Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Rehabilitation Center Of South Georgia during CMS and state inspections, most recent first.
Unsecured zinc oxide cream was found in the open on the bedside table or stand in three residents’ rooms, visible to residents and visitors. The residents had diagnoses including dementia, Alzheimer's, cerebral palsy, CKD, HF, and DM with neuropathy; two had BIMS scores showing moderate to severe cognitive impairment, and none had a medication self-administration assessment, physician order for the cream, or care plan focus for self-administration. The DON confirmed the cream in each room and stated one resident did not have a current wound or skin condition requiring it.
A resident with COPD, emphysema, cardiomegaly, and HTN had a care plan for altered respiratory status that included oxygen via nasal cannula as ordered. Staff observed the resident receiving oxygen at 4 LPM even though the physician order was for 2 LPM continuous as the resident would allow; an ADON confirmed the setting and adjusted it, and the MDS Coordinator stated staff were expected to review the care plan and follow it.
Incorrect Tube Feeding Water Flush Rate: A resident with a feeding tube, dysphagia, CKD stage four, and type 2 DM was ordered Glucerna 1.5 at 40 cc/hr with purified water flushes at 50 cc/hr. Although the MAR reflected the ordered care, repeated observations showed the feeding pump delivering the water flush at 40 cc/hr. An LPN confirmed the pump was set incorrectly and adjusted it after reviewing the order; the DON and Administrator stated staff were expected to follow and verify the ordered tube feeding and flush rates.
Oxygen Flow Rate Not Administered as Ordered: A resident with COPD, emphysema, cardiomegaly, and HTN was observed receiving oxygen by nasal cannula at 4 LPM even though the physician order specified 2 LPM continuous as tolerated. The ADON confirmed the incorrect flow rate and adjusted it to the ordered setting.
The facility failed to serve food at safe and appetizing temperatures, affecting 115 residents. Observations revealed that lunch items were initially too hot, and by the time they were served, they were below acceptable temperature levels. The discrepancy was due to inconsistent thermometer readings, confirmed by the Dietary Manager.
The facility failed to properly dispose of and contain garbage, as two out of three dumpsters were found open, exposing trash. This was observed in the presence of the Dietary Manager, who acknowledged the responsibility to keep dumpsters closed. The facility's policy requires dumpsters to be closed and free of litter.
The facility failed to implement comprehensive care plans for residents, leading to improper fall interventions and lack of personalized activities. Observations showed beds not in the lowest position and fall mats misplaced, while residents in the memory care unit had limited engagement despite care plan directives. Staff interviews confirmed these deficiencies.
A facility failed to provide an ongoing activity program for residents in the memory care unit, affecting four residents with severe cognitive impairments. These residents had specific preferences for activities, but the facility's schedule was limited, with no weekend activities. Observations showed residents often left sitting with the television on, without engagement in meaningful activities. The Activity Director acknowledged the lack of individualized activities and the Administrator noted no current improvement plan to address the issue.
A resident in a long-term care facility was unable to get out of bed for seven days due to a lack of lift pads necessary for transfers, despite being cognitively intact and desiring to participate in activities. Staff interviews revealed that the issue was known but unresolved, with no clean lift pads available. The facility administrator was unaware of the situation, although numerous lift pads had been purchased previously.
The facility failed to protect residents from abuse by other residents, as evidenced by incidents involving residents with severe cognitive impairments. A resident with Alzheimer's disease exhibited aggressive behaviors, slapping another resident and engaging in altercations with others. Another resident, known for aggression, grabbed a fellow resident's face. Staff misunderstood these incidents as behaviors rather than abuse, and the facility's actions and inactions led to the deficiency.
The facility did not follow its Abuse Prohibition Policy by failing to conduct reference checks for three employees, including the Administrator, DON, and a CNA. This oversight was confirmed by HR, who discovered the lapse during an audit, and the Administrator acknowledged the expectation for reference checks to be completed before hiring.
The facility failed to conduct thorough investigations of resident-to-resident incidents, lacking written statements from witnesses or staff, despite policy requirements. Incidents involved residents with severe cognitive impairments, and an LPN confirmed witnessing an incident but was not interviewed. The Administrator acknowledged the absence of necessary documentation.
A facility failed to provide necessary transfer documentation for a resident hospitalized for syncope evaluation. Despite the facility's policy requiring a transfer summary and telephone report, no documentation was found in the resident's EMR. Interviews with the Corporate Nurse and an LPN confirmed the absence of documentation, potentially impacting the care provided by the receiving facility.
A facility failed to provide written notification to a resident, their responsible party, and the Ombudsman regarding a hospital transfer. The resident, with multiple health conditions, was transferred for syncope evaluation after becoming unresponsive. Despite policy requirements, only verbal notifications were given to families, and the Ombudsman was not informed.
A facility failed to provide a written bed hold notice to a resident or their representative within 24 hours of an emergency hospital transfer, as required by their policy. The policy mandates informing residents of the bed hold policy upon admission and prior to any transfer. In this case, there was no documentation indicating that the resident or their representative received the required notice following an emergency transfer for a syncope evaluation. The Financial Coordinator admitted to contacting the representative by phone on the third day if the resident is out for three days or more, but not sending any written notice.
The facility failed to implement fall prevention measures for two high-risk residents. One resident, severely cognitively impaired and dependent on staff, was observed with her bed not in the lowest position as required. Another resident, with a history of falls, had a fall mat incorrectly placed at the foot of the bed instead of the right side. These deficiencies were confirmed by staff observations and interviews.
A resident with Alzheimer's and dementia did not receive a physician-ordered rivastigmine patch due to a failure in reordering the medication in time. The LPN reported the medication was never ordered, and the facility's policy to reorder medications four to five days in advance was not followed.
A facility failed to ensure monthly medication regimen reviews by the consultant pharmacist included monitoring of antibiotic usage for a resident with a history of UTIs. The resident was initially prescribed an ineffective antibiotic, and the facility's infection control program did not maintain an order of events, leading to a failure in recognizing the incorrect administration.
A medication error rate of 7.41% was observed in an LTC facility, exceeding the acceptable rate of 5%. An LPN crushed and administered enteric-coated aspirin instead of the prescribed chewable form to a resident with dementia. Additionally, the LPN documented a refusal of Colace without confirming with the resident. The Corporate Nurse and Administrator acknowledged the errors.
A medication cart was left unlocked and unattended by an LPN, allowing a resident with diabetes, bipolar disorder, and heart failure to access medications not prescribed for them. The LPN confirmed she could not see the cart or the medications when away, and another LPN stated the cart should always be locked when unattended.
The facility failed to follow infection control guidelines during wound care, medication administration, and contact precautions. An LPN did not change gloves or perform hand hygiene during a dressing change, while another LPN handled medications with bare hands. Staff also entered a contact isolation room without proper PPE. These actions were against the facility's policies and posed a risk of infection spread.
A facility failed to monitor and evaluate antibiotic use for a resident with a history of UTIs, leading to inappropriate antibiotic prescriptions. The resident experienced multiple infections and was prescribed various antibiotics, some of which were not suitable for the identified bacteria. The facility's antibiotic stewardship program was not effectively implemented, resulting in a lack of proper tracking and evaluation of antibiotic use. Staff interviews revealed a lack of communication and coordination among the healthcare team.
The facility failed to ensure that the Social Service Director (SSD) had the proper qualifications for a facility with over 120 beds. The SSD, promoted on 11/3/2023, had an Associate of Arts degree and a Certificate of Completion for a Social Worker 4-Day Virtual Training Course. The Administrator expressed concerns about the SSD not having a Bachelor's degree but was told not to worry since the SSD was working towards her degree. The SSD confirmed she was 26 percent away from completing her Social Worker degree.
Unsecured zinc oxide cream left at bedside
Penalty
Summary
The facility failed to ensure that three sampled residents did not have unauthorized, unsecured medications at bedside. During observations, a tube of zinc oxide cream was found in the open on the bedside table or bedside stand in the rooms of three residents, visible to residents and visitors. The facility policy required self-administered medications to be stored in a safe and secure place not accessible by other residents, and if safe storage was not possible, the medications were to be stored in a central medication cart or resident medication room with nursing control of access. For one resident, the EHR showed diagnoses including unspecified dementia, cerebral palsy, and chronic pulmonary disorder disease, and the quarterly MDS showed a BIMS score of 6 indicating moderate cognitive impairment; there was no care plan focus for self-administration, no physician order for zinc oxide or self-administration, and no medication self-administration assessment completed. For a second resident, the EHR showed diagnoses including dementia, Alzheimer's, atrial fibrillation, and chronic kidney disease, and the quarterly MDS showed a BIMS score of 0 indicating severe cognitive impairment; there was no physician order for zinc oxide or self-administration and no medication self-administration assessment completed. For the third resident, the EHR showed diagnoses including unspecified dementia with behavioral disturbances, heart failure, and type 2 diabetes with diabetic neuropathy; the quarterly MDS showed a BIMS score of 13 indicating little to no cognitive impairment, but there was no care plan focus for self-administration, no physician order for zinc oxide or self-administration, and no medication self-administration assessment completed. The DON confirmed the zinc oxide cream in each room and removed it, and stated that one resident did not have a current wound or skin condition requiring the cream.
Care Plan Not Followed for Ordered Oxygen Therapy
Penalty
Summary
The facility failed to follow the comprehensive care plan for one resident with COPD, emphysema, cardiomegaly, and hypertension. The resident’s care plan, last revised 5/19/2021, identified altered respiratory status/difficulty breathing related to anxiety, asthma, and COPD, with a goal for the resident to have no complications related to shortness of breath. The interventions included oxygen via nasal cannula as ordered. The physician order dated 1/11/2024 directed oxygen at 2 LPM via nasal cannula continuously as the resident would allow. Observations on 12/2/2025 at 12:23 pm, 2:20 pm, and 4:15 pm showed the resident lying in bed receiving oxygen by nasal cannula with the flow rate set at 4 LPM. During the 4:15 pm observation, the ADON confirmed the oxygen was set to 4 LPM and adjusted it to 2 LPM. The MDS Coordinator stated on 12/4/2025 that staff were expected to review the care plan to ensure it was followed.
Incorrect Tube Feeding Water Flush Rate
Penalty
Summary
The facility failed to ensure that one of six residents receiving nourishment via a feeding tube, R84, received water flushes as ordered by the physician. R84’s record showed diagnoses including adult failure to thrive, dysphagia, chronic kidney disease stage four, and type 2 diabetes mellitus. The quarterly MDS documented that the resident was dependent with eating and had a feeding tube, with fluid intake via the tube feeding documented as two to 501 cc per day. The physician ordered Glucerna 1.5 at 40 cc per hour and purified water flush of 50 cc per hour via pump. The MAR for 12/1/2025 through 12/31/2025 reflected the ordered feeding and flushes as administered, but observations on 12/2/2025, 12/3/2025, and 12/4/2026 showed the feeding pump delivering the water flush at 40 cc per hour instead of 50 cc per hour. An LPN confirmed the pump was set incorrectly and changed the setting after reviewing the order. The DON stated nurses were expected to check tube feeding and flush rates every shift, and the Administrator stated staff were expected to follow physician orders when setting tube feeding and flush rates.
Oxygen Flow Rate Not Administered as Ordered
Penalty
Summary
The facility failed to ensure that R77 received oxygen therapy in accordance with the physician order. R77 had diagnoses including COPD with acute exacerbation, emphysema, cardiomegaly, and hypertension, and the EHR and MDS showed the resident received oxygen therapy. The physician order dated 1/11/2024 directed oxygen at 2 LPM via nasal cannula continuously as the resident would allow. However, observations on 12/2/2025 at 12:23 pm, 2:20 pm, and 4:15 pm showed R77 lying in bed receiving oxygen by nasal cannula with the flow rate set at 4 LPM. During the 4:15 pm observation, the ADON confirmed the oxygen was set at 4 LPM and adjusted it to 2 LPM, and stated that if a resident with COPD received too much oxygen, it placed them at risk for adverse effects, including hypercapnia.
Deficiency in Serving Food at Safe Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature during an observed meal, potentially affecting the satisfaction and palatability of food for 115 out of 119 residents. The facility's policy on food serving temperatures mandates that hot foods should be maintained at a minimum holding temperature of 140 degrees Fahrenheit and served at a point of service temperature between 120-140 degrees Fahrenheit or based on resident preference. However, during an observation, the temperatures of lunch items on the steam table were significantly higher than the required holding temperatures, with beef tips measuring up to 200 degrees Fahrenheit and lima beans up to 206 degrees Fahrenheit. A test tray was prepared and served to the 500 Hallway, where the food was found to be below acceptable temperature levels. The beef tips on the test tray measured 100 degrees Fahrenheit, mashed potatoes 130 degrees Fahrenheit, and lima beans 104 degrees Fahrenheit, all confirmed by the Dietary Manager (DM) as cold to warm. The discrepancy in temperature readings was attributed to the use of different thermometers, with the analog thermometer showing a 45-degree cooler reading than the digital one, despite being properly calibrated. This inconsistency in temperature monitoring led to the deficiency in serving food at the appropriate temperature.
Improper Garbage Disposal and Containment
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage, as observed during a survey. Two out of three dumpsters located in the parking lot behind the kitchen were found with their side doors pushed back and left open, exposing boxes and bags of trash. This observation was made in the presence of the Dietary Manager (DM), who acknowledged that the dumpsters should be closed and noted that while others use the dumpsters, it is the facility's responsibility to keep them closed. The facility's policy on Garbage and Rubbish Disposal, dated 1/8/2009, mandates that garbage and rubbish containing food wastes must be stored to be inaccessible to vermin, and outside dumpsters must be kept closed and free of litter around the area.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan with measurable goals and plans related to fall and activity interventions for several residents. For one resident, the care plan directed staff to place the bed in the lowest position due to a fall risk, but observations on multiple occasions showed the bed was not in the correct position. Another resident's care plan required a fall mat to be placed on the right side of the bed, but it was observed at the foot of the bed with a wheelchair parked on top of it. Interviews with staff confirmed these discrepancies, indicating a lack of adherence to the care plans. Additionally, residents in the memory care unit were observed to have limited engagement in activities that met their individual needs. Despite care plans indicating preferences for activities such as watching television, reading, and listening to music, residents were seen lined up against walls with minimal interaction from staff. The television and music were on, but there were no personalized engagement activities provided. Interviews with staff confirmed that care plan interventions were not being implemented as expected.
Deficiency in Activity Program for Memory Care Unit Residents
Penalty
Summary
The facility failed to provide an ongoing activity program tailored to meet the individual interests and needs of residents in the memory care unit, specifically affecting four residents with severe cognitive impairments. These residents, diagnosed with various forms of dementia, had specific preferences for activities such as listening to music, participating in religious activities, and engaging in group activities. However, the facility's activity schedule was limited, with group activities like Bible study, music, and crafts scheduled only once a day and no activities planned for weekends. Observations revealed that residents were often left sitting in chairs lined up against the walls with the television on, tuned to the Hallmark station, without any engagement in meaningful activities. Staff interviews indicated that the activity department did not provide individual activities for the memory care unit residents, and there were no materials available for engagement, such as puzzles or arts and crafts. The Activity Director acknowledged the lack of a weekend schedule and the need for more individualized activities, noting that the facility had not yet implemented the Music and Memory program. The Administrator, new to her position, was aware of the deficiency in activities for the memory care unit but stated there was no current performance improvement plan to address the issue. The absence of a dedicated activity staff member for the memory care unit and the lack of implementation of planned programs contributed to the deficiency, leaving residents without adequate engagement and potentially disruptive due to the lack of stimulation.
Resident's Right to Self-Determination Compromised Due to Equipment Shortage
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing the necessary equipment to allow the resident to get out of bed as desired. The resident, who was cognitively intact and required substantial assistance for mobility due to multiple sclerosis and contractures, was unable to leave the bed for seven days. This was due to the unavailability of lift pads needed for the mechanical lift used for transfers. Despite the facility's policy supporting resident choice, the lack of equipment hindered the resident's ability to participate in daily activities and social interactions, leading to feelings of isolation. Interviews with staff, including CNAs, LPNs, and the housekeeping supervisor, revealed that the issue of missing lift pads was known but unresolved. Staff reported that they frequently lacked the necessary lift pads to assist the resident, and the housekeeping supervisor confirmed that there were no clean lift pads available for exchange. The central supply staff mentioned that lift pads had been ordered, but their whereabouts were unknown. The facility administrator was unaware of the situation until informed by surveyors, despite having purchased a significant number of lift pads since the previous year.
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from physical abuse by other residents, as evidenced by multiple incidents involving residents with severe cognitive impairments. Resident R60, diagnosed with early Alzheimer's disease, exhibited physical and verbal behavioral symptoms towards others. On one occasion, R60 slapped another resident, R101, who also had severe cognitive impairment and no prior behaviors directed towards others. This incident was witnessed by staff, and although no injuries were reported, it was documented as resident-to-resident abuse. Another incident involved resident R93, who had a history of physical and verbal aggression towards others. R93, while agitated, grabbed the face and jaw of R60, but staff intervened, and no injuries were reported. This incident was also marked as resident-to-resident abuse. Additionally, R60 was involved in another altercation with resident R55, where R60 attempted to take R55's tea and subsequently hit and grabbed R55's arm, leaving no injuries. Interviews with staff, including LPN4, revealed a misunderstanding of the nature of these incidents, with some staff considering them as behaviors rather than abuse. The facility's administrator acknowledged the potential for abuse between residents but noted the lack of intent due to the residents' cognitive impairments. Despite these acknowledgments, the facility's actions and inactions in preventing and addressing these incidents led to the deficiency in protecting residents from abuse.
Failure to Conduct Employee Reference Checks
Penalty
Summary
The facility failed to implement its Abuse Prohibition Policy and Procedures by not conducting reference checks for three out of ten employees whose files were reviewed. The policy, dated January 2017, mandates a thorough investigation of potential hires, including checking references and information from previous or current employers to uncover any criminal prosecutions. However, the employee files for the Administrator, Director of Nursing (DON), and a Certified Nursing Assistant (CNA) did not include any reference checks, despite the policy's requirements. During interviews, the Human Resources (HR) department confirmed the absence of reference checks for the mentioned staff members. HR attributed this oversight to a previous HR employee who failed to complete the reference checks, which was discovered during an audit of employee files. The Administrator also stated that reference checks were expected to be completed before hiring to ensure applicants were suitable to work in the residents' home, indicating a lapse in following the established hiring procedures.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations of resident-to-resident incidents, as required by their policy titled 'Abuse Investigation.' This deficiency was identified for four residents who were reviewed for abuse. The policy mandates that all reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source be promptly and thoroughly investigated, including interviews with the person(s) reporting the incident and any witnesses, with witness reports being documented in writing. However, the investigations involving these residents lacked written statements from witnesses or staff, which is a critical component of the investigation process. The report highlights specific incidents involving residents with severe cognitive impairments, as indicated by their Brief Interview for Mental Status (BIMS) scores. For instance, one resident had a BIMS score of zero, indicating severe cognitive impairment. Despite the presence of witnesses, such as an LPN who confirmed witnessing an incident and documented it in the clinical records, the facility's investigations did not include interviews or written statements from these witnesses. The Administrator acknowledged the absence of such documentation and stated that interviews should have been conducted and statements collected, but they were not found in the incident files.
Failure to Provide Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide the receiving facility with necessary documentation regarding the transfer of a resident, identified as R86, who was hospitalized. According to the facility's policy titled 'Discharging the Resident,' a transfer summary and a telephone report should be completed and communicated to the receiving facility when a resident is transferred. However, upon review of R86's Electronic Medical Record (EMR), there was no documentation or record of information provided to the hospital. This oversight was confirmed during interviews with the Corporate Nurse and a Licensed Practical Nurse (LPN), who both acknowledged the absence of documentation indicating what information was sent with the resident. R86 was admitted to the facility with diagnoses including nonrheumatic mitral valve insufficiency, occlusion and stenosis of the right carotid artery, and hypertension. A change in condition was noted on 6/26/2024, when R86 experienced an episode of syncope, leading to a decision to send the resident to the hospital for evaluation. Despite this critical situation, the facility did not ensure that the necessary transfer documentation was completed and sent with the resident, potentially affecting the care provided by the receiving facility.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident, their responsible party, and the Ombudsman regarding a transfer to the hospital. The facility's policy, titled 'Notice of Transfer/Discharge,' mandates that such notifications include the reason for transfer, effective date, location, appeal rights, and contact information for the state long-term care ombudsman. However, the policy did not address the requirement to provide written information to the resident, their representative, and the Ombudsman. This oversight was identified during a review of the facility's records and staff interviews. The deficiency involved a resident who was admitted with conditions including nonrheumatic mitral valve insufficiency, occlusion and stenosis of the right carotid artery, and hypertension. On a specific date, the resident experienced a change in condition, becoming unresponsive and requiring a hospital transfer for syncope evaluation. Despite the facility's policy, there was no documentation of written notification being provided to the resident, their responsible party, or the Ombudsman. Interviews with facility staff revealed that only verbal notifications were given to families, and the Ombudsman was not notified of hospital transfers.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or their representative within 24 hours of an emergency hospital transfer, as required by their policy. The policy, dated 1/19/2022, mandates that residents be informed of the bed hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. In cases of emergency transfers, the policy specifies that the facility must provide the resident or their representative with written information about the bed hold policy within 24 hours, including any charges and the time limit for holding the bed as per the State Medicaid Plan. In the case of the resident identified as R86, there was no documentation in the electronic medical record indicating that the resident or their representative received the required written notice following an emergency transfer to the hospital for a syncope evaluation. The Financial Coordinator admitted during an interview that they typically contact the resident's representative by phone on the third day if the resident is out for three days or more, but do not send any written notice regarding the bed hold. This oversight created a potential gap in communication, leaving the resident and their representative without necessary information to safeguard the resident's return to the facility.
Failure to Implement Fall Prevention Measures for High-Risk Residents
Penalty
Summary
The facility failed to implement accident prevention measures for two residents, R43 and R84, who were at high risk for falls. R43, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed multiple times with her bed not in the lowest position, contrary to her care plan directives. Despite being identified as a high fall risk, the staff did not ensure the bed was adjusted accordingly, as confirmed by interviews with the CNA and RN responsible for her care. Similarly, R84, who had a history of falls and was also severely cognitively impaired, was supposed to have a fall mat placed on the right side of the bed as per the care plan. However, observations revealed that the fall mat was incorrectly placed at the foot of the bed with a wheelchair parked on top of it. This misplacement was confirmed by multiple staff members, including CNAs and an RN, indicating a failure to adhere to the prescribed fall prevention measures.
Failure to Provide Physician-Ordered Medication
Penalty
Summary
The facility failed to provide a physician-ordered medication for a resident during a medication administration observation. The resident, who was diagnosed with Alzheimer's disease with late onset and dementia, had a physician's order for a rivastigmine (Exelon) patch to be applied transdermally once a day. However, during the observation, the Licensed Practical Nurse (LPN) stated that the medication was never ordered, and there was no patch available to replace the one that had been removed. The facility's policy on medication ordering and receiving from the pharmacy, dated May 1, 2020, requires medications to be reordered four to five days in advance to ensure an adequate supply. Despite this policy, the medication was not reordered in time, leading to its unavailability. The Corporate Nurse indicated that reordering should occur when down to one or two patches, but this was not adhered to, resulting in the deficiency.
Failure to Monitor Antibiotic Usage in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that the monthly medication regimen reviews (MRRs) conducted by the consultant pharmacist included appropriate monitoring of antibiotic usage for a resident. The facility's policy required the consultant pharmacist to perform a comprehensive MRR at least monthly, evaluating the resident's response to medication therapy and reporting findings to relevant staff. However, the MRRs for the resident from June 2023 to June 2024 did not contain any information about antibiotic use or the number of antibiotics prescribed, which was a requirement under the facility's Antibiotic Stewardship Program. The resident in question had a history of diabetes, chronic kidney disease, dementia, psychotic disorder with hallucinations, and urinary tract infections. The resident was hospitalized for altered mental status and dysuria, and was initially prescribed an antibiotic that was not effective against the bacteria present. The facility later prescribed a different antibiotic. During interviews, it was revealed that the pharmacy's monthly reviews did not include antibiotic reviews, and the facility's infection control program did not maintain an order of events, leading to a failure in recognizing the incorrect antibiotic administration and the need for changes.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.41 percent during a medication administration observation. This deficiency was identified through observation, staff interviews, and record reviews. Specifically, two medication errors were made for one resident out of 27 opportunities. The errors involved the administration of an incorrect form of aspirin and the premature documentation of a medication refusal. The facility's policy on crushing medications was not followed, as enteric-coated aspirin was crushed and administered to the resident. The resident involved, identified as R77, was admitted with diagnoses of dementia, constipation, and cardiac murmur, and had a severely impaired cognitive status with a BIMS score of five out of 15. The resident had physician orders for aspirin 81 mg chewable tablet and Colace 100 mg, with instructions to crush medications. However, the LPN administered crushed enteric-coated aspirin instead of the chewable form and documented the refusal of Colace without confirming with the resident. The Corporate Nurse confirmed the error, and the Administrator stated that medications should be administered correctly.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that one of six medication carts was locked and that a cup of medications was not left unattended, which had the potential to affect a resident, R79. During an observation, LPN 9 was seen preparing medication for another resident when R79 approached the medication cart. LPN 9 left the cart unlocked and went into a resident's room, leaving the cart unattended. Upon returning, LPN 9 locked the cart but left a cup of pills on top of it and again went to the doorway of a resident's room, leaving the medication cup unattended and accessible to R79. Interviews conducted with LPN 9 confirmed that she could not see the front side of the medication cart or the cup of medications when she was away from the cart. Another LPN, LPN 5, stated that the cart should always be locked when the nurse is not with it. R79, who was sitting near the cart, had access to both the drawers of the medication cart and the cup of pills left on top, posing a risk of accessing medications not prescribed for him.
Infection Control Deficiencies in Wound Care, Medication Administration, and Contact Precautions
Penalty
Summary
The facility failed to adhere to proper infection control guidelines during a dressing change for a resident with a wound on the left second toe. The Licensed Practical Nurse (LPN) performing the wound care did not use a barrier on the bedside table, placed the dirty bandage on the bed, and did not have a trash receptacle nearby. The LPN did not change gloves after cleaning the wound and proceeded to clean bottles with the same gloves, without allowing the disinfectant to dry for the required two minutes. The LPN also failed to perform hand hygiene after removing gloves and did not use a barrier on the treatment cart. Another deficiency was observed during the administration of oral medications to a resident with severe cognitive impairment. The LPN placed pills on a notepad and handled them with bare hands before administering them to the resident. This was against the facility's policy, which requires medications to be placed in a medicine cup and handled with gloves. The LPN acknowledged the mistake during an interview, and the Infection Preventionist confirmed that handling medications with bare hands was not in compliance with the policy. The facility also failed to implement contact precautions for a resident with a urinary tract infection requiring isolation. Staff members, including a Resident Assistant and a Housekeeper, entered the resident's room without donning the required personal protective equipment (PPE). The Resident Assistant believed PPE was not necessary if not providing direct care, and the Housekeeper admitted to not wearing a gown and gloves. The Infection Preventionist confirmed that PPE should be applied before entering and removed before exiting the room, which was not followed by the staff.
Failure to Monitor and Evaluate Antibiotic Use
Penalty
Summary
The facility failed to effectively monitor and evaluate antibiotic use for a resident, leading to potential safety risks related to antibiotic usage. The resident, who had a history of urinary tract infections, was admitted with multiple diagnoses including diabetes, chronic kidney disease, and dementia. Over several months, the resident experienced multiple urinary tract infections and was prescribed various antibiotics, some of which were not appropriate for the bacteria identified in cultures. The facility's antibiotic stewardship program, as outlined in their policy, was not adequately implemented, resulting in a lack of proper tracking and evaluation of antibiotic use. The facility's Infection Preventionist (IP) and Nurse Practitioner (NP) did not adequately track the resident's antibiotic usage and catheterization events, leading to missed opportunities to identify inappropriate antibiotic prescriptions. The IP admitted that the facility's infection control program did not maintain a clear order of events, which contributed to the oversight. Additionally, the NP did not ensure that cultures were obtained before prescribing antibiotics, and there was a lack of communication and coordination among the healthcare team regarding the resident's care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's antibiotic treatment and catheterization history. The IP acknowledged that the pharmacy's monthly medication reviews did not include antibiotics, and the NP did not respond to questions about the overall management of the resident's condition. The facility administrator emphasized the need for the entire team, including pharmacy, to be informed and aligned on infection control and antibiotic stewardship practices.
Unqualified Social Service Director in Facility with Over 120 Beds
Penalty
Summary
The facility failed to ensure that the Social Service Director (SSD) had the proper qualifications for a facility with over 120 beds. The facility is licensed for 178 beds. The personnel file review revealed that the SSD, promoted on 11/3/2023, had an Associate of Arts degree with a concentration in elementary education and a Certificate of Completion for a Social Worker 4-Day Virtual Training Course from the Georgia Health Care Association. The Administrator expressed concerns to corporate about the SSD not having a Bachelor's degree but was told not to worry since the SSD was working towards her Bachelor's Degree in Social Work. The SSD confirmed she did not have a four-year degree or a Social Worker degree and was currently 26 percent away from completing her Social Worker degree. The previous SSD was let go, and management felt the current SSD could do the job despite her lack of qualifications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 70 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tifton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Tifton | 1.3 mi | ★★★★★ | 22 | 0 |
| Pruitthealth - Ocilla | 17.2 mi | ★★★★★ | 7 | 0 |
| Palemon Gaskins Mem Nsg Home | 17.4 mi | ★★★★★ | 16 | 0 |
| Pruitthealth - Ashburn | 18 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Sylvester | 19.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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