Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 15 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
7D
2E
1F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 2 citations
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review and resident and staff interviews, the facility failed to update resident (R) care plans when significant events occurred for one of 27 sampled residents (R) (R84). Specifically, the facility failed to update/revise the care plan after instances of communication did not work for R84.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Routine Cleaning and Disinfection and Infection Prevention and Control Program Policy, the facility failed to ensure that there was a clean and comfortable environment to prevent transmission of infection as evidenced by unbagged and unlabeled urinals in four of 19 resident bathrooms on the third floor of the Legacy building. This deficient practice had the potential to place residents at risk for infection.
July 10, 2025Complaint inspection · 1 citation
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on staff interviews, record review, and review of the facility policies titled, Incident and Accidents and Abuse Prohibition Policy, the facility failed to ensure allegations of potential abuse were thoroughly investigated for one of three residents (R) (R6) who had an allegation of abuse.
July 25, 2024Standard inspection, Complaint inspection · 4 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Food and Supply Storage, the facility failed to discard frozen/refrigerated food items by expiration date, failed to label and date items in two of three reach in refrigerator units, and failed to maintain proper sanitary conditions by ensuring kitchen staff wore hairnets and beard guards while preparing food for residents. The deficient practice had the potential to affect 99 residents who received an oral diet from the kitchen. The facility census was 105 residents. Findings Include: Review of facility policy titled Food and Supply Storage date revised January 2024 under Procedures revealed: Cover, label, and date unused portions and open packages. Complete all sections on a 'company name' orange label or use 'company names' labeling system. [...]
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to keep potentially hazardous materials in a secured area. Specifically, the janitorial room on one of three floors (third floor) was unlocked and taped open, and treatment solution was left in the room on the nightstand of one resident (R) (R309) in room [ROOM NUMBER] of 24 rooms on the third floor where 23 residents with severe cognitive impairment resided. The deficient practice had the potential for residents residing on the third floor to come in contact with hazardous chemicals and waste. The facility census was 105 residents.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to properly keep a complete record of the controlled drug shift audit, as evidenced by missing signatures on audit sheets for eight of twelve medication carts. This had the potential to cause residents to go without prescribed medications. The facility census was 105.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, staff interview, record review, and review of the facility policy titled, Oxygen Concentrator, the facility failed to properly care for the oxygen concentrator (machine that produces oxygen from room air) of one of eight residents (R) (R77) that use oxygen. Specifically, oxygen concengtrator filters were not cleaned timely.
May 25, 2022Standard inspection · 8 citations
- J
Provide and implement an infection prevention and control program.
- J
Report COVID19 data to residents and families.
Inspectors wroteBased on record review and interviews, the facility failed to ensure residents, resident representatives, and/or family members were notified by 5:00 p.m. the following day, of confirmed COVID-19 infections in the facility. On 5/9/22 the facility was notified by the family that resident (R) (R#83) had an exposure to COVID-19, and subsequently R#83 tested positive on 5/11/22; however, the facility did not notify residents, resident representatives, and/or family members of the new positive case until 5/21/22, 10 days after R#83 tested positive. The facility's failure had the potential to affect all residents, residents' representatives, and residents' families of the facility. The facility census was 104. [...]
- J
Perform COVID19 testing on residents and staff.
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review, interviews, review of facility video footage, and policy review, it was determined the facility failed to protect one of four residents (R) R#23 from sexual abuse. Observation of facility video footage revealed on 1/1/22, R#270 (a cognitively intact resident) stood in front of R#23 for approximately 11 minutes while R#23, who was severely cognitively impaired, was seated in a chair. Observation of the video revealed during the approximate 11 minutes, R#270 touched/rubbed R#23's breast area on four separate occasions. On two of the four occasions, R#270 touched/rubbed R23's breasts while R#270 was standing in front of the resident with his/her genitals exposed. R#270 was also observed touching/rubbing his/her genitals in front of R#23. In addition, the facility failed to protect one of four residents, R#58, from potential sexual abuse. [...]
- G
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, review of facility video footage, and facility policy review, it was determined the facility failed to report an incident of abuse for one of four residents (R) (R#58) reviewed for abuse. Specifically, R#270 exposed his genitals to R#58 on 1/2/22, and the facility failed to report the alleged incident to the Georgia Department of Community Health (DCH).
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the diagnosis of multiple sclerosis for one resident (R) R#20 of 56 residents whose MDS was reviewed. Specifically, the facility failed to ensure R#20 used a splint or brace before indicating the resident utilized one on the MDS.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with physician orders for one resident (R) (R#321) of one sampled resident reviewed for treatment of swelling and thrombosis (blood clot) to the legs. Specifically, the facility failed to ensure staff applied compression stockings (TED hose) and elevate the lower extremities to reduce swelling.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure fall prevention interventions were added to the care plan and consistently implemented for one resident (R) (R#95) of three residents reviewed for accidents/hazards.
Fire safety inspections
8 fire safety citations on file: 2 on December 11, 2025, 5 on July 25, 2024, 1 on May 25, 2022.
Every fire safety citation8 citations
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 11, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · December 11, 2025 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · July 25, 2024 · Corrected (the home has a date of correction)
- F
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · July 25, 2024 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · July 25, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 25, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · July 25, 2024 · Corrected (the home has a date of correction)
- D
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
K 111 · May 25, 2022 · Corrected (the home has a date of correction)