Inspection Reports for Brown’s Health & Rehab Center
226 SOUTH COLLEGE STREET, STATESBORO, GA, 30458
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 26, 2024, found no deficiencies after a revisit survey verified correction of prior issues. Earlier inspections in late 2024 identified deficiencies related to failure to provide written transfer and bed hold notices to residents and failure to develop a care plan for a resident who smoked. Prior complaint investigations included a substantiated case in April 2024 involving medication administration errors that caused harm to two residents, resulting in staff suspension and termination; no fines or license actions were listed in the available reports. Previous surveys also noted life safety code deficiencies such as blocked exits and maintenance issues, which were later corrected. The overall trend shows improvement with recent inspections confirming correction of earlier cited deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
57 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Brown's Health & Rehab Center following a survey completed on December 26, 2024.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 7, 2024, Recertification Survey.
Findings
All deficiencies cited in the prior Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Census: 19
Deficiencies: 3
Date: Nov 7, 2024
Visit Reason
A State Licensure survey was conducted at Brown's Health & Rehab Center from November 4, 2024, through November 7, 2024, to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to provide written transfer notices to residents or their representatives, failure to provide written notice of bed hold policy at transfer, and failure to develop and implement a care plan for a resident who smoked.
Deficiencies (3)
Facility failed to provide a written notice of transfer to residents or their representatives for one resident (R19) reviewed for hospitalization.
Facility failed to provide notice of bed hold, in writing, at the time of transfer or within 24 hours for one resident (R19) reviewed for hospitalization.
Facility failed to develop and implement a care plan for smoking for one resident (R24) who smoked.
Report Facts
Sample size: 19
BIMS score: 15
BIMS score: 7
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Interviewed regarding transfer form process and lack of written transfer notices |
| BB | Registered Nurse (RN) | Interviewed about transfer notices sent to hospital but not to residents |
| AA | Director of Nursing (DON) and Registered Nurse (RN) Unit Manager | Confirmed no bed hold policy was provided to resident R19 upon hospital transfer |
| CC | Medical Records Clerk | Responsible for uploading bed hold notifications; confirmed no notice was provided to R19 |
| GG | Certified Nursing Assistant (CNA) | Observed escorting resident R24 to smoking area and confirmed smoking routine |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 4
Date: Nov 7, 2024
Visit Reason
A standard survey was conducted from November 5 through November 7, 2024, including investigation of Complaint Intake GA00249784, which was unsubstantiated.
Complaint Details
Complaint Intake GA00249784 was investigated in conjunction with the standard survey and was unsubstantiated.
Findings
The facility was found not substantially compliant with Medicare/Medicaid regulations, with deficiencies including failure to provide written information about the right to accept or refuse medical or surgical treatment to residents, failure to provide written notice of transfer and bed hold policy to a resident transferred to the hospital, and failure to develop a care plan for a resident who smoked.
Deficiencies (4)
Failed to provide residents or representatives written information regarding the right to accept or refuse medical or surgical treatment for four of 19 sampled residents.
Failed to provide a written notice of transfer to residents or their representatives for one resident reviewed for hospitalization.
Failed to provide notice of bed hold, in writing, at the time of transfer or within 24 hours for one resident reviewed for hospitalization.
Failed to develop and implement a care plan for smoking for one of four residents who smoked.
Report Facts
Sample size: 19
BIMS score: 15
BIMS score: 7
Deficiencies cited: 4
Census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Named in interview regarding transfer form and lack of written transfer information |
| BB | Registered Nurse (RN) | Named in interview regarding notice of transfer sent to hospital but not to resident |
| CC | Medical Records Clerk | Named in interview regarding responsibility for uploading bed hold notifications and confirming none was given to resident R19 |
| AA | Director of Nursing (DON) and Registered Nurse (RN) Unit Manager | Named in interview confirming bed hold policy was not provided to resident R19 |
| GG | Certified Nursing Assistant (CNA) | Named in interview confirming escorting resident R24 to smoking area |
Inspection Report
Life Safety
Census: 58
Capacity: 63
Deficiencies: 5
Date: Nov 6, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition requirements.
Findings
The facility was found not in substantial compliance with life safety requirements, with multiple deficiencies noted including blocked exit doors, smoke doors failing to latch, corroded sprinkler heads, unsealed smoke wall penetrations, and power strips placed on the floor. These issues affected various smoke compartments and could impact resident safety.
Deficiencies (5)
Exit door in D Hall was blocked by an end table, obstructing means of egress.
Smoke doors in B Hall failed to latch when tested.
Sprinkler heads in the kitchen were corroded.
Smoke wall penetrations in A Hall were not properly sealed.
Power strip was found on the floor in the maintenance office.
Report Facts
Smoke compartments affected: 1
Residents potentially affected: 20
Smoke compartments affected: 2
Residents potentially affected: 25
Smoke compartments affected: 1
Residents potentially affected: 20
Smoke compartments affected: 2
Residents potentially affected: 25
Smoke compartments affected: 1
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior survey dated 2024-04-11.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00244586 regarding medication administration errors that caused harm to two residents.
Complaint Details
Complaint number GA00244586 was substantiated. Actual harm occurred when pain medication with sedative effects was administered improperly to residents R1 and R2 on 3/6/2024, causing lethargy and requiring Narcan treatment and hospital transfer. LPN AA was identified as responsible, suspended, and terminated. The incident was reported to the State Agency and Nursing Board.
Findings
The facility failed to follow physician orders for administering pain medication to two residents, resulting in both becoming lethargic and hard to arouse, requiring emergency treatment with Narcan and hospital transfer. One resident was admitted to the hospital and did not return, while the other returned to the facility after evaluation.
Deficiencies (2)
Failure to ensure two residents were protected from medication errors, resulting in actual harm due to administration of sedative pain medication causing lethargy and emergency treatment.
Failure to ensure residents were free of significant medication errors related to pain medication administration.
Report Facts
Census: 54
Medication doses timing: 2
Medication doses timing: 3
Narcan doses: 1
Narcan doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named as responsible for medication errors and improper documentation; suspended and terminated following investigation. |
| Director of Nursing | Director of Nursing (DON) | Provided interview details about the incident, disciplinary actions, and corrective measures. |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate complaints #GA00233903, #GA00230637, and #GA00228678.
Complaint Details
Complaints #GA00230637 and #GA00233903 were unsubstantiated. Complaint #GA00228678 was substantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. Complaints #GA00230637 and #GA00233903 were unsubstantiated, while complaint #GA00228678 was substantiated. No regulatory violations were cited.
Report Facts
Complaint identifiers: #GA00233903, #GA00230637, #GA00228678
Total census: 56
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the prior survey conducted from 7/15/22 through 7/17/22.
Findings
All deficiencies cited as a result of the 7/15/22 through 7/17/22 survey were found to be corrected during the revisit survey on 9/15/22.
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/15/22 through 7/17/22 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Renewal
Census: 31
Deficiencies: 2
Date: Jul 17, 2022
Visit Reason
A Licensure Survey was conducted from 7/15/22 through 7/17/22 to assess compliance with licensure requirements.
Findings
The facility was found deficient in infection control practices related to hand hygiene and glucometer sanitation during resident care, and in maintaining the physical environment with multiple areas of chipped and peeling paint in residents' rooms and hallways.
Deficiencies (2)
Failure to wash/sanitize hands and change gloves during wound treatment for one resident (#48) and failure to clean/sanitize a glucometer during a routine fasting blood sugar check on one resident (#24).
Facility failed to maintain building and equipment in good repair, evidenced by chipped/peeling paint on handrails in two halls and in three residents' rooms (rooms 2, 3, and 9).
Report Facts
Sample size: 31
Number of residents' rooms reviewed: 9
Number of rooms with chipped/peeling paint: 3
Number of halls with chipped/peeling paint on handrails: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to clean/sanitize glucometer and not following infection control practices during blood sugar check |
| LPN BB | Licensed Practical Nurse | Observed failing to wash/sanitize hands and change gloves properly during wound care |
| Director of Nursing | Director of Nursing | Provided information about infection control training and expectations |
| Administrator | Administrator | Confirmed environmental observations and discussed maintenance staffing |
Inspection Report
Routine
Census: 61
Deficiencies: 5
Date: Jul 17, 2022
Visit Reason
A standard survey was conducted at Brown's Health and Rehab Center from July 15, 2022 through July 17, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including maintenance of a safe and homelike environment, care plan timing and revision, accident hazard prevention, respiratory care, and infection control practices. Deficiencies included chipped/peeling paint in resident areas, failure to revise care plans after falls, inadequate fall prevention interventions, improper oxygen equipment maintenance, and lapses in infection control during wound care and glucometer use.
Deficiencies (5)
Facility failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by chipped/peeling paint on handrails and in residents' rooms.
Failed to evaluate and revise care plan interventions for fall prevention for a resident with history of falls.
Failed to implement appropriate new measures to prevent additional falls for a resident with multiple falls.
Failed to provide respiratory care consistent with professional standards for residents receiving oxygen therapy, including failure to clean oxygen concentrator filters and properly store nasal cannula.
Failed to follow infection control practices during wound care and glucometer use, including failure to wash/sanitize hands and clean glucometer between uses.
Report Facts
Resident census: 61
Sample size: 31
Sample size: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to clean glucometer and implement fall interventions |
| LPN BB | Licensed Practical Nurse | Observed failing to wash/sanitize hands and change gloves during wound care |
| DON | Director of Nursing | Interviewed regarding expectations for care plan revisions, fall interventions, respiratory care, and infection control |
| MDS Coordinator | Licensed Practical Nurse | Interviewed regarding care plan revisions for fall prevention |
| Unit Manager LPN DD | Licensed Practical Nurse | Interviewed regarding fall tracking and interventions |
| LPN CC | Licensed Practical Nurse | Interviewed regarding oxygen therapy equipment maintenance |
Inspection Report
Life Safety
Census: 59
Capacity: 63
Deficiencies: 0
Date: Jul 16, 2022
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 compliance with the Life Safety Code requirements and the Emergency Preparedness Program met regulatory standards.
Report Facts
Certified beds: 63
Census: 59
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 15, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00220138 and #GA00221267.
Complaint Details
Complaints #GA00220138 and #GA00221267 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00220138 and #GA00221267 were unsubstantiated and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Brown's Health & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed on the page provided.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/29/2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 6/29/2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 6/29/2021 Complaint Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
The inspection was conducted as a Licensure Survey to assess compliance for renewal of the facility's license.
Findings
No deficiencies were identified during the Licensure Survey conducted from 6/28/2021 through 6/29/2021.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jun 29, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00215054, GA00215494, and GA00215310. Two complaints were unsubstantiated, and one complaint was substantiated.
Complaint Details
Complaint GA00215310 was substantiated; complaints GA00215054 and GA00215494 were unsubstantiated.
Findings
The facility failed to ensure that residents were allowed to receive visitors on weekends for two of three residents reviewed, contrary to CMS visitation guidance. The facility restricted visitation on weekends due to limited staff availability despite low county COVID-19 positivity rates and a high resident vaccination rate.
Deficiencies (1)
Failure to ensure residents were allowed to receive visitors on weekends as required by CMS visitation guidance.
Report Facts
Resident census: 60
Vaccinated residents: 46
County COVID-19 positivity rate: 1.4
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211539.
Complaint Details
Complaint #GA00211539 was substantiated with no regulatory violations.
Findings
The complaint #GA00211539 was substantiated with no regulatory violations found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 26, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208884.
Complaint Details
Complaint #GA00208884 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint #GA00208884 was unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Routine
Census: 50
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal 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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 50
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00207838.
Complaint Details
Complaint #GA00207838 was substantiated with no deficiencies found.
Findings
The complaint #GA00207838 was substantiated, but no deficiencies were identified during the investigation.
Inspection Report
Routine
Census: 58
Deficiencies: 0
Date: Aug 11, 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 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 57
Deficiencies: 0
Date: Jul 2, 2020
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.
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 recommended practices to prepare for COVID-19.
Report Facts
Total census: 57
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 1, 2019
Visit Reason
A follow-up to the Recertification survey of May 8, 2019 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of June 22, 2019.
Inspection Report
Life Safety
Census: 58
Capacity: 63
Deficiencies: 5
Date: May 6, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards at Brown's Health & Rehab Center.
Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code and related standards due to deficiencies including lack of sprinkler coverage beneath exterior porches, obstructed corridor doors, smoke compartment doors not closing fully, failure to conduct annual fire door inspections, and improper oxygen cylinder storage.
Deficiencies (5)
Failed to provide NFPA 101 and NFPA 13 fire sprinkler coverage beneath exterior porches of C and D Halls built of combustible materials.
Failed to maintain a clear and unobstructed doorway to room 28 due to a patient bed blocking the corridor door swing, preventing the door from closing fully.
Failed to provide NFPA 101 compliant smoke compartment doors as doors would not close fully when released by door hold open devices.
Failed to provide annual fire door and smoke door inspections as required by NFPA 101 and NFPA 80.
Failed to provide NFPA 99 compliant oxygen cylinder storage; three cylinders were free standing and subject to being knocked over or damaged.
Report Facts
Residents at risk: 20
Residents at risk: 20
Residents at risk: 20
Residents at risk: 58
Residents at risk: 4
Certified Beds: 63
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2018
Visit Reason
A complaint survey was conducted on 10/22/2018 and 10/23/2018 to investigate complaints #GA 00191947 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaints #GA 00191947; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 22, 2018
Visit Reason
A follow-up to the Recertification survey of May 2, 2018 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of June 16, 2018.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 20, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 60
Capacity: 63
Deficiencies: 4
Date: May 1, 2018
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety requirements, including failure to update the Emergency Preparedness Plan since 2014, lack of a required risk assessment, smoke barriers not constructed to required fire resistance standards, and failure to conduct and document required fire drills.
Deficiencies (4)
Emergency Preparedness Plan was not updated since 10/06/2014 and did not meet Appendix Z requirements.
Emergency Preparedness Plan did not include a Risk Assessment as required by Appendix Z.
Smoke barriers were not constructed to a 1/2-hour fire resistance rating and had unsealed penetrations allowing smoke passage.
Fire drills were not conducted and properly documented during the 3rd shift of the 1st quarter of 2018.
Report Facts
Residents at risk: 60
Certified beds: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the inspection and discovery of deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 18, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00180804.
Complaint Details
Complaint GA00180804 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
Abbreviated Survey
Deficiencies: 0
Date: Jul 11, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00176670 and GA00177086.
Complaint Details
The complaint was substantiated but no deficiencies were cited.
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
Follow-Up
Deficiencies: 0
Date: Jul 3, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 21, 2017
Visit Reason
A follow-up visit was conducted to verify correction of deficiencies identified in the prior recertification survey.
Findings
The deficiencies identified in the prior recertification survey had been corrected at the time of this follow-up visit.
Inspection Report
Life Safety
Census: 58
Capacity: 63
Deficiencies: 1
Date: May 9, 2017
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 NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to ensure the fire alarm system was inspected, tested, and properly maintained according to NFPA 72 standards. Specifically, the sensitivity test for the smoke detectors had not been completed.
Deficiencies (1)
Failure to ensure that the fire alarm system was inspected, tested, and properly maintained in accordance with NFPA 72, including incomplete sensitivity testing of smoke detectors.
Report Facts
Census: 58
Certified beds: 63
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