/2021. During an interview, the Director of Human Resources confirmed that some employees were hired before receiving their GCHEXS background screening, relying instead on a local background screening.
Failure to Provide Bed-Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed-hold policy to a resident or the resident's representative upon transfer to the hospital. This deficiency was identified during a review of records and interviews, where it was found that the facility did not ensure that the resident or their representative was informed about the bed-hold process. Specifically, for one resident who was transferred to the hospital, there was no evidence in the medical record that the resident or their representative received information regarding the facility's bed-hold policy. The resident in question had been admitted to the facility with multiple diagnoses, including intracranial hemorrhage, hypertension, Alzheimer's disease, metabolic encephalopathy, and stage 3 chronic kidney disease. The resident was transferred to the hospital with an anticipated return, yet the facility did not provide the necessary bed-hold information. Interviews revealed that the Social Services Director was unsure who was responsible for preparing and sending the Bed Hold Letter, and there was no log or system in place to ensure compliance with this requirement.
Failure to Assist Residents with ADL Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, R5 and R15, who were dependent on staff for care. R5, who was cognitively intact, expressed a desire to have facial hair removed but was not assisted by staff despite multiple observations over several days. The Certified Nursing Assistant (CNA) responsible for R5's care did not notice the facial hair and stated that shaving was typically done on shower days. The Director of Nursing (DON) confirmed that R5's facial hair should have been trimmed on her designated shower day. Similarly, R15, who had severe cognitive impairment, was observed with facial hair and expressed a need for it to be removed. The CNA assigned to R15 initially stated she had not tended to the resident and later claimed she had checked on her but did not inquire about facial hair removal. The DON confirmed that R15's facial hair should have been addressed on her shower days. These observations and interviews indicate a failure to provide necessary ADL care for these residents.
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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 Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| University Nursing & Rehab Ctr | 0.6 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Athens Heritage | 1.4 mi | ★★★★★ | 6 | 0 |
| Pruitthealth - Grandview | 2.4 mi | ★★★★★ | 4 | 0 |
| Oaks - Athens Skilled Nursing, The | 2.9 mi | ★★★★★ | 4 | 0 |
| High Shoals Health And Rehabilitation | 8.3 mi | ★★★★★ | 0 | 0 |
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