Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Altamaha Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that an area was not free from accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet safety standards, and insufficient oversight was observed.
The facility failed to maintain food safety and sanitation standards, risking food-borne illness for 52 residents. Observations showed improper food storage, expired items not disposed of, and bare-hand contact with ready-to-eat food. Moldy strawberries were found, and staff lacked awareness of proper food handling procedures.
The facility failed to follow infection control protocols, including proper cleaning of a glucometer between residents and maintaining TB testing records for staff. A nurse used a glucometer without cleaning it per manufacturer's instructions, and six staff files lacked required TB test documentation. Additionally, the facility did not maintain a current infection surveillance program for 2024.
The facility failed to provide written information about the right to formulate an advance directive to five residents or their representatives. Despite the facility's policy requiring this information to be given upon admission or readmission, documentation was missing for these residents, including those with varying levels of cognitive impairment. The Social Services Director confirmed the lack of documentation, indicating a systemic issue in the facility's process.
The facility did not follow its policy to conduct background and criminal checks for four staff members, including CNAs, an LPN, and a DA. The Administrator could not provide the necessary documentation, attributing the lapse to the absence of a Human Resource Director responsible for managing this information.
The facility failed to provide written transfer notices to residents and their representatives during emergent hospital transfers, as required by policy. This affected several residents with various medical conditions, including severe cognitive impairments. Staff interviews revealed uncertainty about responsibility for issuing these notices, and the Administrator confirmed that transfer notices had not been sent to the Ombudsman since taking over the role.
The facility failed to provide written bed hold notices to several residents or their representatives during hospital transfers, as required by policy. This deficiency was identified through record reviews and staff interviews, revealing a lack of clarity about responsibility for issuing these notices. Residents with various medical conditions, including severe cognitive impairments, were affected by this oversight.
A facility failed to update a resident's care plan to include fall interventions such as a low bed, geri chair, and fall mats, despite the resident's moderately impaired cognition and recent falls. Additionally, required care plan conferences were not documented since the resident's admission, as confirmed by staff interviews.
The facility failed to document proper assessments and alternatives for bed rail use for three residents. One resident was observed with assist bars despite no documented failed alternatives, while another had no recent bed rail assessment. The administrator confirmed the lack of documentation, increasing potential risks associated with bed rail use.
A resident in the facility did not receive several prescribed medications due to delays in pharmacy delivery and lack of follow-up documentation. The medications, including Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, were not administered as ordered, and there was no documentation explaining the missed doses. Staff interviews revealed issues with pharmacy delivery times and procedures for handling unavailable medications.
Facility nurses failed to document behaviors and nonpharmacological interventions before administering Seroquel IM to a resident with moderately impaired cognition. The resident's EMR showed orders for Haldol IM for agitation, but the MAR lacked documentation of behaviors or interventions prior to medication administration. The Regional Operations Manager confirmed the absence of documentation, indicating non-compliance with the facility's behavior management policy.
A significant medication error occurred when a resident with diabetes did not receive insulin as ordered due to its unavailability. A registered nurse attempted to administer insulin but found it belonged to another resident. The resident missed multiple insulin doses, and the facility's policy for medication administration was not followed. The Medical Director stated that he could have arranged for the insulin from a local pharmacy if notified of the delay.
The facility failed to post daily nurse staffing information accurately for three out of four survey days, affecting the transparency of available nursing staff for 52 residents. Observations revealed missing postings, and the Administrator confirmed the oversight.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision in the area, as directly observed by surveyors.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which could potentially lead to food-borne illness among the 52 residents receiving meals from the facility kitchen. Observations revealed that food was improperly stored, with sixteen boxes of canned foods and perishables found resting directly on the pantry floor. Additionally, expired foods were not disposed of in a timely manner, as evidenced by opened cartons of thickened juices and turkey lunch meat being kept beyond their acceptable use-by dates. Interviews with kitchen staff indicated a lack of awareness regarding the proper disposal timelines for these items. Further deficiencies were noted during meal service, where a cook was observed handling dinner rolls with bare hands, touching various surfaces without washing hands in between. Moldy food was also found in storage, with a 16oz. carton of strawberries discovered in a refrigerated reach-in. A dietary aide confirmed that staff did not consistently check produce upon arrival to ensure it was still edible. These actions and inactions demonstrate a failure to maintain proper food safety and sanitation practices as outlined in the facility's Nutrition Services Manual.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically in the cleaning and disinfecting of a glucometer between residents' use. During an observation, a registered nurse used a glucometer on a resident without cleaning it according to the manufacturer's instructions, which required the use of Medline Micro-Kill Bleach Germicidal Bleach Wipes. Instead, the nurse used an alcohol wipe after being prompted and admitted to not receiving any formal training on the proper cleaning procedure. The facility's policy required the glucometer to be cleaned and disinfected between each patient, but there was no evidence of training provided to the staff, including the nurse involved in the incident. The facility also failed to comply with pre-employment and annual tuberculosis (TB) testing guidelines. Six out of nine personnel files reviewed lacked documentation of the required two-step TB test at the time of employment, and two personnel files did not have the annual TB test documentation. The administrator confirmed the absence of this information and attributed it to the lack of a Human Resource Director, who was responsible for maintaining these records. This oversight in maintaining proper health records for staff could potentially compromise the safety and health of both staff and residents. Additionally, the facility did not maintain a current infection surveillance program for 2024. The Director of Nursing was unable to provide documentation of infection tracking and trending for the year, as the previous records were not organized or available. The new Director of Nursing, who had been in the position for a short time, was in the process of establishing a new program but had not yet implemented it. The administrator acknowledged the expectation of having an infection surveillance program in place, but no documentation from 2024 was available to demonstrate compliance.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information regarding the right to formulate an advance directive to five residents or their representatives. This deficiency was identified through a review of records, interviews, and policy review. The facility's policy, dated 08/09/22, mandates that the Social Service Director must inform and educate residents or their Power of Attorney in writing about the right to an advance directive upon admission or readmission. However, documentation was missing for five residents, indicating that they were not provided with the necessary information. Resident 48, with moderate cognitive impairment, and Resident 18, with intact cognition, were not documented as having received this information. Similarly, Resident 12, who had severe cognitive impairment, and Resident 24, had no documentation of receiving advance directive information. Resident 4, who was cognitively intact, confirmed that they had not received this information until recently, despite being in the facility since 2016. The Social Services Director confirmed the lack of documentation for these residents, highlighting a systemic issue in the facility's process for informing residents about their rights to formulate an advance directive.
Failure to Conduct Background Checks for Staff
Penalty
Summary
The facility failed to adhere to its policy of conducting background and criminal checks at the time of employment for four out of nine employee files reviewed. This deficiency involved two Certified Nurse Aides (CNAs), one Licensed Practical Nurse (LPN), and one Dietary Aide (DA). The facility's policy, dated December 21, 2023, mandates that background checks, including criminal history and fingerprinting, be conducted upon submission of an employment application. However, the Administrator was unable to provide the required background and criminal check information for these employees, citing the absence of a Human Resource Director responsible for uploading this information into the computer system.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written transfer or discharge notices to seven residents and their representatives, as required by policy, during emergent hospital transfers. The policy titled 'Discharge Plan/Transfers' did not address the need for a written notice of transfer, its required contents, or the provision of the notice to the resident and their representative. This oversight was identified through a review of the facility's records, which showed no evidence of written transfer notices for the residents involved. Resident 27, who had multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without a written notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was admitted to the hospital from dialysis without receiving a written transfer notice. Interviews with staff, including the Director of Nursing and a Licensed Practical Nurse, revealed uncertainty about who was responsible for issuing these notices. Additional residents, including those with severe cognitive impairments, were also transferred without the required documentation. For instance, Resident 116 was sent to a behavioral hospital due to behavioral issues, and Resident 44, with a BIMS score indicating severe cognitive impairment, was transferred following a change in condition. The facility's Administrator acknowledged the lack of documentation and stated that since taking over the role, transfer notices had not been sent to the Ombudsman, further highlighting the systemic nature of the issue.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to seven residents or their representatives during hospital transfers or therapeutic leaves. This deficiency was identified through a review of records, interviews, and facility policy. The facility's policy mandates that residents or their responsible parties receive written information about the bed hold policy at admission and before any transfer. However, the facility did not adhere to this policy for the residents reviewed. Resident 27, who has multiple medical diagnoses including end-stage renal disease and Alzheimer's dementia, was transferred to the hospital without receiving a written bed hold notice. Similarly, Resident 29, with conditions such as congestive heart failure and chronic respiratory failure, was also transferred without the required documentation. Interviews with staff, including the Director of Nursing, revealed a lack of clarity about who was responsible for providing the bed hold notice, indicating a systemic issue in the facility's process. Other residents, including those with severe cognitive impairments, were also transferred without receiving the necessary written notices. For instance, Resident 116, with a BIMS score indicating severe cognitive impairment, was sent to a behavioral hospital without documentation of a bed hold notice. Interviews with the Social Service Director and the Administrator confirmed that there was no documentation of the bed hold policy being provided to residents or their representatives, highlighting a consistent failure across multiple cases.
Failure to Revise Care Plan and Conduct Conferences
Penalty
Summary
The facility failed to revise the care plan for a resident to include necessary fall interventions and did not conduct care plan conferences as required. The resident, who had a moderately impaired cognitive status, was observed in various settings, including a geri chair and with a fall mat next to the bed, but these interventions were not documented in the care plan. The resident had returned from the hospital and experienced falls, yet the care plan was not updated to reflect the use of a low bed, geri chair, or fall mats. Additionally, there was no evidence of care plan conferences being held since the resident's admission, despite the facility's policy requiring such conferences after the completion of the Minimum Data Set (MDS) and during quarterly reviews. Interviews with staff, including the MDS Coordinator, confirmed the absence of documentation for care plan conferences and the lack of updates to the care plan to include the necessary interventions for fall prevention.
Failure to Document Bed Rail Assessments and Alternatives
Penalty
Summary
The facility failed to ensure proper assessment and documentation for the use of bed rails for three residents. Resident 5 was observed with bilateral assist bars in the up position on multiple occasions, yet their electronic medical record (EMR) showed no documented failed alternatives to bed rails. The assessments conducted did not justify the use of side rails as an enabler to promote independence. Similarly, Resident 38 was observed with bilateral assist bars, despite stating they did not use them. The EMR for Resident 38 also lacked documentation of failed alternatives, and no documentation was provided upon request. The facility's administrator confirmed that alternatives should have been documented prior to bed rail use. Resident 3 was found with half side rails on both sides of their bed, but their EMR lacked a recent bed rail assessment. The last assessment was incomplete, and the previous one indicated the family's request for side rails. The administrator acknowledged the absence of recent assessments and confirmed the incomplete status of the last assessment. These deficiencies in documentation and assessment increased the potential risks associated with bed rail use, including injury, entrapment, and death.
Medication Administration Deficiency Due to Pharmacy Delays
Penalty
Summary
The facility failed to ensure timely provision of medications from the pharmacy, resulting in a deficiency in medication administration for a resident. The resident, who was admitted with diagnoses including atherosclerotic heart disease and diabetes mellitus, did not receive several prescribed medications as ordered by the physician. These medications included Atorvastatin, Ondansetron, Carvedilol, Metformin, Eliquis, and Levothyroxine, which were not administered on multiple occasions as documented in the Medication Administration Record (MAR). There was no follow-up documentation to indicate why these medications were not administered. Interviews with facility staff revealed that the medication orders were automatically sent to the pharmacy upon a resident's admission, and the pharmacy delivered medications twice a day. However, it was noted that if a resident was admitted in the afternoon or later, medications might not be delivered until the following morning. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that if a medication was unavailable, it should be sourced from the emergency kit, and a progress note should be documented in the electronic medical record (EMR) to explain the unavailability. Despite these procedures, there was no documentation in the EMR to account for the missed doses. The Director of Nursing acknowledged that pharmacy deliveries had been problematic, with instances of medications not arriving as scheduled. The Medical Director stated that in cases where medications were not available upon admission, the nursing staff should have arranged for the medication to be held until it arrived or sourced it from a local pharmacy. The lack of timely medication delivery and absence of documentation for missed doses contributed to the deficiency identified by the surveyors.
Failure to Document Behaviors and Interventions Before Antipsychotic Administration
Penalty
Summary
The facility nurses failed to document the behaviors and nonpharmacological interventions attempted prior to administering antipsychotic medication, Seroquel IM, to a resident. This oversight was identified during a review of the facility's policy on behavior management, which mandates that targeted behaviors be identified and monitored, and appropriate nonpharmacological interventions be implemented before administering psychoactive medication. The resident in question, who had a moderately impaired cognition with a BIMS score of 12 out of 15, was admitted to the facility and had returned from the hospital. The resident's EMR indicated orders for Haldol IM as needed for agitation, but the MAR did not document any behaviors or interventions prior to the administration of the medication. The Regional Operations Manager confirmed during an interview that there was no documentation of behaviors or nonpharmacological interventions in the resident's records. The absence of documentation suggests that these steps were not completed, which could lead to the resident receiving unnecessary medication. The facility's failure to adhere to its policy on behavior management and documentation was evident in this case, as the necessary steps to justify the use of antipsychotic medication were not recorded.
Significant Medication Error Due to Insulin Unavailability
Penalty
Summary
The facility nurse failed to follow the physician's order and provide a resident with insulin according to the sliding scale order, resulting in a significant medication error. The resident, who was diagnosed with diabetes mellitus and had moderately impaired cognition, did not have the insulin available for administration. During an observation, a registered nurse (RN) attempted to administer six units of Humulin R insulin to the resident based on the Medication Administration Record (MAR), but discovered that the insulin belonged to another resident. The RN reported the unavailability of the correct insulin to the Regional Operations Manager and ordered the insulin, but the resident did not receive the insulin as ordered. The resident missed insulin doses at multiple designated times, and the facility's July MAR indicated that the resident routinely received sliding scale Humulin R insulin prior to the incident. The facility's policy required staff to compare the MAR with the medication label multiple times before administration, which was not followed in this case. The Medical Director stated that the facility should have contacted him if there was a delay in receiving the insulin, as he could have arranged for the medication to be obtained from a local pharmacy. Additionally, the nurses were expected to perform Accu-Chek tests to monitor the resident's glucose levels and notify the Medical Director of any elevated levels.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted to accurately reflect the actual staff hours available to care for the 52 current residents. This deficiency was observed on three out of four survey days. Specifically, observations on 07/28/24 at 6:43 PM, 07/29/24 at 9:30 AM and 10:40 AM, and 07/30/24 at 6:05 PM revealed that the daily nurse staffing was not posted. During an interview on 07/31/24 at 8:15 AM, the Administrator confirmed that the staffing information should have been posted in the glass display window near the front of the facility each day, but it was not posted for three of the four survey days.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jesup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Health Systems Jesup | 0.4 mi | — | 0 | 0 |
| Jesup Ridge Of Journey Llc | 2.9 mi | — | 0 | 0 |
| Coastal Manor | 12.1 mi | — | 0 | 0 |
| Glenvue Health & Rehab | 22.6 mi | — | 0 | 0 |
| Appling Nursing And Rehabilitation Pavilion | 28.7 mi | — | 0 | 0 |
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