Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
NANCY HART OPERATION LLC
ELBERTON, GA · 67 certified beds · Last Life Safety survey July 24, 2025
CMS Certification Number 115686 · first certified October 2003
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed January 1, 2024 (change of ownership)from NANCY HART CENTER FOR NURSING AND HEALING LLC
Position within GA
25 citations — more than 97% of the 356 certified nursing homes in GA. Compared within GA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to March 2027. This facility’s last Life Safety survey was July 2025. Facilities in GA are typically surveyed 14–20 months after the last one (median 16), measured over 532 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 25 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in GA, and nationally. Surveyors differ markedly between states, so the GA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in GA | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 6, 2023 | 8 |
| February 29, 2024 | 11 |
| July 24, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 3 | 2025-07-24 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-07-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-07-24 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2025-07-24 |
| E-0030 | List the names and contact information of those in the facility. | 2 | 2025-07-24 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-01-06 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-02-29 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2023-01-06 |
What the citations cover
- Smoke Deficiencies 10
- Emergency Preparedness Deficiencies 5
- Egress Deficiencies 5
- Miscellaneous Deficiencies 2
- Other 3
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Emergency Preparedness Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Miscellaneous Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 24, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 7, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 7, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 7, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 7, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 7, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 7, 2025) |
February 29, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (April 14, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (May 23, 2024) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (May 23, 2024) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (May 23, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 14, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 14, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 23, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 14, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 14, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 14, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 14, 2024) |
January 6, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 20, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (February 20, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.