Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Lake Emory Post Acute Care during CMS and state inspections, most recent first.
A resident with severe dementia, daily wandering, and a high fall risk experienced multiple falls with serious injuries over several months, while care plan interventions remained limited to basic measures such as nonskid strips, clothing adjustments, and redirection. The resident’s room was located near an exit and away from the nurse’s station, and the resident was known by CNAs to be impulsive and ambulatory, often attempting to walk without assistance. On one occasion, staff left a large rolling trash can in the hallway near the resident’s room, despite training that it should be stored in the shower room; the resident attempted to use it for support, it rolled away, and the resident fell, sustaining a right femur fracture. This sequence of events reflects the facility’s failure to identify and remove an environmental hazard for a resident with a known history of falls.
A resident with moderate dementia verbally abused their severely cognitively impaired roommate, using profane and derogatory language in front of the roommate's family. The incident was reported to an LPN and the DON, and a grievance was filed, but the required report to the State Agency was not made within the mandated timeframe because staff did not initially recognize the incident as abuse.
Two cognitively impaired residents eloped from a facility after being let out unsupervised by an RN. Despite having a history of wandering and requiring wander guards, the residents were allowed to leave with other smokers. They were found by emergency services about a mile away after being missing for approximately an hour. The incident revealed a lack of communication and adherence to elopement prevention protocols among staff.
Two cognitively impaired residents eloped from an LTC facility after an RN allowed them to exit unsupervised. Despite having wander guards and being identified as elopement risks, the residents were found a mile away by emergency services. The incident revealed a failure in supervision and adherence to safety policies.
Two residents with severe cognitive impairment eloped from the facility without supervision and were not reported to their responsible parties. The residents, who were allowed to exit unsupervised by an RN, were found a mile away. The facility's policy requires notifying the responsible parties, but no documentation of such notifications was found.
The facility failed to ensure foods in the refrigerator and nourishment kitchen were free from expiration. Observations revealed expired lettuce and milk, which were overlooked by staff. The Dietary Manager confirmed the oversight, and the Facility Administrator emphasized the importance of discarding expired items.
Failure to Remove Environmental Hazard for High-Risk Fall Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident with a known history of frequent falls and severe cognitive impairment. The resident was admitted with diagnoses including a displaced left humerus fracture, severe dementia with anxiety, and muscle weakness, and was assessed as a high fall risk with a Morse Fall Scale score of 50. MDS assessments documented severe cognitive impairment (BIMS 00/15 and later unable to complete), daily wandering, delusional behaviors, inattention, disorganized thinking, and both short- and long-term memory loss. The resident was described as active, ambulatory, and impulsive, with a pattern of attempting to stand or ambulate without assistance and requiring consistent redirection. Between late August and mid-December, the resident experienced ten documented falls, three of which resulted in major injuries, including a nasal fracture, a subdural hemorrhage with a right clavicle fracture, and later a right femur fracture. Progress notes described multiple unwitnessed and witnessed falls in various locations, including another resident’s room, during ambulation to the shower room, behind the nurse’s station, in front of the wheelchair in the dining room, at the nurse’s station, and in the hallway. Despite this pattern of falls and injuries, the fall care plan interventions remained limited to measures such as ensuring proper pants length, using nonskid strips, offering redirecting activities, removing slippers from the room, placing a resident identifier outside the room, and assisting or redirecting the resident when seen walking without assistance. On the date of the cited incident, staff left a large grey rolling trash receptacle in the hallway near the exit door by the resident’s room, contrary to staff training that the trash can must be kept in the shower room and not left in hallways except when being emptied into the dumpster. The resident, known to be impulsive and ambulatory, exited the room, attempted to use the rolling trash can for support, and fell when it rolled away, striking the rail and holding the right upper thigh, with a subsequent diagnosis of a right femur fracture. The room’s location near an outside exit door and far from the nurse’s station, combined with the resident’s established fall history and behaviors, and the presence of the rolling trash can in the hallway, constituted the facility’s failure to identify and remove an environmental hazard for a high-risk resident.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of resident-to-resident mental abuse to the State Agency as required by its own policy and federal regulations. The incident involved a resident with moderate vascular dementia and psychotic disturbance (the aggressor) verbally abusing their roommate, who had severe cognitive impairment. The aggressor used profane language, made derogatory remarks about the roommate, and demanded that the roommate and their family leave the shared room. The roommate's family member, visibly upset and concerned for the resident's safety, reported the incident to nursing staff and filed a grievance. Facility documentation shows that the incident occurred when the family member brought the resident back to their room and was met with verbal hostility from the roommate. The nurse on duty reported the incident to the DON, and the roommate was moved to another room. The family member completed a grievance form, which was submitted to the Social Service Director. However, the initial report to the State Agency was not completed until the following day, outside the required reporting timeframe for abuse allegations that do not result in serious bodily injury. The facility's policy mandates immediate reporting of abuse allegations, but staff did not recognize the incident as abuse at the time, partly because the family member did not explicitly use the term "abuse." The DON was notified, and the grievance was documented, but the delay in recognizing and reporting the incident resulted in a failure to meet the required reporting timeline. The administrator later acknowledged that the incident should have been reported on the day it occurred, regardless of the terminology used by the family member.
Neglect Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure that two residents, identified as R2 and R3, were free from neglect, resulting in their successful elopement from the facility. Both residents were severely cognitively impaired, with BIMS scores of 6 out of 15, indicating severe cognitive impairment. R2 had a history of wandering and was not oriented to her surroundings, requiring supervision and a wander guard. Similarly, R3 was not oriented to place or time and had a history of wandering, also requiring a wander guard. Despite these precautions, both residents were allowed to leave the facility unsupervised. On the evening of the incident, a Registered Nurse (RN) on duty let R2 and R3 out the back door along with other smokers, without any escort or supervision. The RN assumed the residents were competent to be outside unsupervised. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM. During this time, the facility staff, including the Assistant Director of Nursing (ADON) and several Certified Nursing Assistants (CNAs), were alerted to the residents' absence and began searching for them. The residents were eventually found by emergency services about a mile down the road, having been gone for approximately an hour. Interviews with facility staff revealed a lack of communication and proper protocol in handling the situation. The CNA who discovered the residents were missing reported the incident to the RN, who initially refused to call for assistance until a thorough check of the facility was completed. The ADON was notified and arrived at the facility to assist in the search. The residents were found by following emergency vehicles that had responded to a call about the residents being seen on the road. The incident highlighted a significant lapse in supervision and adherence to the facility's elopement prevention policies.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide appropriate supervision to prevent the elopement of two residents, identified as R2 and R3, from the facility. Both residents were severely cognitively impaired, with R2 having a history of wandering and requiring a wander guard. On the evening of the incident, an RN allowed R2 and R3 to exit the facility through the back door along with other residents who intended to smoke, without any escort or supervision. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM, having been found by emergency services about a mile away from the facility. R2 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, vascular dementia, Alzheimer's Disease, and major depressive disorder. R2's care plan indicated she was an elopement risk and required a wander guard. Similarly, R3 was admitted with vascular dementia, osteoarthritis of the knee, major depressive disorder, and Atherosclerotic heart disease. R3's care plan also included the use of a wander guard. Despite these precautions, both residents were able to leave the facility unsupervised, which was a significant oversight in their care. Interviews with facility staff revealed a lack of immediate action when the residents were discovered missing. The Assistant Director of Nursing was informed of the situation and arrived at the facility to assist in the search. The residents were eventually located by following emergency services vehicles, which had responded to a call about the residents. The incident highlighted a failure in the facility's elopement prevention measures and the need for staff to adhere strictly to policies regarding resident supervision and safety.
Failure to Notify Responsible Parties of Resident Elopement
Penalty
Summary
The facility failed to notify the responsible parties of two residents, identified as R2 and R3, following an elopement incident. According to the facility's policy on elopement, the Director of Nurses or their designee is required to notify the Administrator, appropriate community agencies, the attending physician, and the resident's legal representative when a resident is located after an elopement. However, in this case, there was no documentation in the progress notes of either resident indicating that their responsible parties were informed of the elopement. Both residents were severely cognitively impaired, with BIMS scores of 6 out of 15, and had diagnoses including vascular dementia and major depressive disorder. The incident occurred when an RN allowed R2 and R3 to exit the facility unsupervised along with other smokers. The residents were last seen at 9:00 PM and returned at approximately 9:45 PM, having been located about a mile from the facility. Interviews with the Administrator and the responsible parties for R2 and R3 revealed that neither the residents' family members nor their legal representatives were informed of the elopement. The Administrator acknowledged that the notification responsibility typically falls to the nursing staff, and there was no record of such notifications being made in this instance.
Expired Food Items Found in Facility's Kitchen and Nourishment Kitchen
Penalty
Summary
The facility failed to ensure that foods stored in the refrigerator and nourishment kitchen were free from expiration, as observed during a survey. The facility's policy required that all products be properly labeled and dated, but during observations, it was found that two clear bags containing a total of 12 heads of lettuce were not labeled with an open date and had a use-by date that had passed. The lettuce was observed to be brown with pink build-up, indicating spoilage. Additionally, in the nourishment kitchen, three cartons of Dairy Pure 1% low-fat milk were found with an expiration date that had already passed. Interviews with the Dietary Manager (DM) revealed that staff are expected to check for expired foods in all storage areas, but the expired items were overlooked. The DM acknowledged that the heads of lettuce were at the bottom and missed during checks. The DM also confirmed that the expired milk did not belong in the refrigerator. The Facility Administrator expressed that her expectation was for all items to be discarded by their use-by dates to prevent compromising other foods.
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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 Inman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Manor - Inman | 0.1 mi | ★★★★★ | 3 | 0 |
| Inman Healthcare | 0.9 mi | ★★★★★ | 0 | 0 |
| Golden Age Operations | 1.1 mi | ★★★★★ | 0 | 0 |
| Rosecrest Rehabilitation And Healthcare Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Valley Falls Terrace | 6.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.