Inspection Reports for Anderson Mill Center for Nursing and Healing LLC
2130 ANDERSON MILL RD, GA, 30106
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 23, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a survey completed on 06/23/2025 at Anderson Mill Center for Nursing and Healing LLC.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Jun 23, 2025
Visit Reason
A revisit survey was conducted on June 23, 2025, including investigation of Complaint Intake Number GA00254962.
Findings
The complaint was found unsubstantiated, and all deficiencies cited in the May 2, 2025 recertification and complaint survey were corrected.
Complaint Details
Complaint Intake Number GA00254962 was investigated and found unsubstantiated.
Report Facts
Facility census: 120
Inspection Report
Life Safety
Census: 163
Capacity: 170
Deficiencies: 0
May 14, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Census: 163
Certified beds: 170
Inspection Report
Annual Inspection
Deficiencies: 2
May 2, 2025
Visit Reason
A State Licensure survey was conducted at Anderson Mill Center for Nursing and Healing from April 29, 2025, through May 2, 2025, to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to provide routine drugs for one resident due to pharmacy issues with a schedule IV-controlled substance, and failure to establish an infection prevention and control program evidenced by improper use of personal protective equipment and hand hygiene during medication administration for two residents.
Deficiencies (2)
| Description |
|---|
| Failure to provide routine drugs or obtain them under an agreement for one of 32 sampled residents; pharmacy failed to notify nursing of the need for additional information to supply a schedule IV-controlled substance. |
| Failure to establish an infection prevention and control program including improper use of PPE and hand hygiene during medication administration for two residents. |
Report Facts
Sampled residents: 32
Medication dose missed: 1
Residents observed for infection control: 3
Residents with PPE/hand hygiene deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Observed not administering prescribed medication and not performing hand hygiene during medication administration |
| EE | Registered Nurse (RN) Unit Manager | Interviewed regarding medication delivery issues and pharmacy communication |
| CC | Licensed Practical Nurse (LPN) | Observed not donning required PPE during medication administration |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 3
May 2, 2025
Visit Reason
A standard survey was conducted from April 29, 2025 through May 2, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Anderson Mill Center for Nursing and Healing.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide routine drugs due to pharmacy issues, medication errors exceeding 5% for one resident, and failure to implement proper infection prevention and control practices including inadequate use of PPE and hand hygiene during medication administration.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, revealing noncompliance with federal regulations.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide routine drugs or obtain them under an agreement for one resident; pharmacy failed to notify nursing of need for additional information to supply a schedule IV-controlled substance. | D |
| Medication error rate was 6.89% for one resident, exceeding the 5% threshold, including incorrect medication administration and documentation errors. | D |
| Failed to establish an infection prevention and control program including proper use of PPE and hand hygiene during medication administration for two residents. | D |
Report Facts
Census: 128
Medication error rate: 6.89
Medication administration opportunities: 29
Residents sampled: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Named in medication administration errors and failure to perform hand hygiene |
| EE | Registered Nurse (RN) Unit Manager | Interviewed regarding medication availability and pharmacy communication |
| CC | Licensed Practical Nurse (LPN) | Observed failing to use proper PPE during medication administration |
Inspection Report
Abbreviated Survey
Census: 141
Deficiencies: 0
Feb 15, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00243698, GA00243620, GA00242500, and GA00241696.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00243698, GA00243620, GA00242500, and GA00241696 were investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Nov 20, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Anderson Mill Center for Nursing and Healing LLC, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 136
Deficiencies: 0
Nov 20, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 13, 2023 Complaint Survey.
Findings
All deficiencies cited as a result of the October 13, 2023 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on October 13, 2023, with all cited deficiencies corrected.
Report Facts
Census: 136
Inspection Report
Abbreviated Survey
Deficiencies: 1
Oct 13, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 10/11/2023 to 10/13/2023 to investigate multiple complaints, including GA00235938, GA00236201, GA00236573, GA00236660, GA00238554, and GA00239662.
Findings
The investigation found that five complaints were unsubstantiated, while one complaint (GA00239662) was substantiated with a deficiency related to failure to provide timely and appropriate incontinence care for one resident, which had the potential to promote infection.
Complaint Details
Complaints GA00235938, GA00236201, GA00236573, GA00236660, and GA00238554 were unsubstantiated. Complaint GA00239662 was substantiated with deficiency related to incontinence care.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely and appropriate incontinence care for one resident, including not removing stool before pressure ulcer care and not providing frontal incontinence care after a bowel movement. | SS= D |
Report Facts
Complaint identifiers investigated: 6
MDS date: Jul 13, 2023
Care plan date: Jul 19, 2023
Observation date and time: Oct 12, 2023
Follow-up observation time: 1133
Interview date and time: Oct 12, 2023
Interview date and time: Oct 13, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse | Observed pressure ulcer care and described incontinence care practices | |
| Consultant Wound Nurse | Observed pressure ulcer care and described incontinence care practices | |
| Director of Nursing | Director of Nursing | Interviewed regarding proper incontinence care procedures |
Inspection Report
Routine
Deficiencies: 1
Oct 13, 2023
Visit Reason
A State Licensure survey was conducted at Anderson Mill Center for Nursing and Healing, LLC from October 11, 2023 through October 13, 2023 to assess compliance with state health regulations.
Findings
The facility failed to provide timely and appropriate incontinence care for one of four residents reviewed, specifically resident R7, which had the potential to promote infection. Observations and interviews revealed inadequate incontinence care during pressure ulcer treatment.
Deficiencies (1)
| Description |
|---|
| Failure to provide timely and appropriate incontinence care for resident R7, including not providing frontal incontinence care during pressure ulcer treatment. |
Report Facts
Residents reviewed for incontinence care: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Nurse (WCN) | Provided pressure ulcer care and involved in observation of deficient incontinence care | |
| Consultant Wound Nurse (CWN) | Assisted in pressure ulcer care and involved in observation of deficient incontinence care | |
| Certified Nursing Assistant (CNA) | Called to assist during pressure ulcer care but delayed response noted | |
| Director of Nursing (DON) | Interviewed regarding proper incontinence care procedures |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Jun 6, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers from May 23, 2023 to June 6, 2023.
Findings
All complaints investigated were unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaints GA00233936, GA00234252, GA00234335, GA00234337, GA00234388, GA00234454, GA00234473, GA00234500, and GA00235330 were investigated and found to be unsubstantiated.
Report Facts
Resident Census: 133
Inspection Report
Follow-Up
Deficiencies: 0
May 16, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Plan of Correction
Deficiencies: 0
May 11, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Anderson Mill Center for Nursing and Healing LLC following a regulatory inspection.
Findings
The document does not contain any detailed findings or deficiencies; it appears to be a blank or placeholder form for reporting deficiencies and corrective actions.
Inspection Report
Re-Inspection
Census: 139
Deficiencies: 0
May 11, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 11, 2023 Standard Survey.
Findings
All deficiencies cited in the March 11, 2023 Standard Survey were found to be corrected during the May 11, 2023 revisit survey.
Inspection Report
Census: 137
Deficiencies: 0
May 4, 2023
Visit Reason
A Federal Focused Concern Survey was completed by the Centers for Medicare & Medicaid Services (CMS) on May 3-4, 2023.
Findings
The facility was found in compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 24, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 04/17/2023 and 04/23/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's NHSN during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Census: 135
Deficiencies: 0
Apr 20, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate GA00234409 on April 20, 2023.
Findings
No deficiencies were cited as a result of this survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 17, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN) during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the NHSN between 04/10/2023 and 04/16/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Renewal
Deficiencies: 3
Mar 11, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from March 7, 2023 through March 11, 2023 to assess compliance with licensure requirements.
Findings
The facility was found deficient in medication storage practices, infection control procedures, and environmental cleanliness. Specific issues included unlocked medication carts, unlabeled and expired medications, failure to clean reusable resident equipment and surfaces between residents, inadequate hand hygiene, and unsanitary conditions in multiple resident rooms and restrooms.
Deficiencies (3)
| Description |
|---|
| Medication carts were left unlocked and unsecured when unattended; multiple medications were unlabeled or expired; improper disposal and storage of medications. |
| Failure to clean or disinfect reusable resident equipment and surfaces between residents; inadequate hand hygiene during resident care. |
| Unsafe, unclean, and unsanitary environment in 13 of 76 resident rooms including buildup of brown and white fuzzy material on heating/cooling units and ceiling vents, black substance around toilets, and other cleanliness issues. |
Report Facts
Medication carts inspected: 6
Residents sampled for infection control: 64
Resident rooms inspected: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed discarding expired medication improperly and verifying medications on 500 Hall medication cart |
| RN GG | Registered Nurse | Observed leaving medication cart unlocked and unattended on 600 Hall |
| LPN DD | Licensed Practical Nurse | Observed performing glucometer checks without proper hand hygiene or surface cleaning |
| Medication Technician CC | Medication Technician | Observed verifying medications on 600 Hall medication cart |
| Director of Nursing | Director of Nursing | Provided expectations and plans for re-education on medication storage, infection control, and hand hygiene |
| Housekeeping AA | Housekeeping Staff | Interviewed regarding cleaning responsibilities and awareness of environmental deficiencies |
| Maintenance Director | Maintenance Director | Verified environmental deficiencies and described cleaning responsibilities |
| Director of Housekeeping | Director of Housekeeping | Described cleaning schedules and responsibilities, and plans for education |
| Administrator | Administrator | Provided expectations for cleanliness and plans for staff education |
Inspection Report
Routine
Census: 143
Deficiencies: 7
Mar 11, 2023
Visit Reason
A standard survey was conducted from March 7, 2023 through March 11, 2023, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure resident dignity and respect, failure to assess resident self-administration of medications, failure to maintain a safe and sanitary environment in multiple resident rooms, failure to submit PASARR Level II screenings for two residents, failure to administer oxygen therapy according to physician orders, failure to properly store and label medications, and failure to ensure appropriate infection control practices.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey as listed in the report.
Severity Breakdown
SS= D: 5
SS= E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure resident right to dignity and respect related to catheter privacy and staff knocking on doors before entering rooms. | SS= D |
| Failed to ensure one resident was assessed for self-administration of medications. | SS= D |
| Failed to maintain a safe, clean, sanitary environment in 13 resident rooms with buildup of fuzzy material on heating/cooling units and vents, black substance around toilets, and splatter on walls. | SS= D |
| Failed to submit PASARR Level II screening for two residents requiring evaluation for specialized services. | SS= D |
| Failed to ensure oxygen therapy was administered according to physician orders and oxygen tubing was dated and labeled. | SS= D |
| Failed to ensure proper medication storage including locking medication carts when unattended, labeling opened medications, discarding expired medications, and proper refrigeration. | SS= E |
| Failed to ensure appropriate infection control practices including cleaning reusable equipment between residents, using barriers or cleaning surfaces before placing equipment, and performing hand hygiene during resident care. | SS= E |
Report Facts
Resident census: 143
Number of resident rooms with unsafe sanitary conditions: 13
Number of sampled residents: 64
Liters per minute oxygen: 5
Liters per minute oxygen ordered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN QQ | Licensed Practical Nurse | Confirmed catheter bag should be in privacy bag for resident #44 |
| CNA II | Certified Nursing Assistant | Admitted to not knocking on resident doors before entering |
| CNA JJ | Certified Nursing Assistant | Admitted to not knocking on resident doors before entering |
| Director of Nursing | Director of Nursing | Provided expectations on knocking on doors, medication self-administration, infection control, and medication cart security |
| LPN MM | Licensed Practical Nurse | Removed medications from resident room #97 |
| LPN NN | Licensed Practical Nurse | Unaware of residents self-administering medications |
| LPN OO | Licensed Practical Nurse | Unaware of residents self-administering medications |
| LPN PP | Licensed Practical Nurse | Unaware of residents self-administering medications |
| Housekeeping AA | Housekeeping Staff | Aware of unsanitary conditions on vents and toilets but did not clean them |
| Maintenance Director | Maintenance Director | Verified unsanitary conditions and responsibilities for cleaning vents and toilets |
| Director of Social Services | Director of Social Services | Responsible for PASARR Level II screenings; confirmed missing screenings for residents #102 and #61 |
| LPN HH | Licensed Practical Nurse | Observed leaving medication cart unlocked |
| RN GG | Registered Nurse | Observed leaving medication cart unlocked |
| LPN BB | Licensed Practical Nurse | Discarded expired medication improperly |
| Medication Technician CC | Medication Technician | Observed unlabeled and expired medications on medication cart |
| LPN FF | Licensed Practical Nurse | Observed unlabeled and expired medications on medication cart |
| LPN DD | Licensed Practical Nurse | Observed unlabeled and expired medications on medication cart and improper glucometer use |
Inspection Report
Life Safety
Census: 145
Capacity: 170
Deficiencies: 3
Mar 9, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with cooking facility safety devices, corridor door latching, and electrical panel labeling. These deficiencies affected 1 of 6 smoke compartments.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| In the kitchen, one of the hood suppression spray head caps was found off the head and needed replacement. | SS= D |
| Resident room door for #614 would not close completely to latch as required, risking smoke spread. | SS= D |
| The electrical panel in the laundry room did not list which circuit controlled which, failing to meet electrical safety requirements. | SS= D |
Report Facts
Smoke Compartments affected: 1
Certified beds: 170
Census: 145
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Feb 15, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints #GA00221067 and #GA00220571.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and implemented CMS and CDC recommended practices for COVID-19. Complaint #GA00220572 was substantiated with no deficiency cited, and complaint #GA00221067 was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint #GA00220572 was substantiated with no deficiency cited. Complaint #GA00221067 was unsubstantiated with no deficiencies cited.
Report Facts
Total census: 101
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