Inspection Reports for
Buckhead Center for Nursing and Healing
54 Peachtree Park Dr NE, Atlanta, GA 30309, GA, 30309
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
304% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
18% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 25, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity, participation in care planning, call light accessibility, activities of daily living care, weight monitoring, medication administration errors, food preferences, food labeling, and infection control practices.
Deficiencies (9)
F 0550: The facility failed to provide a dignified dining experience for residents, including staff not sitting with residents during meals and inappropriate use of cell phones in resident rooms.
F 0553: The facility failed to ensure two residents were invited to participate in their quarterly care plan meetings, violating resident rights.
F 0558: The facility failed to ensure the call light was accessible for one resident, placing him at risk of falls and distress.
F 0677: The facility failed to provide adequate activities of daily living care for one resident, evidenced by unclean fingernails and inadequate bathing.
F 0692: The facility failed to monitor and follow up on significant weight loss for three residents, risking continued weight loss without intervention.
F 0760: The facility failed to ensure two residents were free from significant medication errors, including late and early insulin administration without proper monitoring or documentation.
F 0806: The facility failed to honor food preferences for one resident who requested salads that were not provided.
F 0812: The facility failed to properly label and date several food items in the refrigerator, risking exposure of residents to spoiled food.
F 0880: The facility failed to follow glucometer disinfection procedures and hand hygiene during blood glucose checks and wound care, risking cross contamination and infection.
Report Facts
Residents sampled: 33
Medication administrations late: 30
Medication administrations late: 10
Medication administrations late: 17
Medication administrations late: 12
Medication administrations late: 7
Medication administrations late: 3
Residents affected by call light accessibility: 1
Residents affected by dignity issues: 2
Residents affected by care plan participation deficiency: 2
Residents affected by ADL care deficiency: 1
Residents affected by weight monitoring deficiency: 3
Residents affected by medication errors: 2
Residents affected by food preference deficiency: 1
Residents affected by food labeling deficiency: 116
Residents affected by infection control deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in dignity issue for not sitting with resident during meal |
| CNA3 | Certified Nursing Assistant | Named in dignity issue for answering cell phone in resident room |
| Director of Nursing | Director of Nursing | Provided statements confirming dignity issues and medication administration policies |
| DSS | Director of Social Services | Provided statements about care plan meeting invitations |
| SSA | Social Service Assistant | Discussed care plan meeting invitations |
| LPN4 | Licensed Practical Nurse | Involved in call light accessibility observation |
| Nurse Manager 3 | Nurse Manager | Discussed ADL care and fingernail cleanliness |
| LPN5 | Licensed Practical Nurse | Observed resident fingernail condition |
| RD | Registered Dietician | Discussed weight monitoring and follow-up |
| UM2 | Unit Manager | Discussed weight monitoring responsibilities |
| LPN6 | Licensed Practical Nurse | Observed administering insulin early and not disinfecting glucometer |
| LPN2 | Licensed Practical Nurse | Observed failing to perform hand hygiene during wound care |
| RN2 | Registered Nurse | Acknowledged hand hygiene failure during wound care |
| Dietary Manager | Dietary Manager | Confirmed failure to provide requested salad and food labeling issues |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Provided policy interpretation and infection control statements |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Sep 25, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident care, including accessibility of call lights, adequacy of activities of daily living (ADL) care, and medication administration errors.
Complaint Details
The investigation was complaint-driven, focusing on issues raised by residents and responsible parties about call light accessibility, hygiene neglect, and medication errors. The complaints were substantiated by observations, interviews, and record reviews.
Findings
The facility failed to ensure call light accessibility for one resident, provide adequate ADL care for another resident, and prevent significant medication errors for two residents. These failures posed risks of falls, poor hygiene, and potential hyperglycemia or hypoglycemia.
Deficiencies (3)
F 0558: The facility failed to ensure the call light was accessible for Resident 99, placing him at risk of falls and distress when unable to alert staff.
F 0677: The facility failed to provide adequate ADL care for Resident 128, evidenced by unclean fingernails and reported lack of bathing.
F 0760: The facility failed to ensure residents were free from significant medication errors, including early and late insulin administration for Residents 131 and 152.
Report Facts
Residents sampled: 33
Insulin administrations late: 30
Insulin administrations late: 10
Insulin administrations late: 17
Insulin administrations late: 12
Insulin administrations late: 7
Insulin administrations late: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Observed Resident 99 unable to use call light and commented on call pad placement |
| Director of Nursing | Director of Nursing | Stated Resident 99 could not press call pad by hand and staff should attach call pad to head |
| Nurse Manager 3 | Nurse Manager | Expected resident fingernails to be cleaned during scheduled baths |
| LPN5 | Licensed Practical Nurse | Noted Resident 128's fingernails needed cleaning |
| LPN6 | Licensed Practical Nurse | Administered insulin early to Resident 131 and explained rationale |
| LPN3 | Licensed Practical Nurse | Explained timing for sliding scale insulin administration |
| Regional Director of Clinical Services | Regional Director of Clinical Services | Clarified medication error definitions and reporting requirements |
Inspection Report
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Buckhead Center for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 141
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the complaint survey completed on 2025-03-26.
Complaint Details
The revisit was conducted following a complaint survey completed on 2025-03-26; all deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected as of 2025-04-09.
Report Facts
Facility census: 141
Inspection Report
Annual Inspection
Census: 142
Capacity: 153
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
A State Licensure survey was conducted at Buckhead Center for Nursing and Healing from February 26, 2025, through March 26, 2025, to assess compliance with state health regulations.
Findings
The facility failed to maintain cold food temperatures at or below 41 degrees Fahrenheit, specifically coleslaw was found at temperatures above the safe range, potentially promoting the growth of pathogens affecting 142 of 153 residents receiving an oral diet.
Deficiencies (1)
Failed to ensure cold food temperature was maintained at 41 degrees F or less, with coleslaw observed at 50 degrees F instead of below 41 degrees F.
Report Facts
Residents affected: 142
Total residents: 153
Number of coleslaw bowls prepared improperly: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed and instructed removal of improperly held coleslaw; provided temperature checks and interview statements | |
| Dietary Aide | Prepared coleslaw bowls not held on ice and served at unsafe temperature |
Inspection Report
Abbreviated Survey
Census: 153
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and concerns, including complaint GA00253994 which was substantiated with deficiencies.
Complaint Details
Complaint GA00253994 was substantiated with deficiencies; other complaints investigated were unsubstantiated.
Findings
The facility failed to maintain cold food temperatures at 41 degrees Fahrenheit or below, specifically coleslaw was found at temperatures above the safe threshold, potentially promoting foodborne illness affecting 142 of 153 residents on an oral diet.
Deficiencies (1)
Failure to ensure cold food was maintained at 41 degrees Fahrenheit or less, with coleslaw temperatures observed above 40 degrees F.
Report Facts
Residents affected: 142
Facility census: 153
Number of coleslaw bowls improperly held: 10
Temperature of coleslaw: 50
Temperature log reading: 34
Temperature stated by Dietary Manager: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Conducted temperature observations and interviews regarding food temperature deficiencies | |
| Dietary Aide | Prepared coleslaw bowls not held on ice as required |
Inspection Report
Census: 142
Capacity: 153
Deficiencies: 1
Date: Mar 21, 2025
Visit Reason
The inspection was conducted to evaluate compliance with food safety standards, specifically the maintenance of proper cold food temperatures during meal service.
Findings
The facility failed to maintain cold food temperatures at or below 41 degrees Fahrenheit, specifically coleslaw was observed at temperatures above the safe threshold. This posed a potential risk for foodborne illness affecting 142 of 153 residents receiving an oral diet.
Deficiencies (1)
F0812: The facility failed to ensure cold food was maintained at 41 degrees Fahrenheit or less. Prepared bowls of coleslaw were observed at temperatures above 50 degrees Fahrenheit, not held on ice as required.
Report Facts
Residents affected: 142
Total residents: 153
Temperature observed: 50
Temperature log: 34
Temperature stated by DM: 32
Inspection Report
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Buckhead Center for Nursing and Healing following a survey completed on December 6, 2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Buckhead Center for Nursing and Healing following a survey completed on December 6, 2024.
Findings
No deficiencies or findings are stated in the document; the form appears to be a blank template or placeholder for deficiencies and plan of correction information.
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
A State Licensure survey was conducted at Buckhead Center for Nursing and Healing from October 29, 2024, through November 7, 2024, to assess compliance with state licensure requirements.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection period.
Inspection Report
Abbreviated Survey
Census: 144
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility, initiated on 2024-10-29 and concluded on 2024-11-07.
Complaint Details
The survey investigated multiple complaints (GA00252191, GA00250729, GA00251683, GA00250411, GA00251965, GA00250790, GA00251739, GA00250755, GA00251021, GA00249795). All complaints except GA00251965 were unsubstantiated. Complaint GA00251965 was substantiated with deficiencies.
Findings
Complaint GA00251965 was substantiated with deficiencies related to the Business Office Manager (BOM) providing ADL care, specifically shaving a resident without proper certification or family permission. Other complaints were unsubstantiated.
Deficiencies (1)
Facility failed to ensure clinical staff were trained and competent to provide ADL care for one resident; the Business Office Manager, whose CNA certification expired in 2019, was observed shaving a resident without permission or proper role.
Report Facts
Complaint numbers investigated: 10
Census: 144
BIMS score: 11
Nurse Aide Certification Expiration Year: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Observed providing ADL care (shaving resident R7) without current CNA certification and without family permission |
| Administrator | Administrator | Interviewed and stated BOM should not have been shaving resident R7 and should have delegated to Unit Manager or CNA |
Inspection Report
Annual Inspection
Census: 144
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements related to staff training and competency in providing Activities of Daily Living (ADL) care.
Findings
The facility failed to ensure clinical staff were trained and competent to provide ADL care for one of four residents reviewed. Specifically, the Business Office Manager (BOM), whose nursing assistant certification had expired, was observed shaving a resident without proper authorization or training, which was outside her job scope.
Deficiencies (1)
F 0940: The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members. The Business Office Manager provided ADL care, including shaving a resident, without current certification or proper authorization.
Report Facts
Facility census: 144
Original CNA certification date: Jun 25, 2005
Certification expiration date: Jun 25, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Observed providing ADL care without current CNA certification | |
| Administrator | Stated that the BOM should not have been shaving the resident |
Inspection Report
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Buckhead Center for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 144
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification-Complaint Survey concluded on July 25, 2024.
Findings
All deficiencies cited in the prior Recertification-Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 13, 2024
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 of the follow-up survey conducted on September 13, 2024.
Inspection Report
Life Safety
Census: 134
Capacity: 188
Deficiencies: 6
Date: Jul 31, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 Edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including inoperative exit sign lighting on the 4th floor, failure to lock out the fire alarm panel electrical circuit, low pressure in a fire extinguisher in the laundry room, resident room doors scrubbing the floor delaying closure, unsealed penetrations compromising smoke barriers, missing ceiling tiles, and open electrical circuits in the laundry room panel.
Deficiencies (6)
Exit sign lighting was inoperative on the 4th floor near room 422, affecting emergency evacuation.
Failure to lock out the electrical circuit to the fire alarm panel, potentially hindering early evacuation.
Fire extinguisher in the laundry room was below pressure and needed charging or replacement.
Resident room doors in rooms 214 and 223 were scrubbing the floor, hindering smooth closing and delaying smoke compartment containment.
Multiple penetrations above ceilings and fire barriers were not properly sealed, and ceiling tiles were missing in maintenance areas, compromising smoke compartment integrity.
Electrical panel in the laundry room had multiple open circuits, posing fire hazard risk.
Report Facts
Residents affected by exit sign deficiency: 20
Residents affected by fire alarm panel circuit issue: 200
Staff affected by fire extinguisher deficiency: 3
Residents affected by door maintenance deficiency: 20
Residents affected by smoke barrier penetrations: 200
Staff affected by electrical panel deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and observations |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of medication and other care concerns at Buckhead Center for Nursing and Healing.
Complaint Details
The investigation was initiated due to a complaint of misappropriation of narcotics involving two residents. The facility conducted an investigation after discovering 49 oxycodone pills missing during a narcotic count on 6/12/2024. Licensed Practical Nurse (LPN)5 admitted to removing medications and falsifying statements. The Director of Nursing confirmed the investigation and subsequent findings.
Findings
The facility failed to prevent misappropriation of narcotic medications for two residents, failed to develop resident-specific care plans for high-risk medications, failed to provide consistent pressure ulcer care and repositioning, failed to maintain range of motion interventions, and failed to properly store nebulizer equipment, resulting in minimal to actual harm to residents.
Deficiencies (5)
F0602: The facility failed to protect residents from misappropriation of medication when 49 oxycodone pills were unaccounted for during a narcotic count involving two residents.
F0656: The facility failed to develop care plans with resident-specific goals and interventions for one resident reviewed for anticoagulant and antidepressant medication use.
F0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers, resulting in a resident acquiring a stage 4 sacral wound and an unstageable right lower leg wound due to lack of repositioning and offloading pressure devices.
F0688: The facility failed to consistently apply knee splints to prevent further decrease in range of motion for one resident with limited ROM.
F0695: The facility failed to properly store a nebulizer mask to prevent cross-contamination for one resident, leaving the mask uncovered on a nightstand.
Report Facts
Missing oxycodone pills: 49
Residents reviewed for care plans: 32
Residents reviewed for pressure ulcers: 6
Residents reviewed for limited ROM: 3
Residents reviewed for respiratory care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Admitted to removing medications and falsifying statements during narcotic count investigation |
| LPN4 | Unit Manager | Verified missing narcotics and reported to Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Confirmed investigation of narcotic misappropriation and care plan deficiencies |
| CNA3 | Certified Nursing Assistant | Interviewed regarding repositioning and application of knee splints |
| LPN1 | Licensed Practical Nurse | Interviewed regarding repositioning and application of knee splints |
| Rehab Director | Rehabilitation Director | Provided information on therapy discharge and splinting instructions |
| LPN3 | Licensed Practical Nurse | Verified nebulizer mask storage practices |
| LPN9 | Licensed Practical Nurse | Described responsibilities for nebulizer mask and tubing changes |
| Director of Respiratory Services | Director of Respiratory Services | Provided training details on oxygen humidification and nebulizer cleaning |
Inspection Report
Renewal
Deficiencies: 3
Date: Jul 25, 2024
Visit Reason
A Licensure Survey was conducted from July 22, 2024 through July 25, 2024 to assess compliance with licensure requirements at Buckhead Center for Nursing and Healing.
Findings
The facility failed to provide nursing care and services in accordance with the residents' plans of care for three sampled residents related to developing resident-specific care plans, providing care for pressure ulcers, and consistently applying knee splints to prevent further decrease in range of motion. Observations and interviews revealed lack of documentation and inconsistent implementation of turning, repositioning, and use of pressure-relieving devices and splints.
Deficiencies (3)
Failure to develop a care plan with resident-specific goals and interventions for anticoagulant and antidepressant use for resident R45.
Failure to provide adequate care for pressure ulcers and lack of documentation of turning and repositioning for residents R56 and R63.
Failure to consistently apply knee splints for prevention of further decrease in range of motion for resident R56.
Report Facts
Number of sampled residents: 32
Number of residents with deficiencies: 3
BIMS score: 15
BIMS score: 0
Range of motion degrees: 40
Range of motion degrees: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding resident R56's care and knee splint application |
| CNA1 | Certified Nursing Assistant | Interviewed about turning and repositioning practices for residents R56 and R63 |
| CNA3 | Certified Nursing Assistant | Interviewed about repositioning and knee splint application for resident R56 |
| Director of Nursing | Director of Nursing | Verified care plan deficiencies and turning/repositioning practices |
| Rehab Director | Rehabilitation Director | Confirmed therapy discharge and knee splint instructions for resident R56 |
| MDS Coordinator | MDS Coordinator | Discussed care plan initiation and documentation processes |
| MDS Nurse | MDS Nurse | Discussed standard of practice for turning and repositioning residents |
Inspection Report
Routine
Census: 128
Deficiencies: 5
Date: Jul 25, 2024
Visit Reason
A standard survey was conducted from July 22, 2024, through July 25, 2024, at Buckhead Center for Nursing and Healing to assess compliance with Medicare/Medicaid regulations and long-term care facility requirements.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including medication misappropriation, failure to develop resident-specific care plans, inadequate pressure ulcer prevention and treatment, inconsistent application of knee splints, and improper storage of respiratory equipment.
Deficiencies (5)
Failed to ensure two residents were free from misappropriation of medication when 49 oxycodone pills were unaccounted for during a narcotic count.
Failed to develop care plans with resident-specific goals and interventions for one resident regarding anticoagulant and antidepressant use.
Failed to ensure two residents reviewed for pressure ulcers received consistent care and services, resulting in harm with a resident acquiring a stage 4 sacral wound and an unstageable right lower leg wound.
Failed to consistently apply knee splints for prevention of further decrease in range of motion for one resident.
Failed to properly store a nebulizer mask to prevent cross-contamination for one resident.
Report Facts
Residents present: 128
Unaccounted oxycodone pills: 49
Remaining oxycodone tablets for R115: 9
Remaining oxycodone tablets for R226: 40
BIMS score for R115: 13
BIMS score for R56: 15
BIMS score for R63: 0
Knee splint range of motion: 40
Knee splint range of motion: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Named in medication misappropriation investigation; admitted to lying about missing medications. |
| LPN4 | Unit Manager | Reported missing narcotics and initiated investigation. |
| Director of Nursing | Director of Nursing | Confirmed investigation of medication misappropriation and discussed care plan deficiencies. |
| CNA1 | Certified Nursing Assistant | Provided information on repositioning expectations and communication binder. |
| LPN1 | Licensed Practical Nurse | Discussed repositioning standards and knee splint application knowledge. |
| Rehabilitation Director | Rehabilitation Director | Confirmed discharge from therapy and need for nursing to continue splinting; provided education details. |
| LPN3 | Licensed Practical Nurse | Verified improper storage of nebulizer mask. |
| LPN9 | Licensed Practical Nurse | Described responsibilities for nebulizer mask and tubing changes and acknowledged failures. |
| Director of Respiratory Services | Director of Respiratory Services | Described training and responsibilities related to nebulizer equipment maintenance. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Buckhead Center for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 123
Deficiencies: 0
Date: Oct 20, 2023
Visit Reason
A revisit survey was conducted on 10/20/2023 to verify correction of deficiencies cited during a 9/8/2023 complaint-only survey.
Complaint Details
The revisit survey was conducted following a complaint-only survey on 9/8/2023. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 9/8/2023 complaint-only survey were found to be corrected during the revisit survey.
Report Facts
Census: 123
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
A revisit survey was conducted from September 5 to September 8, 2023, at Buckhead Center for Nursing and Healing to investigate three complaints and verify correction of previous deficiencies.
Complaint Details
Three complaints were investigated: GA00238453 was substantiated with citation; GA00238762 was substantiated without deficiency cited; GA00238731 was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with a re-cited deficiency related to failure to label opened medications with the date opened on multiple medication carts. The facility had ongoing education and auditing processes to address this issue.
Deficiencies (1)
Failure to ensure medications were dated appropriately when opened to determine discard date in three of six medication carts (200 Short Hall, 300 Short Hall, and 400 Long Hall Medication Carts).
Report Facts
Resident census: 111
Medication carts with labeling issues: 3
Audit dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Unit Manager AA | Licensed Practical Nurse Unit Manager | Verified and confirmed medication labeling deficiencies and audit schedule |
| LPN BB | Licensed Practical Nurse | Verified and confirmed opened insulin pens not labeled with opened dates |
| LPN CC | Licensed Practical Nurse | Verified and confirmed opened medications not labeled with opened dates |
| LPN HH | Licensed Practical Nurse | Verified and confirmed opened Basaglar insulin pen not labeled with opened date |
| LPN Unit Manager DD | Licensed Practical Nurse Unit Manager | Completed audits and re-educated agency nurses on medication labeling |
| LPN Unit Manager FF | Licensed Practical Nurse Unit Manager | Identified and corrected medication labeling problems during audits |
| Staffing Development Coordinator | Staffing Development Coordinator | Provided in-services and education on medication labeling to staff and agency nurses |
| Director of Nursing | Director of Nursing | Oversaw education, audits, and corrective actions related to medication storage and labeling |
| Administrator | Administrator | Reported on re-education efforts and called Ad Hoc meeting regarding medication storage audits |
| Vice President of Clinical Operations | Vice President of Clinical Operations | Reported ongoing oversight and monitoring of nursing staff compliance |
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 1
Date: Sep 8, 2023
Visit Reason
An abbreviated/partial survey in conjunction with a revisit survey was conducted from September 5, 2023 through September 7, 2023 to investigate complaint numbers GA00238453, GA00238731, and GA00238762.
Complaint Details
Complaint number GA00238453 was substantiated with deficiency cited, GA00238731 was unsubstantiated, and GA00238762 was substantiated without deficiency cited.
Findings
Complaint number GA00238453 was substantiated with deficiency cited, GA00238731 was unsubstantiated, and GA00238762 was substantiated without deficiency cited.
Deficiencies (1)
Deficiency cited related to complaint number GA00238453
Report Facts
Resident Census: 107
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
A revisit survey was conducted from September 5, 2023 through September 8, 2023 to verify correction of deficiencies cited in the July 20, 2023 Partial Survey.
Findings
All deficiencies cited as a result of the July 20, 2023 Partial Survey were found to be corrected during this revisit survey.
Inspection Report
Enforcement
Deficiencies: 16
Date: Jul 20, 2023
Visit Reason
The visit was conducted due to multiple deficiencies including failure to ensure resident dignity, failure to notify representatives of significant changes, failure to protect residents from neglect, failure to provide safe discharges, and other compliance issues.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity, failure to notify family/legal representatives of significant changes, failure to protect residents from neglect, failure to provide appropriate care and treatment including medication and wound care, failure to provide safe discharges, failure to maintain a safe environment, and failure to provide adequate infection control and pharmaceutical services. Immediate Jeopardy was identified related to unsafe discharge and neglect of a resident with severe cognitive impairment.
Deficiencies (16)
F0550: The facility failed to promote, maintain, and protect a resident's dignity for one of three residents with a urinary catheter by not providing privacy covers for catheter bags.
F0580: The facility failed to notify representatives of significant changes and allowed a resident with severe cognitive impairment to sign an AMA discharge and leave the facility without proper discharge planning, causing immediate jeopardy.
F0584: The facility failed to maintain a clean, comfortable, homelike environment on two floors due to peeling plaster and holes in doors.
F0600: The facility failed to protect one resident from neglect by allowing a cognitively impaired resident to sign an AMA discharge and leave without proper discharge planning or family notification.
F0656: The facility failed to develop and implement complete care plans for three residents, including discrepancies in catheter orders, wound care frequency, and weight monitoring.
F0684: The facility failed to provide podiatry services to four residents as evidenced by long, curling, thick toenails.
F0687: The facility failed to ensure medications were not left at bedside for one resident self-administering without an order and failed to prevent falls and accident hazards for two residents.
F0690: The facility failed to obtain a physician order for the use of an indwelling urinary catheter for one resident and failed to provide appropriate catheter care.
F0691: The facility failed to provide correct size colostomy bags for three residents, impacting resident independence and skin integrity.
F0692: The facility failed to maintain acceptable nutritional status for one resident by not obtaining weights as ordered and not providing adequate nutritional monitoring.
F0695: The facility failed to provide appropriate treatment and care according to orders for three residents related to trach care, wound care, and medication administration.
F0755: The facility failed to ensure timely medication procurement for two residents, resulting in medication delays and missed doses.
F0761: The facility failed to ensure medications were dated appropriately when opened in two medication carts.
F0809: The facility failed to provide bedtime snacks for three residents despite resident council concerns and documented requests.
F0835: The facility administration failed to effectively oversee the facility's discharge process resulting in an unsafe discharge for one resident with severe cognitive impairment.
F0880: The facility failed to maintain an effective infection control program for one resident reviewed for trach care due to failure to utilize proper technique.
Report Facts
Deficiencies cited: 16
Residents affected: 32
Residents affected by Immediate Jeopardy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. ZZZ | Physician | Involved in AMA discharge of resident R#20 |
| LPN CCC | Licensed Practical Nurse | Agency nurse involved in AMA discharge of resident R#20 |
| LPN NNN | Licensed Practical Nurse | Agency nurse involved in AMA discharge of resident R#20 |
| CNA LLL | Certified Nursing Assistant | Provided catheter care for resident R#29 |
| RT JJ | Respiratory Therapist | Performed trach care for resident R#17 with deficiencies |
| LPN PP | Licensed Practical Nurse | Discussed medication cart and insulin storage |
| LPN EEE | Licensed Practical Nurse | Involved in medication administration and cart audits |
| LPN AAA | Licensed Practical Nurse | Conducted 100% AMA discharge audit |
| Regional Director of Clinical Services | Provided education and oversight on abuse prevention and safe discharge | |
| Director of Nursing | Oversight of nursing services and medication administration |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 20, 2023
Visit Reason
A Licensure Survey was conducted from 7/10/23 to 7/20/23 to assess compliance with state regulations and facility licensure requirements.
Findings
The survey identified multiple deficiencies including failure to notify resident representatives of significant health changes, inadequate discharge procedures, medication management issues, improper infection control practices related to tracheostomy care, incomplete nursing care and care planning, failure to follow physician orders, lack of podiatry services, and delayed or missed medication administration.
Deficiencies (5)
Facility failed to notify resident representatives of significant changes in condition for two residents (R#20 and R#24).
Facility failed to notify Department of Human Services related to self-discharge of resident R#20 who signed AMA form and left facility.
Medications were not obtained timely for two residents (R#6 and R#12) and medication carts contained insulin vials without proper open dates or labeling.
Infection control failure: tracheostomy care for resident R#17 was not performed according to professional standards, including improper hand hygiene, reuse of dirty gauze and suction catheter, and failure to change trach ties.
Nursing care deficiencies including failure to develop or update care plans for residents R#17, R#29, and R#28; failure to follow physician orders for residents R#17, R#6, and R#18; lack of physician order for indwelling catheter for R#29; and failure to provide podiatry services to residents R#1, R#6, R#12, and R#21.
Report Facts
Number of residents sampled: 32
Number of medication carts inspected: 6
Number of residents reviewed for nursing care deficiencies: 8
BIMS scores: 6
BIMS scores: 8
BIMS scores: 15
BIMS scores: 13
BIMS scores: 14
BIMS scores: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. ZZZ | Physician | Involved in resident R#20's AMA discharge and interview regarding discharge incident |
| LPN CCC | Licensed Practical Nurse | Agency nurse present during resident R#20's AMA discharge |
| LPN NNN | Licensed Practical Nurse | Agency nurse present during resident R#20's AMA discharge |
| LPN JJJ | Licensed Practical Nurse | Interviewed about notification of change policy |
| OT NNN | Occupational Therapist | Provided information about facility floors and elevator security related to resident R#20 |
| Regional Vice President of Operations | Vice President | Interviewed about facility policies and resident discharge |
| Director of Nursing | Director of Nursing | Interviewed about nursing care, medication administration, and discharge procedures |
| Respiratory Therapist JJ | Respiratory Therapist | Observed performing improper tracheostomy care for resident R#17 |
| Social Services Director TTT | Social Services Director | Interviewed about podiatry services and resident R#18 medication concerns |
| Wound Nurse | Wound Nurse | Interviewed about wound care for resident R#6 |
| LPN EEE | Licensed Practical Nurse | Interviewed about medication administration and wound care |
| LPN PP | Licensed Practical Nurse | Interviewed about medication cart and insulin management |
| LPN QQ | Licensed Practical Nurse | Interviewed about medication cart and insulin management |
| LPN OOO | Licensed Practical Nurse | Interviewed about podiatry care and toenail trimming responsibilities |
| LPN RR | Licensed Practical Nurse | Interviewed about podiatry services and resident toenail care |
Inspection Report
Abbreviated Survey
Census: 107
Deficiencies: 19
Date: Jul 20, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints, initiated on 7/10/23 and concluded on 7/20/23.
Complaint Details
The survey was conducted in conjunction with investigations of multiple complaints (GA00237136, GA00236048, GA00236039, GA00235866, GA00235830, GA00235684, GA00235344, GA00235050, GA00234920, GA00234716, GA00234532, GA00234171, GA00233933, GA00233440, GA00233266, GA00233017, GA00232951, GA00232795, GA00232609, GA00232440, GA00232399, GA00232344, GA00232084, GA00230084, GA00230087, GA00230030, GA00229293, GA00228834, GA00228682, GA00227908, GA00227325, GA00226938, GA00226534, GA00225730, GA00225416, GA00224751, GA00224763). The facility was found not in substantial compliance with multiple deficiencies related to neglect, unsafe discharge, and failure to notify representatives.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to protect a resident from neglect and unsafe discharge, failure to maintain a clean environment, failure to notify representatives of significant changes, failure to provide appropriate care plans, medication administration issues, and inadequate infection control practices.
Deficiencies (19)
Resident R#20 was allowed to sign an Against Medical Advice (AMA) form and leave the facility despite severe cognitive impairment and inability to make safe decisions, resulting in unsafe discharge without representative notification or discharge planning.
Resident R#29's catheter bag was left without a privacy cover, violating dignity and privacy policies.
Facility failed to notify representatives of significant changes for residents R#20 and R#24.
Facility failed to maintain a clean, comfortable environment; observed holes in doors and peeling plaster on walls.
Resident R#20 was neglected by allowing discharge AMA without appropriate supervision and discharge planning.
Facility failed to provide privacy and dignity for resident R#29 by not covering catheter bag.
Resident representatives were not notified of significant changes or AMA discharge for residents R#20 and R#24.
Facility failed to maintain and repair physical environment including peeling plaster and holes in doors.
Resident R#20 was discharged AMA without appropriate physician assessment or supervision.
Resident R#17's tracheostomy care and suctioning were not performed according to professional standards, including inadequate hand hygiene, improper cleaning technique, and failure to change trach ties.
Resident R#6's wound care was not provided as ordered; wound dressings were applied less frequently than physician orders.
Resident R#18 did not receive prescribed medication (dasatinib) for extended periods due to insurance and pharmacy issues.
Residents R#1, R#6, R#12, and R#21 had long, thick, curling toenails indicating failure to provide podiatry services or toenail care.
Resident R#38 was self-administering a Symbicort inhaler left at bedside without physician order or care plan approval.
Facility failed to maintain resident weights per policy for resident R#28, with missing documented weights for extended periods.
Residents R#12, R#13, and R#16 were not routinely offered bedtime snacks as requested by residents and documented in Resident Council minutes.
Facility administration failed to effectively oversee the discharge process resulting in unsafe discharge of resident R#20.
Facility failed to ensure timely availability of medications for residents R#6 and R#12, resulting in missed doses and delayed treatment.
Resident R#20 was discharged AMA without appropriate physician assessment or supervision.
Report Facts
Resident census: 107
Deficiencies cited: 36
Medication doses missed: 3
Medication doses missed: 4
Weight missing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. ZZZ | Physician | Involved in AMA discharge of resident R#20 |
| LPN CCC | Licensed Practical Nurse | Involved in AMA discharge of resident R#20 |
| LPN NNN | Licensed Practical Nurse | Involved in AMA discharge of resident R#20 |
| CNA LLL | Certified Nursing Assistant | Provided catheter care for resident R#29 |
| LPN EEE | Licensed Practical Nurse | Involved in medication administration and cart audits |
| RT JJ | Respiratory Therapist | Performed trach care for resident R#17 |
| LPN PP | Licensed Practical Nurse | Involved in medication administration and cart audits |
| LPN QQ | Licensed Practical Nurse | Involved in medication administration and cart audits |
| CNA YY | Certified Nursing Assistant | Provided care for resident R#21 |
| LPN AAA | Licensed Practical Nurse | Conducted AMA discharge audit |
| Regional Director of Clinical Services | Provided education and oversight | |
| Director of Nursing | Provided education and oversight | |
| Dietary Manager | Received education on safe discharge | |
| Maintenance Director | Received education on safe discharge | |
| Admissions Concierge | Received education on safe discharge | |
| Director of Social Services | Received education on safe discharge |
Inspection Report
Complaint Investigation
Deficiencies: 18
Date: Jul 20, 2023
Visit Reason
Complaint investigation triggered by concerns about resident rights, neglect, notification failures, and unsafe discharge practices.
Complaint Details
The complaint investigation focused on resident rights violations, neglect, failure to notify representatives, unsafe discharge of a cognitively impaired resident, and inadequate care practices. Immediate Jeopardy was identified related to unsafe discharge and lack of medical supervision.
Findings
The facility failed to protect resident dignity, notify representatives of condition changes, ensure safe discharge practices, maintain a safe environment, provide appropriate care including wound, trach, medication, colostomy, and pain management, and ensure proper oversight by administration. Immediate Jeopardy was identified related to unsafe discharge of a cognitively impaired resident.
Deficiencies (18)
F 0550: The facility failed to promote, maintain, and protect a resident's dignity for one resident with a urinary catheter by not providing privacy covers for catheter bags.
F 0580: The facility failed to notify representatives of significant changes and allowed a cognitively impaired resident to discharge AMA without proper notification or discharge planning, causing immediate jeopardy.
F 0584: The facility failed to maintain a clean, comfortable, homelike environment on two floors due to peeling plaster and holes in doors.
F 0600: The facility failed to protect a cognitively impaired resident from neglect by allowing him to sign an AMA discharge form and leave without appropriate assessment or notification.
F 0624: The facility failed to ensure a cognitively impaired resident was medically evaluated and supervised before self-discharge AMA, resulting in unsafe discharge and immediate jeopardy.
F 0656: The facility failed to develop and implement complete care plans for three residents, including discrepancies in trach care orders, lack of physician orders for catheters, and failure to document weight monitoring.
F 0684: The facility failed to follow physician orders for trach care, wound care, and medication administration for three residents, including improper trach care technique and missed medication doses.
F 0687: The facility failed to provide podiatry services to four residents, evidenced by long, curling, thick toenails and lack of podiatry visits or documentation.
F 0689: The facility failed to ensure safe medication self-administration and accident prevention for three residents, including medications left at bedside without orders and inadequate fall management.
F 0690: The facility failed to obtain a physician order for the use of an indwelling urinary catheter for one resident and had discrepancies in catheter care and orders.
F 0691: The facility failed to provide correct size colostomy bags for three residents, causing discomfort and loss of independence.
F 0692: The facility failed to maintain acceptable nutritional status for one resident due to failure to obtain and document weights as ordered.
F 0695: The facility failed to provide safe and appropriate respiratory care for one resident with a tracheostomy, including improper trach care technique and failure to follow physician orders.
F 0755: The facility failed to ensure timely medication availability for two residents, resulting in missed doses and delayed treatments.
F 0761: The facility failed to ensure medications were dated appropriately when opened in two medication carts, risking medication safety.
F 0809: The facility failed to provide bedtime snacks for three residents despite resident council complaints and documented requests.
F 0835: The facility administration failed to effectively oversee the discharge process, resulting in unsafe discharge and lack of proper medical evaluation for one resident, causing immediate jeopardy.
F 0880: The facility failed to maintain an effective infection control program for one resident with a tracheostomy due to improper trach care technique.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 3
Residents affected: 2
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dr. ZZZ | Physician | Involved in unsafe discharge and AMA signing of resident R#20 |
| LPN CCC | Licensed Practical Nurse | Agency nurse present during unsafe discharge of resident R#20 |
| LPN NNN | Licensed Practical Nurse | Agency nurse present during unsafe discharge of resident R#20 |
| RT JJ | Respiratory Therapist | Performed improper trach care for resident R#17 |
| LPN PP | Licensed Practical Nurse | Discussed medication cart and insulin storage issues |
| LPN EEE | Licensed Practical Nurse | Observed medication administration and discussed medication availability |
| LPN AAA | Licensed Practical Nurse | Conducted AMA discharge audit and discussed medication availability |
| CNA LLL | Certified Nursing Assistant | Provided catheter care and ostomy care for resident R#29 |
| LPN SS | Licensed Practical Nurse | Provided ostomy care and discussed colostomy bag sizing for resident R#29 |
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00234636 and #GA00233924.
Complaint Details
Complaints #GA00234636 and #GA00233924 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00234636 and #GA00233924 were unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 9, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to provide adequate activities of daily living (ADL) care, pain management, and infection control at the Buckhead Center for Nursing and Healing.
Complaint Details
The visit was complaint-related, triggered by allegations of inadequate ADL care, pain management, and infection control practices. The complaints were substantiated based on record reviews and staff and resident interviews.
Findings
The facility failed to provide baths per protocol for one resident, failed to ensure pain medication availability for another resident, and failed to follow proper hand hygiene and glove use during wound care for a third resident. These deficiencies posed minimal harm or potential for actual harm to a few residents.
Deficiencies (3)
F 0677: The facility failed to provide baths per facility protocol for one of 14 sampled residents. The facility lacked an actual ADL care policy and documentation showed missed baths for resident R#112.
F 0697: The facility failed to ensure pain medication was available for one resident reviewed for pain management. Resident R#59 experienced delays in receiving prescribed pain medication due to pharmacy and ordering issues.
F 0880: The facility failed to wash or sanitize hands and change gloves during wound treatment for one of two residents reviewed. An agency nurse did not follow proper hand hygiene protocols during wound care for resident R#127.
Report Facts
Residents reviewed for ADL care: 14
Residents reviewed for pain management: 3
Bath dates documented: 12
Pain medication dosage: 5.325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) EE/Wound Care Nurse | Interviewed regarding bathing appropriateness for resident R#112 | |
| Certified Nursing Assistant (CNA) FF | Interviewed about resident rounds and bath schedule | |
| Director of Nursing (DON) | Confirmed bathing documentation and staff education | |
| Unit Manager CC | Unit Manager | Interviewed about pain medication availability for resident R#59 |
| Licensed Practical Nurse (LPN) BB | Agency Nurse | Observed and interviewed regarding improper hand hygiene during wound care |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Buckhead Center for Nursing and Healing following a survey completed on December 30, 2020.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 124
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
An unannounced re-visit and COVID-19 Focused Infection Control re-visit survey was conducted to verify correction of previous deficiencies and compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR part 483.73 related to Emergency Preparedness and 42 CFR §483.80 infection control regulations. No deficiencies were cited and all previously cited deficiencies were corrected.
Report Facts
Census: 124
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