Inspection Reports for
Baptist Village, Inc.
2650 CARSWELL AVE, WAYCROSS, GA, 31502
Back to Facility Profile45 Reports
Inspection Report — Dec 4, 2025
Annual Inspection CMS
Date: Dec 4, 2025
Visit Reason
Annual inspection survey of Baptist Village, Inc. nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report — Nov 15, 2024
State
Date: Nov 15, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Baptist Village, Inc., indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report — Nov 15, 2024
Re-Inspection State
Date: Nov 15, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 19, 2024, Recertification with Complaint Survey.
Findings
All deficiencies cited in the prior Recertification with Complaint Survey were found to be corrected during this revisit survey.
Inspection Report — Nov 4, 2024
Follow-Up State
Date: Nov 4, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
The survey found that all previously cited deficiencies were corrected except for doors with self-closing devices that did not latch upon closing in several locations.
Deficiencies (1)
Doors in an exit passageway, stairway enclosure, or hazardous area enclosure did not latch upon closing in Room 173, Room 712, Room 194, and an unnumbered door next to Room 145.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed the findings of doors not latching upon closing during the tour of the facility. |
Inspection Report — Sep 20, 2024
Life Safety State
Date: Sep 20, 2024
Visit Reason
The visit was a Life Safety Code Survey 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 fire safety requirements, specifically regarding self-closing doors that failed to latch and sprinkler system maintenance issues including wiring attached to sprinkler piping.
Deficiencies (2)
Doors in an exit passageway, stairway enclosure, or hazardous area enclosure failed to self-close and positively latch upon closing at multiple locations including Rooms 173, 316, 712, 194, and an unnumbered door next to Room 145.
Technical or electrical wiring was attached to sprinkler piping above Room 314, violating sprinkler system maintenance requirements.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door latch failures and wiring attached to sprinkler piping during facility tour |
Inspection Report — Sep 19, 2024
Annual Inspection State
Date: Sep 19, 2024
Visit Reason
A State Licensure survey was conducted at Baptist Village, Inc. from September 17, 2024, through September 19, 2024, to assess compliance with state health regulations.
Findings
The facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of two of four sampled residents with indwelling urinary catheters, potentially diminishing their quality of life.
Deficiencies (1)
The facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of two of four sampled residents (R71 and R94) with indwelling urinary catheters.
Report Facts
Number of sampled residents with uncovered catheter bags: 2
Survey dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Confirmed that urinary catheter drainage bags for residents R71 and R94 were uncovered and later covered. |
| AA | Assistant Director of Nursing (ADON) | Revealed that all residents with urinary catheters should have the drainage bag in a privacy bag. |
Inspection Report — Sep 19, 2024
Routine State
Date: Sep 19, 2024
Visit Reason
A standard survey was conducted from September 17 through September 19, 2024, including investigation of multiple complaint intake numbers which were unsubstantiated without deficiencies.
Complaint Details
Complaint Intake Numbers GA00237574, GA00238572, GA00242650, GA00241716, GA00244104, and GA00245656 were investigated and found unsubstantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to protect dignity of residents with urinary catheters and failure to implement care plan interventions, including incorrect oxygen therapy administration for sampled residents.
Deficiencies (3)
Failure to ensure urinary catheter drainage bags were covered to protect the dignity of two residents with indwelling urinary catheters.
Failure to implement care plan interventions for two residents, potentially resulting in inadequate treatment or care.
Failure to administer oxygen therapy in accordance with physician orders for two residents, including incorrect oxygen flow rates.
Report Facts
Complaint Intake Numbers investigated: 6
Residents sampled: 48
Residents with urinary catheter dignity issue: 2
Residents with care plan intervention failure: 2
Oxygen flow rate orders: 2
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Confirmed urinary catheter drainage bags were uncovered and oxygen flow rates were incorrect for residents R71, R94, and R66 |
| AA | Assistant Director of Nursing (ADON) | Stated expectations for urinary catheter privacy bags and oxygen flow rate monitoring |
| CC | Licensed Practical Nurse (LPN) | Verified and adjusted oxygen flow rate for resident R66 |
| FF | MDS Coordinator | Stated nursing staff responsibility for ensuring resident care plans were followed |
Inspection Report — Sep 19, 2024
Complaint Investigation CMS
Date: Sep 19, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to maintain resident dignity by not covering urinary catheter drainage bags and failure to implement care plan interventions including proper oxygen therapy administration.
Complaint Details
The investigation was complaint-driven, focusing on allegations that urinary catheter drainage bags were not covered and that oxygen therapy was not administered according to physician orders. The complaints were substantiated based on observations and staff interviews.
Findings
The facility failed to ensure urinary catheter drainage bags were covered for two residents, compromising their dignity. Additionally, the facility failed to follow physician orders for oxygen therapy for two residents, administering incorrect oxygen flow rates contrary to care plans.
Deficiencies (3)
F 0550: The facility failed to cover urinary catheter drainage bags for two residents, exposing urine and compromising dignity.
F 0656: The facility failed to implement care plan interventions for two residents, resulting in oxygen therapy not being administered as ordered.
F 0695: The facility failed to provide safe and appropriate respiratory care by administering oxygen at incorrect flow rates for two residents.
Report Facts
Residents affected: 2
Residents affected: 2
Sample size: 48
Oxygen flow rate: 2
Oxygen flow rate observed: 3
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Confirmed urinary catheter drainage bags were uncovered and verified oxygen flow rate errors for resident R94 |
| CC | Licensed Practical Nurse (LPN) | Verified and adjusted oxygen flow rate for resident R66 |
| AA | Assistant Director of Nursing (ADON) | Stated expectation that all residents with urinary catheters have drainage bags in privacy bags and that oxygen flow meters be set as prescribed |
| FF | MDS Coordinator | Stated nursing staff responsibility to ensure resident care plans were followed |
Inspection Report — Jul 18, 2023
Follow-Up State
Date: Jul 18, 2023
Visit Reason
A Follow-Up Survey was conducted via desk review to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report — Jun 21, 2023
Plan of Correction State
Date: Jun 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Baptist Village, Inc., indicating a regulatory inspection was conducted.
Findings
The document contains initial comments and a summary statement of deficiencies identified during the inspection, but no specific deficiencies or findings are detailed on this page.
Inspection Report — Jun 21, 2023
Re-Inspection State
Date: Jun 21, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/27/2023 Recertification Survey.
Findings
All deficiencies cited as a result of the 4/27/2023 Recertification Survey were found to be corrected.
Inspection Report — Jun 16, 2023
Follow-Up State
Date: Jun 16, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies related to facility maintenance and inspection.
Findings
The facility failed to ensure proper inspection, testing, and maintenance of fire doors as required by NFPA standards. No documentation was available to confirm that inspections and testing had been performed by the third party vendor or the Maintenance Director as planned.
Deficiencies (1)
Failure to ensure proper inspection, testing, and maintenance of fire doors throughout the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding lack of door inspection documentation during facility tour. |
Inspection Report — Apr 27, 2023
Life Safety State
Date: Apr 27, 2023
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including interior wall finishes, sprinkler system installation and maintenance, fire door inspections, corridor door maintenance, smoke barrier construction, electrical safety, smoking regulations, combustible decorations, portable space heaters, and oxygen cylinder storage.
Deficiencies (17)
Facility storing paper bags on shelves in the exit corridor, violating interior wall and ceiling finish requirements.
Sprinkler riser gauges not replaced or recalibrated every 5 years.
Sprinkler piping failed to be kept free of external loads; wires supported by sprinkler pipes.
Backflow preventers throughout the facility not inspected annually; last inspection in 2020.
5-year internal inspection of sprinkler system not completed since 2016.
Fire Department Connections signage illegible and connections seized shut.
Dry sprinkler riser yellow tagged for non-compliance.
Damaged door sweeps on corridor doors not providing proper protection.
Door gap exceeded maximum allowable 1/8 inch.
Penetrations in fire walls above-ceiling not correctly sealed.
Power strip in Room 123 not mounted off the floor.
Junction box above-ceiling near Room 315 missing cover.
Unsafe smoking practices in designated smoking area; cigarette butts discarded on ground and cigarette refuse container lid missing.
Privacy curtain in CNA Training Room lacked NFPA 701 compliance tag and fire-retardant treatment records.
Fire rated doors throughout the facility have not been inspected since 2020.
Space heaters in Office #111 and Nurse's Station 3 lacked thermostatic documentation.
Oxygen cylinder storage outside lacked signage for 'full' and 'empty' cylinders.
Report Facts
Inspection Date: Apr 27, 2023
Years since last sprinkler internal inspection: 7
Years since last backflow preventer inspection: 3
Years since last fire door inspection: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 4/27/2023 |
Inspection Report — Apr 27, 2023
Routine CMS
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with respiratory care, infection prevention, and equipment storage policies at the nursing home.
Findings
The facility failed to ensure oxygen equipment was properly cleaned and stored for two residents, increasing infection risk. Additionally, the facility lacked a designated qualified Infection Preventionist following a recent resignation.
Deficiencies (2)
F 0695: The facility failed to provide safe and appropriate respiratory care by not properly cleaning and storing oxygen equipment for two residents, increasing the risk of respiratory infections.
F 0882: The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program after the previous IP nurse resigned.
Report Facts
Residents affected: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Responsible for maintenance and cleaning of oxygen equipment for resident R#159 |
| AA | Assistant Director of Nursing (ADON) | Confirmed oxygen equipment was not properly stored for resident R#113 |
| Director of Nursing (DON) | Confirmed lack of qualified Infection Preventionist and responsibility for oxygen equipment maintenance | |
| Administrator | Confirmed lack of policy for oxygen equipment storage and absence of qualified Infection Preventionist |
Inspection Report — Apr 27, 2023
Complaint Investigation State
Date: Apr 27, 2023
Visit Reason
A standard survey was conducted from April 25, 2023, through April 27, 2023, including investigation of Complaint Intake Number GA00234039, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00234039 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop a person-centered care plan for oxygen use for one resident, improper cleaning and storage of oxygen equipment for two residents, and failure to designate a qualified Infection Preventionist nurse.
Deficiencies (3)
Failure to develop a person-centered care plan related to oxygen use for resident #113.
Failure to ensure oxygen equipment was properly cleaned and stored when not in use for residents #113 and #159, increasing risk of respiratory infections.
Failure to designate at least one qualified Infection Preventionist responsible for infection prevention, control, and immunizations.
Report Facts
Oxygen liters per minute: 2
Oxygen liters per minute: 3
BIMS score: 14
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Responsible for maintenance and cleaning of oxygen equipment for resident #159; mentioned resident refused assistance and care orders changed to PRN. |
| AA | Assistant Director of Nursing (ADON) | Confirmed oxygen equipment was lying on the floor and not properly stored. |
| DON | Director of Nursing | Confirmed nurse assigned to resident's hall responsible for oxygen equipment maintenance and cleaning; confirmed no qualified Infection Preventionist nurse. |
| Administrator | Confirmed no policy for storing respiratory equipment; confirmed no qualified Infection Preventionist nurse after previous nurse resigned on 4/18/2023. |
Inspection Report — Apr 27, 2023
Annual Inspection CMS
Date: Apr 27, 2023
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements related to resident care, infection prevention, and equipment maintenance.
Findings
The facility failed to develop a complete care plan for oxygen use for one resident, did not properly clean and store oxygen equipment for two residents, and lacked a designated qualified Infection Preventionist nurse.
Deficiencies (3)
F 0656: The facility failed to develop a person-centered care plan for resident #113 regarding prn oxygen therapy use.
F 0695: The facility failed to ensure oxygen equipment was properly cleaned and stored for residents #113 and #159, increasing risk of respiratory infections.
F 0882: The facility failed to designate a qualified Infection Preventionist responsible for the infection prevention and control program.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) EE | Responsible for maintenance and cleaning of oxygen equipment for resident #159 | |
| Assistant Director of Nursing (ADON) AA | Confirmed oxygen equipment was improperly stored for resident #113 | |
| Director of Nursing (DON) | Confirmed lack of qualified Infection Preventionist and responsibility for oxygen equipment maintenance | |
| Administrator | Confirmed lack of qualified Infection Preventionist and lack of policy for oxygen equipment storage |
Inspection Report — Nov 28, 2022
Plan of Correction State
Date: Nov 28, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Baptist Village, Inc., indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report lists deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided document.
Inspection Report — Nov 28, 2022
Re-Inspection State
Date: Nov 28, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 16, 2022 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on September 16, 2022; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the September 16, 2022 Complaint Survey were found to be corrected.
Report Facts
Inspection Report — Nov 28, 2022
Abbreviated Survey State
Date: Nov 28, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00227521.
Complaint Details
Complaint GA00227521 was investigated and found to be unsubstantiated.
Findings
The investigation of complaint GA00227521 was unsubstantiated, with no deficiencies noted in the report.
Inspection Report — Sep 16, 2022
Abbreviated Survey State
Date: Sep 16, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00225682, initiated on 2022-08-09 and concluded on 2022-09-16 after receipt of hospital records.
Complaint Details
Investigation of complaint GA00225682; no deficiencies cited.
Findings
Although a concern was identified during the investigation, no State Licensure deficiencies were cited.
Inspection Report — Sep 16, 2022
Complaint Investigation State
Date: Sep 16, 2022
Visit Reason
The inspection was initiated as an Abbreviated/Partial Extended Survey investigating complaint GA00225682, which was substantiated after review of hospital records and incident details.
Complaint Details
Complaint GA00225682 was substantiated. Actual harm occurred on 6/29/2022 when resident #1 fell from bed during ADL care, sustaining a cervical fracture. The CNA was found to have rolled the resident away from herself contrary to proper technique. The facility acknowledged the issue and took immediate corrective action, including removing the CNA from the facility.
Findings
The facility failed to ensure proper supervision and use of appropriate techniques during Activities of Daily Living (ADL) care for one resident, resulting in a fall from bed and a cervical fracture. The investigation found that a Certified Nursing Assistant (CNA) rolled the resident away from herself during care, leading to the resident falling and sustaining harm.
Deficiencies (1)
Failure to ensure that Activities of Daily Living (ADL) care was provided using appropriate techniques to prevent accidents, resulting in a resident fall and cervical fracture.
Report Facts
Date of fall: Jun 29, 2022
Brief Interview Mental Status score: 12
Admission date: Oct 13, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in fall incident for improper technique during ADL care |
| LPN KK | Licensed Practical Nurse | Present during fall incident, documented and reported events |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statement regarding the fall incident |
Inspection Report — Jan 26, 2022
Abbreviated Survey State
Date: Jan 26, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00218197.
Complaint Details
Complaint #GA00218197 was substantiated with no deficiencies cited.
Findings
The complaint #GA00218197 was substantiated with no deficiencies cited during the survey.
Inspection Report — Sep 24, 2021
Renewal State
Date: Sep 24, 2021
Visit Reason
A Recertification Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health (DCH) at Baptist Village from September 21, 2021 through September 24, 2021.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483.5-483.95, Subpart B Requirements for Long Term Care Facilities.
Inspection Report — Sep 24, 2021
Routine State
Date: Sep 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from September 21, 2021 through September 24, 2021 to assess the facility's compliance with infection control regulations related to COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Sep 22, 2021
Life Safety State
Date: Sep 22, 2021
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and adherence to NFPA 101 Life Safety Code 2012 edition.
Findings
Baptist Village, Inc. was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Report Facts
Certified beds: 254
Inspection Report — Feb 9, 2021
Routine State
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Inspection Report — Jan 12, 2021
Routine State
Date: Jan 12, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices for COVID-19.
Inspection Report — Dec 9, 2020
Routine State
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Inspection Report — Sep 29, 2020
Abbreviated Survey State
Date: Sep 29, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00202699 and #GA00208510.
Complaint Details
Complaints #GA00208510 and #GA00202699 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00208510 and #GA00202699 were unsubstantiated and no regulatory violations were cited.
Inspection Report — Aug 4, 2020
Routine State
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report — Jul 17, 2020
Routine State
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant CMS and CDC regulations and recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Inspection Report — Oct 3, 2019
Abbreviated Survey State
Date: Oct 3, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00199731 and GA00198807.
Complaint Details
The complaints investigated were substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were substantiated but no deficiencies were cited.
Inspection Report — Jul 26, 2019
Re-Inspection State
Date: Jul 26, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey of June 6, 2019.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.
Inspection Report — Jun 4, 2019
Life Safety State
Date: Jun 4, 2019
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 plan requirements and Life Safety Code standards.
Report Facts
Certified beds: 254
Inspection Report — Oct 15, 2018
Abbreviated Survey State
Date: Oct 15, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00191883.
Complaint Details
Complaint GA00191883 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report — Jun 5, 2018
Follow-Up State
Date: Jun 5, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report — Apr 19, 2018
Annual Inspection State
Date: Apr 19, 2018
Visit Reason
A standard survey was conducted at Baptist Village, Inc. from April 16, 2018 through April 19, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report — Apr 17, 2018
Life Safety State
Date: Apr 17, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to deficiencies in the fire alarm system installation, sprinkler system maintenance, smoke barrier construction, and smoke barrier door self-closing functionality, which could place all 204 residents at risk in the event of a fire.
Deficiencies (4)
Fire alarm system breaker switch not identified and not provided with a red breaker lock; electrical panel not identified.
Automatic sprinkler system was obstructed by a cardboard box in the freezer and was not properly inspected, tested, and maintained.
Smoke barriers were improperly sealed or left unsealed above ceiling at fire separation walls, failing to provide a 1/2 hour fire resistance rating.
Smoke barrier doors in the Men's Memory Care Unit did not completely self-close.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report — Sep 5, 2017
Abbreviated Survey State
Date: Sep 5, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00178928 from 9/1/17 to 9/5/17.
Complaint Details
Complaint GA00178928 was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was not substantiated and no deficiencies were cited.
Inspection Report — Aug 16, 2017
Abbreviated Survey State
Date: Aug 16, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA 00178099 at Baptist Village.
Complaint Details
Investigation of complaint GA 00178099 determined the complaint was unsubstantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Regulations with no deficiencies cited.
Inspection Report — Jul 6, 2017
Abbreviated Survey State
Date: Jul 6, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00176624.
Complaint Details
The complaint was unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report — Apr 21, 2017
Routine State
Date: Apr 21, 2017
Visit Reason
A standard survey was conducted at Baptist Village from April 18, 2017 through April 21, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report — Apr 19, 2017
Life Safety State
Date: Apr 19, 2017
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 to be in substantial compliance with the Life Safety Code requirements at 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 edition.
Inspection Report — Apr 18, 2017
Abbreviated Survey State
Date: Apr 18, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00173809.
Complaint Details
The complaint was substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.
Inspection Report — Mar 16, 2017
Complaint Investigation State
Date: Mar 16, 2017
Visit Reason
A complaint survey was conducted from 2017-03-15 to 2017-03-16 at Baptist Village by a Registered Nurse to investigate complaint #GA00163517 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00163517 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
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