Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Healthcare during CMS and state inspections, most recent first.
A resident with intact cognition and known skin integrity risks reported being left on a bedpan for an extended period and not being adequately cleaned by a CNA. The following shift, another CNA found the resident on soiled linens with a blister on the left upper thigh but did not report this new skin issue to the charge nurse or DON. Subsequent documentation showed development of an open area on the thigh associated with pain, and later NP evaluation identified a larger wound requiring sharp excisional debridement. These events show failure to provide adequate incontinent care and to promptly assess and report a new wound, contrary to the facility’s abuse/neglect prevention policy and CNA responsibilities.
A cognitively intact resident with skin-related diagnoses reported delayed and inadequate incontinent care after using a bedpan, describing prolonged waits for staff response and feeling not properly cleaned by a CNA. The next morning, another CNA found feces-soiled linen and a blister on the resident’s left upper thigh, later documented as a new open area. The resident texted the Administrator stating that a CNA had left feces on her and that she had developed a painful blister, but the Administrator did not report this allegation of neglect to the State Survey Agency as required by facility policy.
A resident with lymphedema and identified risk for pressure ulcers developed a new open wound on the upper thigh, documented by a NP with specific wound measurements. Although the existing care plan included interventions to observe and document skin changes, the care plan was not updated to include this new wound. The Wound Care Nurse and the resident confirmed the wound location, while the MDS Coordinator reported not receiving recent weekly wound reports and only recently learning of the wound. The MDS Coordinator confirmed that the care plan had not been revised in real time as required by facility procedures, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
The facility did not complete a required Georgia Criminal History Check System (GCHEXS) fingerprint background check for a CNA, as identified during review of ten employee files with a census of eighty residents. The facility’s abuse-prevention policy required criminal background checks for all employment candidates, but there was no documentation of a fingerprint records check for this CNA. The HR manager, who is responsible for background and fingerprint checks and maintaining employee files, confirmed that the GCHEXS fingerprint check had not been conducted, resulting in a deficiency under F-Tag 600.
The facility did not have an infection prevention and control program in place, as observed by surveyors. This deficiency reflects the absence of systematic infection control measures for residents and staff.
Three residents did not have completed documentation for consent, declination, or education regarding pneumococcal and influenza vaccinations, despite facility policy requiring this information. The DON confirmed that while vaccine administration was recorded, there was no additional documentation for consent or education in the medical records.
A resident with a suprapubic catheter was observed multiple times with an uncovered urinary catheter bag visible from the hallway. Staff, including an LPN and CNA, confirmed the bag was not covered and acknowledged it should have been for privacy and dignity. The DON stated that catheter bags are expected to be covered at all times except when being emptied, and agreed that not covering the bag was a dignity issue.
Expired medications, including melatonin and aspirin, as well as expired medical supplies such as oxygen masks and tubing, were found on a medication cart and in a medication room. Multiple staff, including LPNs and the DON, confirmed that these items should have been removed according to facility policy, but they remained accessible, indicating a failure to follow proper medication and supply management procedures.
A resident with severe cognitive impairment and significant care needs was found to be living in a room with a persistent sewage odor in the bathroom. The odor, reported by the resident's representative and confirmed by staff and maintenance, was attributed to infrequent use of the bathroom fixtures, leading to a dry P-trap and resulting in an unpleasant environment.
Neglect of Incontinent Care and Delayed Wound Reporting Leading to Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect and to assess and provide timely wound and incontinent care to a cognitively intact resident with known skin integrity risks. The resident, who had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema, was care planned as being at risk for pressure ulcer development and skin integrity issues, with interventions directing staff to observe, document, and report any changes in skin status. On a night shift, the resident reported being left on a bedpan for approximately an hour and a half. When the CNA on that shift (CNA BB) assisted with post-toileting care, the resident told her she did not feel adequately cleaned; CNA BB did not recheck or further clean the resident and left the room. The next morning, the resident reported burning in the left upper thigh and informed another CNA (CNA EE) that she had not been cleaned well. During morning care, CNA EE found the pad under the resident soiled with feces and wet with urine and observed a blister on the resident’s left upper thigh, but did not report the new blister to the charge nurse or DON. A subsequent Skin Wound Note documented a new open area on the left posterior thigh with the resident reporting pain while sitting on the bedpan. Later, an NP wound care consult documented that the thigh wound had been present for approximately two weeks per nursing report and measured 3.5 cm x 4.0 cm x 0.2 cm, requiring sharp excisional debridement to remove necrotic tissue and decrease bacterial burden. On observation by the surveyor with the Wound Care Nurse, the left upper thigh area was open to air, shiny pink and granular, about the size of a half dollar. These findings demonstrate that the facility did not follow its abuse/neglect prevention policy and CNA job responsibilities to provide necessary care and to report changes in condition, resulting in neglect of incontinent care and delayed wound assessment and treatment for this resident.
Failure to Report Allegation of Neglect to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the State Survey Agency (SSA) as required by its own abuse and neglect reporting policy. The facility’s policy, dated 1/2025, states that any complaint, allegation, observation, or suspicion of resident neglect must be immediately communicated to the Abuse Coordinator and promptly investigated and documented, and that all alleged violations involving mistreatment, abuse, or neglect will be thoroughly investigated under the direction of the Administrator in accordance with state and federal law. Despite this, the Administrator acknowledged that an allegation of neglect reported by a resident was not reported to the SSA. The resident involved was cognitively intact, with a BIMS score of 15, and had diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. The resident reported that during a night shift she requested assistance for incontinent care after using a bedpan and experienced multiple delays before a CNA assisted her. She stated that when the CNA finally provided care, she did not feel adequately cleaned, and the CNA did not verify cleanliness before leaving. The next morning, another CNA found soiled linen with feces and a blister on the resident’s left upper thigh, which the resident reported as burning. A subsequent skin/wound note documented a new open area on the left posterior thigh. The resident texted the Administrator describing that a CNA had left feces on her and that she had developed a painful blister. The Administrator confirmed receiving this text but did not report the allegation of neglect to the SSA, despite being aware it should have been reported.
Failure to Update and Implement Care Plan for Newly Developed Pressure Ulcer
Penalty
Summary
Surveyors identified a failure to implement and update the care plan for a newly developed pressure ulcer for one resident. The facility’s policy "RAI Care Planning Management" requires a comprehensive, accurate assessment and real-time modification of the care plan when changes occur. The resident was admitted with diagnoses including a disorder of the skin and subcutaneous tissue and lymphedema. A recent MDS quarterly assessment showed the resident was cognitively intact (BIMS 15), at risk for pressure ulcer development, and had no unhealed pressure ulcers at that time. The existing care plan, dated 6/6/2024, identified potential for pressure ulcer development and skin integrity issues related to immobility and lymphedema, with interventions to observe, document, and report changes in skin status, including wound size, stage, and signs of infection. Subsequently, a NP wound report documented a new open wound on the resident’s thigh that had been present for approximately two weeks, with specific measurements recorded. During observation and interview, the Wound Care Nurse and the resident confirmed the wound was on the left upper thigh, which differed from the NP report that referenced the right thigh. The MDS Coordinator reported she previously received weekly wound sheets from the Wound Care Nurse but had not received one in about a month, and that the DON was now responsible for emailing the weekly wound report. She verified that the last wound report she received did not include this resident and stated that new wounds should be discussed in the morning management meeting and the care plan updated in real time. The MDS Coordinator confirmed she only recently became aware of the upper left thigh wound and that the resident’s care plan had not been updated to reflect this new wound, resulting in a failure to implement care plan interventions for the newly developed pressure ulcer.
Failure to Complete Required GCHEXS Fingerprint Check for CNA
Penalty
Summary
The facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) fingerprint check was conducted for one CNA among ten employee files reviewed, despite a census of eighty residents and a written policy requiring criminal background checks for all employment candidates. The policy titled "Freedom of Abuse Abuse Prevention Fast Alert" dated 1/2025 states that, as part of pre-employment screening, all candidates must authorize a criminal background check for conviction of crimes. During record review with the Human Resources Manager (HRM), there was no documentation of a fingerprint records check for CNA BB, and the HRM confirmed that this CNA did not have a GCHEXS fingerprint check conducted. The HRM also stated that she is responsible for background checks, fingerprint checks, reference checks, and maintaining employee files. This failure to complete the required fingerprint background check for CNA BB resulted in noncompliance cited under F-Tag 600. No resident-specific medical histories, conditions, or direct resident care events were described in the report related to this deficiency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was observed and documented by surveyors, indicating a lack of systematic measures to address infection risks within the facility. No specific residents or staff members were mentioned in the report, and there were no details provided regarding individual medical histories or conditions at the time of the deficiency.
Failure to Document Vaccine Consent and Education
Penalty
Summary
The facility failed to ensure that three of five sampled residents had completed documentation for consent, declination, or proof of education regarding pneumococcal and influenza vaccinations. According to the facility's Infection Control Manual, staff are required to counsel residents or their representatives on the benefits and adverse effects of each vaccine prior to administration and to complete the appropriate vaccine information and consent forms at admission and each time the vaccine is offered. However, record reviews revealed that for one resident, there was no documentation of consent, declination, or education for the pneumococcal vaccine, despite evidence of vaccine administration. For another resident, there was no documentation of consent, declination, or education for either the influenza or pneumococcal vaccines, and no historical record of influenza vaccination. A third resident received the influenza vaccine, but the clinical record lacked documentation of consent, declination, or education for the vaccine. During staff interviews, the DON stated that nurses document vaccine administration in the medical record and that consent and education are provided at admission. However, the DON also confirmed that there was no further documentation available for the residents' vaccines beyond the record of administration. This lack of required documentation for vaccine consent, declination, and education constitutes a deficiency in the facility's implementation of its vaccination policies and procedures.
Failure to Provide Privacy Bag for Urinary Catheter
Penalty
Summary
A deficiency occurred when the facility failed to provide a privacy bag for a resident with a urinary catheter, as required by the facility's Incontinence Management policy. The resident, who had intact cognition and a diagnosis of neuromuscular dysfunction of the bladder with a suprapubic catheter, was observed on multiple occasions lying in bed with an uncovered urinary catheter bag hanging on the bed rail. The bag was visible from the hallway to residents, staff, and visitors. The care plan and physician's orders specified the use of a securement device and maintenance of the catheter, but did not mention the use of a privacy bag. Staff interviews confirmed that the urinary catheter bag was not covered and was visible from the hallway. Both an LPN and a CNA acknowledged that the bag should have been covered to maintain the resident's dignity and privacy, and noted that the lack of a cover could cause embarrassment and discomfort for the resident. The CNA indicated that the bag had not been covered for about a week, possibly due to a shortage of privacy bags. The DON stated that her expectation was for catheter bags to be covered at all times except when being emptied, and agreed that not covering the bag was a dignity issue that could affect the resident emotionally and psychologically.
Expired Medications and Supplies Not Removed from Medication Cart and Room
Penalty
Summary
Expired medications and medical supplies were found on a medication cart and in a medication room during facility observations. Specifically, a bottle of melatonin tablets with an expiration date of 3/2025 was located on the 400 Hall medication cart. Multiple staff members, including LPNs and the Unit Manager, confirmed the presence of the expired medication and acknowledged that it should not have been on the cart. The facility's policy required that expired medications be removed and destroyed according to Environmental Protection Pharmacy guidelines, but this was not followed in this instance. Additionally, in the Back Hall medication room, a bottle of aspirin with an expiration date of 9/2024, three packets of oxygen masks with expiration dates of 12/2016, and one packet of oxygen tubing with an expiration date of 2/2023 were found. Unpackaged and open gauze rolls were also observed on a cupboard surface. Staff interviews confirmed that nurses were responsible for daily audits and removal of expired medications and supplies, but these expired items remained in the medication room. The DON and other staff reiterated that expired medications and supplies should be removed immediately, but this was not done, resulting in the deficiency.
Failure to Maintain Sanitary and Comfortable Resident Environment Due to Persistent Odor
Penalty
Summary
A deficiency was identified when a resident with a history of cerebrovascular accident and severe cognitive impairment, who required assistance with all activities of daily living, was found to be living in an environment with a persistent sewage odor in the bathroom. The resident's representative reported that the smell was an ongoing issue, had been reported to nursing staff, and was sometimes so severe that it made it difficult to remain in the room. The issue was confirmed during observations and interviews with staff and maintenance personnel. The Director of Nursing acknowledged awareness of the odor, attributing it to infrequent use and flushing of the bathroom fixtures. The Corporate Maintenance staff confirmed the presence of the smell and explained it was due to the P-trap in the sink drying out from lack of use, allowing sewer gases to enter the room. The Administrator stated she had not received any complaints about the odor in the resident's room and had previously attributed hallway odors to another resident with a colostomy bag.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health And Rehabilitation | 0.4 mi | ★★★★★ | 5 | 0 |
| Harborview Health Systems Thomaston | 2.5 mi | ★★★★★ | 0 | 0 |
| Heritage Inn Of Barnesville Health And Rehab | 16.9 mi | ★★★★★ | 0 | 0 |
| Warm Springs Medical Center Nursing Home | 19.9 mi | ★★★★★ | 4 | 0 |
| Roberta Trails Of Journey Llc | 21.6 mi | ★★★★★ | 0 | 0 |
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