Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at University Nursing & Rehab Center during CMS and state inspections, most recent first.
Food items in the kitchen freezer were found improperly labeled and dated, including expired french toast, hash brown patties without use-by dates, and uncooked french fries past the use-by date. The DM acknowledged the expired and mislabeled items and stated they would be discarded immediately. The facility policy required proper dating and labeling of ready-to-eat foods.
Failure to assess a resident for self-administration of medications. A resident with diagnoses including bipolar disorder, Alzheimer’s disease, Parkinson’s disease, and schizoaffective disorder had a BIMS of 15 and was independent with ADLs, but there was no EHR assessment for self-administration. Staff left chewable calcium tablets and mouthwash at the bedside, and the resident stated she did not take them right away. A CMT observed the meds at the bedside, gave the resident the Tums, and left the mouthwash there; an LPN unit manager said she was surprised the meds were left at the bedside.
A resident admitted after hernia repair surgery did not have an updated baseline care plan within 48 hours of admission. The care plan did not address Foley catheter care, JP drain output, or surgical incision care, even though physician orders included Foley catheter care every shift and JP drain output recording. During observation, the resident was uncomfortable, agitated, and had expressive aphasia, with a Foley catheter, a JP drain, and a midline abdominal incision with staples. The RN MDS coordinator and DON confirmed the baseline care plan had not been updated with the resident’s new admission information.
A resident with COPD and intact cognition was receiving oxygen via nasal cannula at 3 LPM even though the EMR and eMAR showed no active physician order for oxygen. Staff observed the resident on oxygen on multiple occasions, an LPN confirmed the missing order, and the DON stated that all residents receiving oxygen should have an active physician order and nurses were responsible for verifying orders.
Missing Immunization Education and Documentation: The facility failed to provide and document education, offering, consent, refusal, contraindication, and/or declination for influenza and pneumococcal immunizations for a resident with a BIMS score of 00. The resident’s representative stated pneumococcal immunization was declined, but the chart and GRITS review showed no documented evidence that the resident or representative had been educated or that the vaccines were administered, refused, contraindicated, consented to, or declined.
Failure to Timely Offer and Document COVID-19 Vaccination: A cognitively intact resident was not timely offered the COVID-19 vaccine, was not documented as having received education on the risks and benefits, and the facility could not locate documentation of vaccine administration, refusal, contraindication, or consent before the vaccine was finally offered. The DON and Administrator acknowledged the missing documentation, and the resident stated the vaccine was not offered until that time.
The facility failed to maintain kitchen cleanliness, risking food contamination for 97 residents. Observations revealed missing tiles, grime buildup, and unsecured fixtures. The Dietary Manager and Corporate Maintenance Director were unclear on cleaning responsibilities, and the facility had frequent Maintenance Director turnover. The cleaning schedule and contract did not address these issues.
The facility failed to maintain a safe and homelike environment due to unresolved maintenance issues in several rooms. These included a missing handrail end, burnt-out call light bulbs, lack of call light access, non-functional bed lights, and missing window screens. High turnover in the Maintenance Director position contributed to these deficiencies.
The facility failed to provide adequate nail care for two residents, leading to unmet care needs. One resident, with conditions including hypertension and cerebellar stroke syndrome, had excessively long nails despite expressing a desire for them to be trimmed. Another resident, with cerebral infarction and type two diabetes, was found with long nails, chipped polish, and debris. Staff interviews revealed that CNAs were primarily responsible for nail care during showers, but all staff were expected to assist, indicating a systemic failure in providing necessary personal care.
Improper Food Labeling and Dating in Kitchen Storage
Penalty
Summary
Food items were not properly labeled, dated, or discarded in accordance with the facility's Dating and Labeling Policy during a kitchen tour on 05/11/2026. In the walk-in freezer, surveyors observed a bag of french toast with a use-by date of 05/7/2026, a bag of hash brown patties dated 04/19 with no use-by date indicated, a plastic-wrapped package of hash brown patties labeled with an open date of 04/19 with no use-by date indicated, and a bag of uncooked french fries dated 05/2/2026 with a use-by date of 05/6/2026. The Dietary Manager acknowledged the expired and improperly labeled food items and stated they would be discarded immediately. The facility's policy required proper dates and labels on ready-to-eat food products and directed that foods that expire be discarded immediately.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to offer and assess a resident for self-administration of medications, despite the resident’s ability and expressed routine of handling medications at the bedside. The facility’s policy on Self-Administration of Medications stated that if a resident expressed a desire to self-administer medications, staff and/or the practitioner were to assess the resident’s mental and physical abilities to determine whether self-administration was clinically appropriate. Review of the record for the resident showed diagnoses including bipolar disorder with psychotic features, generalized anxiety disorder, Alzheimer’s disease, Parkinson’s disease with dyskinesia, and schizoaffective disorder. The quarterly MDS showed a BIMS score of 15 and independence with ADLs, and the care plan addressed GERD and adverse reactions, but there was no assessment in the EHR for medication self-administration. Physician orders included Tums 500 mg chewable tablets as needed for GERD, calcium carbonate 1500 mg daily, Pepcid 20 mg at bedtime, and Prilosec OTC 20 mg twice daily. During observation, the resident had medication cups on the bedside table containing chewable tablets and a clear liquid, which the resident identified as calcium and mouthwash given by the nurse. The resident stated she did not take them right away. A CMT observed the medication at the bedside, stated the resident must have spit the tablets back into the cup after administration, then handed the Tums to the resident and left the mouthwash in a cup at the bedside. An LPN unit manager stated she was surprised the CMT left the medication at the bedside, and the DON and Administrator stated that leaving medications at the bedside was unacceptable.
Baseline Care Plan Not Updated for New Admission Needs
Penalty
Summary
The facility failed to provide an updated baseline care plan within 48 hours of admission for one resident, R8. The facility’s policy titled Care Plan-Baseline states that a baseline care plan is to be developed within 48 hours of admission and include initial goals based on admission orders and physician orders. Review of the electronic medical record showed R8 had been admitted after hospitalization for hernia repair surgery with diagnoses including encounter for surgical aftercare following surgery on the digestive system, incisional hernia without obstruction, resolution of an ileus, and failed catheter protocol twice with urinary retention. His most recent MDS before hospitalization showed a BIMS score of 08, indicating moderate cognitive impairment. Review of R8’s care plan dated 03/26/2026 showed no mention of Foley catheter care, a JP drain, or a surgical incision. Physician orders included Enhanced Barrier Precautions, a full liquids diet, JP drain output recording, and Foley catheter care every shift. During observation, R8 was in discomfort, agitated, and had expressive aphasia, limiting his ability to communicate needs. He had a Foley catheter connected to a bedside drainage bag with over 800 ml of clear amber urine, a midline abdominal incision with multiple staples, and a JP drain in the lower quadrant of his abdomen. Staff interviews confirmed the care plan had not been updated with the new admission information and did not address the Foley catheter, JP drain, or surgical incision care.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order was obtained for oxygen therapy for one resident, R19, who was reviewed among 13 residents receiving oxygen. R19 had diagnoses including chronic obstructive pulmonary disease (COPD) and a BIMS score of 15, indicating intact cognition. The care plan initiated 07/17/2025 stated that staff explained the resident needed to keep the oxygen cannula on with the humidifier bottle in place to prevent another nosebleed, and included an intervention to encourage the resident to wear the oxygen nasal cannula. Review of the EMR and eMAR revealed no active physician order for oxygen administration. Despite this, R19 was observed on 05/11/2026 at 10:20 AM receiving oxygen via nasal cannula from an oxygen concentrator set at 3 LPM, and again on 05/13/2026 at 10:30 AM sitting in a geri-chair in the hallway while receiving oxygen via nasal cannula at 3 LPM. The facility policy titled Oxygen Administration stated that a physician's order should be verified before oxygen administration. An LPN confirmed on 05/13/2026 that R19 did not have an active physician order for oxygen therapy, and the DON stated her expectation that all residents receiving oxygen therapy should have an active physician order and that nurses were responsible for verifying physician orders.
Missing Immunization Education and Documentation
Penalty
Summary
The facility failed to ensure that one sampled resident, R10, was provided education regarding influenza and pneumococcal immunizations and failed to maintain documentation related to vaccine administration, refusal, contraindication, consent, and/or declination for sampled residents reviewed for these immunizations. R10 was admitted with a BIMS score of 00, indicating the resident was not cognitively intact. Record review showed no documented evidence that the influenza vaccine had been offered since the last documented consent dated 10/1/2025, and there was no current documentation related to influenza vaccine administration, refusal, contraindication, consent, education, and/or declination at the time of review. R10's responsible representative/daughter stated during interview that she declined the pneumococcal immunization only for R10. However, record review found no documented evidence that R10 or the responsible representative was provided education regarding influenza and/or pneumococcal immunizations, and no documented evidence that either vaccine was administered, refused, contraindicated, consented to, and/or declined at the time of review. The ICPN stated she reviewed GRITS and was unable to locate documentation related to influenza and pneumococcal vaccine offering, administration, refusal, contraindication, and/or consent for R10 prior to 05/14/2026. The DON and Administrator stated residents are educated regarding immunizations upon admission and acknowledged that documentation for R10 could not be located.
Failure to Timely Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that one resident with a BIMS score of 11, indicating cognitive intactness, was timely offered the COVID-19 vaccine, educated on the risks and benefits of vaccination, and had documentation maintained for vaccine administration, refusal, contraindication, and/or consent. The resident was admitted and later readmitted, and the record review found no documented evidence that the resident had previously been offered the COVID-19 vaccine or educated about it before the vaccine was first offered on 05/14/2026. During review of GRITS, the Infection Control Preventionist Nurse/Regional Consultant was unable to locate documentation related to COVID-19 vaccine administration, refusal, contraindication, and/or consent for the resident prior to 05/14/2026. In interviews, the resident stated he had not been offered the COVID-19 vaccine until that date and then authorized the facility to administer it. The DON and Administrator acknowledged that residents are educated regarding immunizations upon admission, but they could not produce documentation showing the resident had been offered the vaccine or educated about its risks and benefits before 05/14/2026.
Facility Fails to Maintain Kitchen Cleanliness, Risking Food Contamination
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen, which could potentially lead to contaminated food being served to 97 of 102 residents receiving an oral diet. During an initial tour of the kitchen, several issues were observed, including missing tiles on the dish room floor, a black substance on the wall underneath the counter, and a buildup of grime on a plastic cover over clean baking pans. Additionally, the air conditioning unit and fans in the kitchen had a heavy buildup of dust, dirt, and grime, and a wall plug near the dish room was unsecured and lacked a cover plate. The Dietary Manager acknowledged these issues, noting that the wall needed replacement and that the facility had been without a Maintenance Director for months. A second tour of the kitchen revealed that the previously identified conditions remained unchanged, and additional issues were noted, such as a metal apparatus with a heavy buildup of grease and grime and walls with peeling paint and black substances. The cleaning schedule provided by the Dietary Manager did not include the items identified during the tours, and there was confusion about the responsibilities for cleaning between the kitchen staff and the Maintenance Director. Interviews with the Corporate Maintenance Director and the Administrator highlighted a lack of clarity and continuity in maintenance responsibilities, with the facility having had three Maintenance Directors in four months. The contract for kitchen staff cleaning responsibilities failed to address the identified concerns.
Facility Maintenance Deficiencies Affect Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several maintenance issues observed in five of the 49 rooms. These issues included a missing handrail end outside one room, which exposed a sharp edge that could potentially cause injuries. Additionally, the call light bulb outside another room was burnt out, preventing staff from knowing if residents in that room needed assistance unless they were at the nurses' station. In another instance, a resident did not have access to a call light, relying on their roommate to signal for help. Furthermore, a resident's bed light had been non-functional for two months, and the window in their room was obscured by a film-like substance, hindering visibility outside. Other deficiencies included the absence of window screens in two rooms, which led to one room having leaves and dead bugs on the windowsill, while the other resident expressed a desire for fresh air but was unable to open the window. Interviews with the Corporate Maintenance Director and the Administrator revealed that the facility had experienced high turnover in the Maintenance Director position, with three different individuals occupying the role in four months, contributing to the unresolved maintenance issues.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, leading to unmet care needs. Resident 85, who was admitted with conditions including hypertension and cerebellar stroke syndrome, was observed with excessively long fingernails and toenails, despite expressing a desire for them to be trimmed. The resident's care plan indicated resistance to care, but also emphasized the need for providing choices during care provision. Observations over two days confirmed that the resident's nails remained untrimmed, and a Licensed Practical Nurse acknowledged the need for trimming. Resident 8, admitted with diagnoses such as cerebral infarction and type two diabetes, was also found with long fingernails and toenails, chipped nail polish, and debris under the nails. The resident's care plan noted difficulties in performing daily living tasks. Observations confirmed the lack of nail care over several days, and interviews with staff, including a CNA and LPN, revealed that CNAs were primarily responsible for nail care during showers, but all staff were expected to assist with residents' needs. The Director of Nursing reiterated this responsibility, highlighting a systemic failure in providing necessary personal care.
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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) |
|---|---|---|---|---|
| Presbyterian Village - Athens | 0.6 mi | ★★★★★ | 1 | 0 |
| Pruitthealth - Athens Heritage | 2 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Grandview | 3 mi | ★★★★★ | 4 | 0 |
| Oaks - Athens Skilled Nursing, The | 3.4 mi | ★★★★★ | 4 | 0 |
| High Shoals Health And Rehabilitation | 7.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.