Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens 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 Colquitt Regional Senior Care & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to implement an effective Antibiotic Stewardship Program, leading to the prescription of antibiotics without proper diagnostic testing or symptom documentation. Over several months, multiple residents were prescribed antibiotics despite not meeting McGreer's criteria for infection. The Infection Preventionist and Director of Nursing confirmed the lack of interventions for these cases, and the facility's ASP data collection was inconsistent.
The facility failed to provide required transfer notices to three residents and their representatives before transferring them to the ER, as well as failed to notify the State LTC Ombudsman of these transfers. The transfer forms lacked information on appeal rights and Ombudsman contact details. The facility's administrator confirmed that prior to May 2024, transfer notices were not sent to the Ombudsman, and some transfers were omitted from the lists sent thereafter.
The facility failed to implement care plans for monitoring psychotropic medications for two residents. One resident was prescribed Aripiprazole and Escitalopram Oxalate without monitoring for side effects or behaviors, despite a care plan indicating such interventions. Another resident was prescribed Celexa, but monitoring for side effects and efficacy was not conducted until months later. The DON confirmed these oversights during interviews.
A facility failed to document discharge needs and assessment for a resident discharged home with a femur fracture. Despite being cognitively intact, there was no record of discharge needs or assessment in the progress notes. Discharge instructions lacked prior assessment documentation. Staff interviews revealed gaps in communication and documentation, with expectations for discharge documentation not being met.
A facility failed to document pressure ulcer dressing changes for a resident, leading to a lack of communication among staff. The facility's policy requires detailed documentation of treatments, but a review of the resident's progress notes showed only one entry over a two-month period. Interviews with the WN/RN and DON confirmed that documentation was inconsistent, despite instructions to record each dressing change.
A facility failed to document and collaborate effectively for a resident requiring dialysis care. The resident, with end-stage renal disease, had incomplete documentation on the Dialysis Transfer Form, missing vital signs, assessments, and signatures. Staff interviews confirmed these deficiencies, highlighting a lack of communication between the facility and the dialysis center.
The facility failed to accurately post daily nurse staffing information, as required by their policy, leading to outdated and incomplete data being displayed. The staffing document did not include certain CNAs, and the responsibility for posting was divided between the DON and RN Supervisor. This resulted in potential misinformation about the nursing staff available to care for the 54 residents.
Deficient Antibiotic Stewardship Program in LTC Facility
Penalty
Summary
The facility failed to develop an effective Antibiotic Stewardship Program (ASP) to monitor antibiotic use, as evidenced by the prescription and administration of antibiotics to residents without appropriate diagnostic testing or documented symptomology. The facility's policy on Antibiotic Stewardship, dated September 2022, required antibiotics to be prescribed and administered under the guidance of the ASP and Quality Assurance and Performance Improvement (QAPI) Committee. However, the facility's ASP data collection was inconsistent, with missing data for February 2024 and no interventions documented for residents whose symptoms did not meet McGreer's criteria for infection. Throughout the months from December 2023 to July 2024, multiple instances were noted where residents were prescribed antibiotics despite their symptoms not meeting McGreer's criteria. For example, in December 2023, three residents were prescribed antibiotics without meeting the criteria, and similar patterns were observed in subsequent months. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that there was no evidence of interventions for these cases, and the facility's ASP was not in place prior to December 2023. Interviews with the IP/DON revealed that the facility used McGreer's criteria to guide the ASP, but there was a lack of evidence for interventions or corrective actions for infections that did not meet the criteria. The IP/DON acknowledged the absence of ASP data for February 2024 and confirmed that no additional interventions were implemented beyond a June 2024 inservice on hand hygiene and perineal care. This deficiency in the ASP has the potential to affect all residents in the facility, with a census of 54 residents.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide a written transfer or discharge notice with the required content to three residents and their representatives before transferring them to the emergency room. The facility's policy on transfer or discharge documentation mandates that appropriate notice be documented in the medical record when a resident is transferred. However, for three residents, there was no documentation in their electronic medical records indicating that they or their representatives were provided with the necessary transfer notice. These residents were transferred to the emergency room due to various medical conditions, including vomiting, abdominal pain, fever, and pneumonia, but the facility did not document the provision of transfer notices. Additionally, the facility did not notify the State LTC Ombudsman office of the transfers or discharges of these residents. The transfer forms provided to the residents' representatives lacked essential information, such as the residents' appeal rights and the contact details of the State Ombudsman office. The facility's administrator confirmed that prior to May 2024, the facility was not sending transfer notices to the State LTC Ombudsman. Although the facility began sending lists of transfers and discharges to the Ombudsman in May 2024, some transfers, including those of the residents in question, were not included in these lists.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to implement a care plan for monitoring the use of psychotropic medications for two residents, R154 and R31. For R154, the facility's policy on antipsychotic medication use was not followed, as there was no monitoring of side effects or behaviors related to the psychotropic medications prescribed, including Aripiprazole and Escitalopram Oxalate. Despite having a care plan that included interventions for mood issues, the Medication Administration Record (MAR) for August 2024 showed no evidence of monitoring for side effects or worsening behaviors. The Director of Nursing (DON) confirmed the lack of monitoring during an interview. Similarly, for R31, the facility did not monitor the side effects or efficacy of the antidepressant Celexa, which was prescribed to manage anxiety and depression. Although the care plan included monitoring for side effects and effectiveness, the MARs for May, June, and July 2024 showed no evidence of such monitoring. It was only on August 12, 2024, that monitoring was initiated. The DON acknowledged that the orders and MAR did not include monitoring conditions for Celexa, confirming the oversight during an interview.
Failure to Document Discharge Needs and Assessment
Penalty
Summary
The facility failed to document discharge needs and assessment for a resident, identified as R44, who was discharged home. R44 was admitted with a diagnosis of a fracture of the right femur and was cognitively intact with a BIMS score of 15 out of 15. However, there was no documentation in the progress notes regarding the discharge needs or assessment for R44, nor was there a record of the discharge date. The discharge instructions provided were dated and included information about medical equipment and a home health company, but lacked documentation of an assessment prior to discharge. Interviews with facility staff revealed gaps in the discharge process. The Social Services Director mentioned discussing equipment needs with R44's husband and faxing a referral to a home health agency, but there was no documentation confirming the agency received the referral. The LPN confirmed the absence of a discharge assessment in the progress notes. The DON and Administrator both expressed expectations for discharge documentation, including details about the resident's condition, medications, and equipment needs, which were not met in this case.
Failure to Document Pressure Ulcer Care
Penalty
Summary
The facility failed to document pressure ulcer dressing changes for a resident, identified as R49, which resulted in a lack of communication among staff involved in the resident's care. The facility's policy on Charting and Documentation requires detailed documentation of procedures and treatments, including the date and time, the name and title of the caregiver, assessment data, and the resident's response to treatment. However, a review of R49's progress notes from June 2024 to August 12, 2024, revealed only one entry on August 3, 2024, indicating that the wound was cleaned and bandaged per physician orders, with no further documentation of wound care. Interviews with the Wound Nurse/Registered Nurse (WN/RN) and the Director of Nursing (DON) confirmed that a progress note should be made each time a wound care dressing is performed, detailing the wound's appearance, drainage, odor, size, and improvement or deterioration. The WN/RN admitted to sometimes forgetting to document in both the Treatment Administration Record (TAR) and the progress notes. The DON stated that she had instructed the wound care nurse to make a progress note for each dressing change a couple of months prior, but this was not consistently followed, leading to the deficiency in documentation.
Incomplete Dialysis Documentation and Collaboration
Penalty
Summary
The facility failed to provide complete documentation and collaboration for a resident requiring dialysis care. The resident, identified as R9, was readmitted with diagnoses of end-stage renal disease and chronic kidney disease. The facility's policy and the dialysis contract required comprehensive documentation of dialysis services, including laboratory values, vital signs, medications, and any changes in the resident's medical status. However, the review of R9's Dialysis Transfer Form revealed incomplete documentation, with missing pre and post-dialysis assessments, signatures, dates, and times. The dialysis center also failed to complete sections of the form that were their responsibility. Interviews with staff, including an LPN and the DON, confirmed the deficiencies in documentation. The LPN acknowledged that the nurse should fill out vital signs and any changes in the resident's condition to inform the dialysis center. The DON confirmed that all areas of the pre and post-dialysis assessments should be completed by the nurse and that any missing documentation from the dialysis center should be addressed by contacting them and having the form completed. This lack of documentation and communication resulted in a deficiency in the care provided to R9.
Inaccurate Posting of Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was accurately posted to reflect the actual staff hours available to care for the 54 residents. The facility's policy required that the number of nursing personnel responsible for providing direct care to residents be posted daily for each shift within two hours of the beginning of each shift. However, an observation on 8/11/2024 revealed that the posted staffing information was outdated, showing the date of 8/9/2024 and indicating 52 residents instead of the current 54. This discrepancy was noted during a survey, and it was found that the document was not updated as required. Interviews with the Administrator revealed that the responsibility for posting the staffing information was assigned to the Director of Nursing (DON) during weekdays and the RN Supervisor on weekends. However, the daily nurse staffing document did not include certain CNAs, such as the rehabilitation CNA, the bath CNA, and the multipurpose CNA. The Administrator admitted that these CNAs were not included in the nursing schedule to prevent other CNAs from perceiving there were extra staff and potentially calling off. This omission led to inaccurate staffing information being posted, which could misinform residents, family members, or visitors about the available nursing staff.
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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 Moultrie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth - Moultrie | 0.7 mi | — | 0 | 0 |
| Pruitthealth - Magnolia Manor | 1 mi | — | 0 | 0 |
| Pruitthealth - Sunrise | 1.1 mi | — | 0 | 0 |
| Southwell Health And Rehabilitation | 20.3 mi | — | 5 | 0 |
| Thomasville Vistas Of Journey Llc | 21.5 mi | — | 25 | 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.