Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Buckhead Center For Nursing And Healing during CMS and state inspections, most recent first.
Surveyors found that four of six resident shower rooms were not kept free of hazards or adequately cleaned. On one floor, razors were on the floor, dirty gloves and a comb were on a shower bed, floors were stained, an opened gallon of bath soap and a bottle of chemical-resistant spray were present, and a razor and hair clippers were in a bag on the floor along with a shower cap and toothbrush. On other floors, surveyors observed multiple opened containers of skin and hair cleaner, conditioner, and skin ointment, along with a strong urine odor. Unit managers and the Environmental Senior Director stated that CNAs were responsible for cleaning after each resident and that environmental services cleaned shower rooms daily, and acknowledged that items should not be left on the floor and that product containers should be closed.
Surveyors found that staff did not follow standard and transmission-based precautions when handling ice on two floors. On one floor, the ice scoop cover on top of the ice machine had visible black specks near the end of the scoop used to dispense ice. On another floor, the ice scoop was observed submerged in ice and water inside the cooler used to serve residents, despite the unit manager acknowledging that the scoop should not be left in the cooler. The Maintenance Director reported that maintenance cleaned and checked ice machines regularly, while nursing staff were responsible for cleaning scoops and covers. The SDC/Infection Control nurse stated that all staff had been in-serviced on hand hygiene and ice scoop protocol, including that scoops should be stored in a holder after use and never left in the ice.
The facility failed to maintain cold food at the required temperature, with coleslaw observed at 50°F during lunch service. The Dietary Aide prepared multiple bowls without using ice, contrary to policy, potentially affecting 142 residents.
A Business Office Manager, whose CNA certification had expired, was observed providing ADL care by shaving a resident with hemiplegia and moderate cognitive impairment. The BOM acted outside her job scope without family permission, highlighting a deficiency in staff training and competency assurance.
Two residents with quadriplegia and pressure ulcers did not receive consistent care in a facility, leading to the progression of ulcers. One resident's care plan initially lacked repositioning interventions, and staff failed to regularly reposition him or apply pressure-relieving devices. The other resident, severely cognitively impaired, was not repositioned as required, with no documentation of care. Staff interviews revealed a lack of adherence to standard practices, resulting in harm to the residents.
Two residents in an LTC facility were affected by the misappropriation of 49 oxycodone pills, which were unaccounted for during a narcotic count. The facility's policy requires discrepancies to be resolved or reported immediately, but this was not followed. One resident had nine pills missing, while another had 40 pills missing. An LPN admitted to concealing the discrepancy by folding the drug record page. The issue was reported by the Unit Manager, leading to an investigation by the DON.
A facility failed to develop comprehensive care plans for a resident prescribed high-risk medications, including an anticoagulant and an antidepressant. Despite policies requiring care plans with specific goals and interventions, none were created for the resident, who had a history of blood clots and depression. Interviews confirmed the oversight, revealing a lapse in the process for initiating care plans for high-risk medications.
A resident with quadriplegia and contractures did not receive consistent application of knee splints to maintain range of motion (ROM) due to staff's lack of knowledge and comfort in applying them. Despite being discharged from physical therapy with instructions for continued splint use, observations showed the splints were not applied, and staff interviews revealed uncertainty about their use. The resident was willing to comply with interventions, but the facility's failure to apply the splints consistently led to a deficiency in care.
A resident with pneumonia and severe cognitive impairment required nebulizer treatments, but the facility failed to store the nebulizer mask properly, leaving it uncovered on the nightstand. Despite the facility's policy and staff training, the mask was not placed in a bag to prevent contamination, as confirmed by staff interviews.
Failure to Maintain Safe and Clean Conditions in Multiple Resident Shower Rooms
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental controls in multiple resident shower rooms. On the 4th floor, observation with the Unit Manager showed four razors on the floor, dirty gloves and a dirty comb on a shower bed, stained/dirty floors, an opened gallon bottle of complete bath soap, and a bottle of chemical resistant spray in the shower room. A razor and hair clippers were found in a black bag on the floor, and a shower cap and toothbrush were lying on the floor. The 4th floor Unit Manager stated that CNAs were supposed to clean up before showering residents and acknowledged that the items found should not be on the floor. The Environmental Senior Director reported that shower rooms were cleaned daily, with responsibilities including cleaning high-touch areas, sweeping and mopping floors, removing linen, and cleaning the area, and stated there had been no complaints about showers not being cleaned. On the 3rd floor, observation with the Unit Manager revealed an open bottle of skin and hair cleaner, an open bottle of conditioner, and an open bottle of skin ointment in the resident shower room. The 3rd floor Unit Manager stated that items in the shower room should be closed and that CNAs were to clean after each resident. On the 2nd floor, observation with the Unit Manager revealed two opened gallon containers of skin and hair cleaner and a strong urine odor in the shower room. The 2nd floor Unit Manager stated that the soap should have a top on it and that CNAs were responsible for cleaning after each resident. These observations and interviews showed that four of six resident shower rooms were not maintained free of hazards and were not cleaned as expected by facility staff, creating the potential for injury and spread of infection as stated in the report.
Improper Ice Scoop Handling and Storage Breaches Infection Control Protocol
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper handling and storage of ice scoops on two of four floors. On the 4th floor, observation of the ice scoop and scoop cover showed black specks near the end of the scoop used to put ice in cups, and the scoop cover was located on top of the ice machine. The 4th floor Unit Manager stated that kitchen staff cleaned the scoops once a week and acknowledged that the scoop should be clean. On the 3rd floor, observation of the ice chest/cooler used to serve residents revealed the ice scoop submerged in ice and water. The 3rd floor Unit Manager later confirmed that the ice scoop was not supposed to be left in the cooler. The Maintenance Director reported that maintenance staff were responsible for cleaning the ice machines, which were checked weekly and monthly, while nursing staff were responsible for cleaning the ice scoops and covers. The Staff Development Coordinator/Infection Control staff stated that all staff had been trained in infection control procedures, including hand hygiene and handling of the ice scoop and holder, and that staff had been educated that the ice scoop should be placed in the scoop holder after use and never left in the ice. Documentation in the maintenance logbook showed monthly checks and cleaning of all four ice machines, and the ice machine cleaning log showed that the ice machines on the 2nd, 3rd, and 4th floors and in the kitchen had been cleaned on specific dates. Staff training records indicated that an in-service on handwashing and ice scoop protocol had been provided for all staff.
Cold Food Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain the required temperature for cold food, specifically coleslaw, which was observed to be above the safe temperature threshold. During a lunch service, the Dietary Manager (DM) noted that the prepared bowls of coleslaw registered at 50 degrees Fahrenheit, which is above the maximum safe temperature of 41 degrees Fahrenheit. This was contrary to the facility's policy that mandates cold food to be held at 41 degrees Fahrenheit or colder to prevent the growth of pathogens that cause foodborne illnesses. The Dietary Aide (DA) had prepared multiple bowls of coleslaw without placing them on ice, which contributed to the temperature rise. Although the DM stated that the coleslaw temperature was initially below 40 degrees Fahrenheit before service, the DA did not follow the procedure of preparing one bowl at a time or using ice to maintain the temperature. This oversight had the potential to affect 142 of the 153 residents receiving an oral diet at the facility.
Unqualified Staff Member Provides ADL Care
Penalty
Summary
The facility failed to ensure that clinical staff were trained and competent to provide Activities of Daily Living (ADL) care, as evidenced by an incident involving the Business Office Manager (BOM) providing such care to a resident. The BOM, whose certification as a Certified Nursing Assistant (CNA) had expired, was observed shaving a resident with hemiplegia, hemiparesis, and moderate cognitive impairment. The resident required substantial/maximal assistance for ADLs, and the BOM was not authorized to perform this task as it was outside her job scope. The BOM admitted to shaving the resident because he was her friend and had requested it, despite not having permission from the resident's family. The facility's Administrator confirmed that the BOM should not have been performing this task, as it was not within her responsibilities and she was not a certified CNA. This incident highlights a deficiency in the facility's training and competency assurance for staff, potentially affecting the care of all residents.
Inconsistent Pressure Ulcer Care Leads to Harm
Penalty
Summary
The facility failed to provide consistent care and services for two residents, R56 and R63, who were at risk for pressure ulcers. R56, who was admitted with quadriplegia and existing pressure ulcers, did not have turning and repositioning documented as an intervention in his care plan until after his ulcers progressed to a Stage 4 and an unstageable wound. Observations and interviews revealed that R56 was not regularly repositioned, and staff were inconsistent in applying pressure-relieving devices such as heel boots. Despite the presence of an air mattress and wedges, there was no documentation of regular repositioning, and staff interviews indicated a lack of adherence to a consistent repositioning schedule. R63, also diagnosed with quadriplegia and severe cognitive impairment, had pressure ulcers upon admission that were not adequately managed. The care plan indicated the need for turning and repositioning, but observations showed that R63 was not repositioned for extended periods, and there was no documentation of repositioning in the Plan of Care. Interviews with staff, including the Director of Nursing and the MDS Nurse, confirmed that repositioning every two hours was a standard practice, yet this was not consistently implemented or documented for R63. The lack of consistent implementation and documentation of repositioning and the use of pressure-relieving devices for both residents led to the development and worsening of pressure ulcers. Staff interviews revealed a reliance on verbal communication and informal practices rather than documented care plans, contributing to the deficiency in care. The facility's failure to adhere to standard practices for pressure ulcer prevention and management resulted in harm to the residents, as evidenced by the progression of R56's ulcers and the inadequate care for R63's existing wounds.
Misappropriation of Narcotics in LTC Facility
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medications, specifically oxycodone, when 49 pills were unaccounted for during a narcotic count. The facility's policy on Controlled Substance Administration and Accountability requires that any discrepancies in the count of controlled substances be resolved by the end of the shift or reported immediately if unresolved. However, this protocol was not followed, leading to the misappropriation of medications for two residents. The first resident, R115, was admitted with conditions including lymphedema and chronic peripheral venous insufficiency. The resident was cognitively intact and had a care plan focusing on pain management, which included the administration of oxycodone as needed. A review of the controlled drug record revealed that nine oxycodone tablets were missing. The second resident, R226, had a history of Alzheimer's Disease and chronic ulcers, with a care plan addressing chronic pain. The controlled drug record indicated that 40 oxycodone tablets were missing. The investigation revealed that LPN5, a contracted agency staff member, was responsible for counting the narcotics but failed to report the missing medications at the beginning of her shift. She admitted to folding the controlled drug record page to conceal the discrepancy. LPN4, the Unit Manager, discovered the missing medications and reported the issue to the DON, who initiated an investigation. Interviews with involved staff confirmed the misappropriation, but attempts to interview LPN6 and LPN8 were unsuccessful.
Failure to Develop Comprehensive Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop comprehensive care plans with resident-specific goals and interventions for a resident who was prescribed high-risk medications, including an anticoagulant and an antidepressant. The facility's policies on High-Risk Medications - Anticoagulants and Comprehensive Care Plans require that care plans include interventions to minimize adverse consequences and measurable objectives to meet the resident's needs. However, a review of the electronic medical record (EMR) for the resident revealed that no care plan had been developed for the use of these medications, despite the resident having a history of venous thrombosis and embolism and a diagnosis of depression. Interviews with the Director of Nursing (DON) and the MDS Coordinator confirmed the oversight. The DON verified that the care plan did not include specific goals and interventions for the medications, while the MDS Coordinator explained that the process involves reviewing an action printout for MDS and nurses to verify and implement a plan of care. The MDS Coordinator acknowledged that the need for a care plan was overlooked, indicating a lapse in the facility's process for ensuring that care plans are initiated for high-risk medications.
Failure to Apply Knee Splints for Resident with Quadriplegia
Penalty
Summary
The facility failed to consistently apply knee splints for a resident with quadriplegia and contractures, leading to a deficiency in maintaining the resident's range of motion (ROM). The resident, who was dependent on staff for all Activities of Daily Living (ADL) care, had been discharged from physical therapy with instructions for the nursing staff to continue using knee splints to maintain ROM. However, observations revealed that the splints were not being applied, and interviews with staff indicated a lack of knowledge and comfort in applying the splints. The resident's care plan included interventions for maintaining ADL functions, but the necessary application of knee splints was not consistently executed. Interviews with the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) revealed that staff were unsure about the use of the assistive devices and lacked proper training or assistance from the therapy department. The Rehab Director confirmed that the nursing team was provided with the knee splints and education on their application, but the staff did not feel comfortable applying them. The resident expressed willingness to comply with interventions to prevent contractures and denied declining care, contradicting staff claims. Despite the Rehab Director's confirmation that the splints were effective in slowing contracture progression, the facility's failure to apply them consistently resulted in a deficiency in care for the resident.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to properly store a nebulizer mask to prevent cross-contamination for a resident who required respiratory care. The facility's policy on nebulizer therapy, revised in March 2023, mandates that the nebulizer cup and mouthpiece be stored in a zip lock bag once dry. However, observations on two consecutive days revealed that the resident's nebulizer mask was left uncovered on the nightstand next to the nebulizer machine. Interviews with staff confirmed that the mask should have been stored in a bag when not in use, as per the facility's policy. The resident in question was admitted with a diagnosis of pneumonia and required nebulizer treatments for shortness of breath. The resident was severely cognitively impaired, as indicated by a score of zero on the Brief Interview for Mental Status. Despite the facility's policy and training provided to the nursing staff, the nebulizer mask was not stored properly, and the night shift nurse failed to change the tubing and mask or place it in a bag. The Director of Nursing and the Director of Respiratory Services acknowledged the oversight, noting that the mask and tubing should be changed weekly and stored in a bag to prevent contamination.
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 300 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — 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 Atlanta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Commons | 1.3 mi | — | 0 | 0 |
| Terraces At Peachtree Hills Place, The | 2.1 mi | — | 0 | 0 |
| Pruitthealth - Virginia Park | 2.5 mi | — | 0 | 0 |
| A.g. Rhodes Home, Inc, The | 3.1 mi | — | 8 | 0 |
| Legacy Transitional Care & Rehabilitation | 3.1 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Buckhead Center For Nursing And Healing.
100% money-back within 48 hours.
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.