Inspection Reports for Budd Terrace

The inspection was a State Licensure survey conducted from May 27, 2025 through May 29, 2025, to determine compliance with the State Long Term Care Requirements.

The facility was cited for multiple deficiencies including failure to develop and implement comprehensive person-centered care plans addressing oxygen therapy and pain management for certain residents, inadequate assistance with activities of daily living (ADLs) such as bathing and grooming, inadequate pain management, and environmental sanitation issues including dirty air conditioner filters and broken mirrors in resident areas.

A standard survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean living areas, failure to provide PASARR Level II screenings, incomplete care plans for oxygen therapy and pain management, inadequate ADL care, medication self-administration issues, oxygen therapy not following physician orders, inadequate pain management, and a medication error rate exceeding 5%.

Complaint Intake Numbers GA00253425, GA00253524, GA00253554, GA00253894, GA00253952, GA00254212, GA00254585, GA00254639, GA00254751, GA00254809, and GA00254810 were investigated. Five were substantiated without deficiencies and six were unsubstantiated.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.

The inspection was a State Licensure survey conducted from May 27, 2025 through May 29, 2025, to determine compliance with the State Long Term Care Requirements.

The facility was found deficient in developing and implementing person-centered comprehensive care plans for oxygen therapy and pain management for certain residents, failure to provide adequate ADL care including showers and grooming, inadequate pain management, and environmental sanitation issues including dirty air conditioner filters and broken mirrors in resident areas.

A standard annual survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean living areas, failure to provide required PASARR Level II screenings, incomplete care plans for oxygen therapy and pain management, inadequate ADL care, medication self-administration issues, oxygen therapy not following physician orders, inadequate pain management, and a medication error rate exceeding acceptable limits.

Complaint Intake Numbers GA00253425, GA00253524, GA00253554, GA00253894, GA00253952, GA00254212, GA00254585, GA00254639, GA00254751, GA00254809, and GA00254810 were investigated. Five were substantiated without deficiencies and six were unsubstantiated.

The visit 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.

The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.

The inspection was a State Licensure survey conducted from May 27, 2025 through May 29, 2025, to determine compliance with the State Long Term Care Requirements.

The facility failed to develop and implement person-centered comprehensive care plans for residents regarding oxygen therapy and pain management, failed to ensure adequate ADL care including showers and grooming, and failed to provide adequate pain management. Environmental sanitation deficiencies were also noted including dirty air conditioner filters, dirty fans, and broken mirrors in resident areas.

The inspection was a State Licensure survey conducted from May 27, 2025, through May 29, 2025, to determine compliance with the State Long Term Care Requirements.

The facility failed to develop and implement person-centered comprehensive care plans for residents regarding oxygen therapy and pain management, failed to ensure adequate ADL care including showers and grooming, and failed to provide adequate pain management for some residents. Environmental sanitation issues were also noted, including dirty PTAC unit filters, dirty personal fans, and a broken mirror stored unsafely.

A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean resident living areas, failure to provide PASARR Level II screenings for qualifying residents, incomplete comprehensive care plans for oxygen therapy and pain management, inadequate ADL care, medication self-administration issues, oxygen therapy not following physician orders, inadequate pain management, and a medication error rate exceeding acceptable limits.

Complaint Intake Numbers GA00253425, GA00253524, GA00253554, GA00253894, GA00253952, GA00254212, GA00254585, GA00254639, GA00254751, GA00254809, and GA00254810 were investigated. Five were substantiated without deficiencies and six were unsubstantiated.

A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean resident living areas, failure to provide PASARR Level II screenings, incomplete comprehensive care plans for oxygen therapy and pain management, inadequate ADL care, medication self-administration issues, oxygen therapy not following physician orders, inadequate pain management, and medication administration errors.

Multiple complaint intake numbers were investigated; some were substantiated without deficiencies, others unsubstantiated. The standard survey included complaint investigations.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.

The inspection was a State Licensure survey conducted from May 27, 2025 through May 29, 2025, to determine compliance with the State Long Term Care Requirements.

The facility was found deficient in developing and implementing person-centered comprehensive care plans for residents, particularly regarding oxygen therapy and pain management. Deficiencies were also noted in providing adequate activities of daily living (ADL) care, including bathing, grooming, and participation in activities. Additionally, environmental sanitation issues were identified, including dirty air conditioner filters, dirty personal fans, and broken mirrors in resident areas.

A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean resident living areas, failure to provide required PASARR Level II screenings, incomplete comprehensive care plans for oxygen therapy and pain management, inadequate ADL care, medication self-administration and storage issues, oxygen therapy not following physician orders, inadequate pain management, and a medication error rate exceeding acceptable limits.

Complaint Intake Numbers GA00253425, GA00253524, GA00253554, GA00253894, GA00253952, GA00254212, GA00254585, GA00254639, GA00254751, GA00254809, and GA00254810 were investigated. Five complaints were substantiated without deficiencies and six were unsubstantiated.

The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety and related regulations.

The facility was found to be 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.

An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00252782.

The complaint GA00252782 was unsubstantiated and no regulatory violations were cited during the survey.

Complaint GA00252782 was investigated and found to be unsubstantiated.

The document is a Statement of Deficiencies and Plan of Correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was conducted.

No specific deficiencies or findings are detailed in the provided report page; only initial comments are noted without further elaboration.

A revisit was conducted to verify correction of deficiencies cited during the October 30, 2024 Complaint Investigation survey.

All deficiencies cited in the October 30, 2024 Complaint Investigation survey were found to be corrected as of November 30, 2024.

The visit was a follow-up to a Complaint Investigation survey conducted on October 30, 2024. All deficiencies were corrected by November 30, 2024.

The inspection was conducted as a State Licensure survey from October 23, 2024 through October 30, 2024 to determine compliance with the State Long Term Care Requirements.

No State Health deficiencies were cited during the survey.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against Budd Terrace at Wesley Woods, with most complaints unsubstantiated except one which was substantiated with deficiencies.

The facility failed to ensure call lights were answered and care provided for one resident, resulting in episodes of incontinence and lack of assistance. Additionally, the facility failed to honor the resident's choice of time and preference for showers, with missed showers not properly documented.

The survey investigated complaint numbers GA00244073, GA00244671, GA00244811, GA00244927, GA00246909, GA00246952, GA00247840, GA00248103, and GA00249834. Complaints GA00244671, GA00244811, GA00244927, GA00246909, GA00246952, GA00247840, GA00248103, and GA00249834 were unsubstantiated. Complaint GA00244073 was substantiated with deficiencies.

A follow-up survey was conducted to verify that all previously cited survey tags have been corrected.

The Emergency Preparedness Program was reviewed and found to be in substantial compliance with regulatory requirements. All previously cited deficiencies have been corrected.

The document is a statement of deficiencies and plan of correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A health revisit survey was conducted to verify correction of deficiencies cited during the December 21, 2023 recertification survey conducted in conjunction with a complaint investigation.

All deficiencies cited in the prior December 21, 2023 recertification survey and complaint investigation were found to be corrected during this revisit survey.

The revisit survey was conducted following a complaint investigation associated with the December 21, 2023 survey.

The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Budd Terrace at Wesley Woods.

The facility failed to follow professional standards of care for one of 26 residents by not transferring a physician-ordered medication (Trelegy inhaler) to the Electronic Medical Record (EMR) system and the Medication Administration Record (MAR).

A standard survey was conducted from December 18 through December 21, 2023, including investigation of multiple complaint intake numbers to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to transfer physician ordered medications to the EMR and MAR, failure to transcribe telephone orders resulting in missed medications, inadequate supervision leading to a resident fall, improper storage of respiratory equipment, and unsecured medication carts.

Complaint Intake Numbers GA00240721 and GA00241101 were substantiated with no deficiencies; GA00241851, GA00240804, and GA00239910 were unsubstantiated.

The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety and related regulations for Medicare/Medicaid participation.

The facility was found not in substantial compliance with Life Safety Code requirements, including deficiencies in kitchen hood suppression system maintenance, fire alarm system testing and maintenance, sprinkler system inspection, and corridor door functionality.

This document is a Statement of Deficiencies and Plan of Correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was completed.

The document contains an initial comment section but does not provide specific findings or deficiencies within the text or image.

A revisit survey was conducted to verify correction of deficiencies cited during the September 29, 2023 Complaint Survey.

All deficiencies cited as a result of the September 29, 2023 Complaint Survey were found to be corrected.

The revisit survey was conducted following a complaint survey on September 29, 2023. All deficiencies from that complaint survey were corrected.

The inspection was a Licensure Survey conducted from September 26, 2023 through September 29, 2023 to assess compliance with state licensure requirements.

The facility failed to maintain an up-to-date and effective Abuse Prevention Program, did not consistently report allegations of abuse to the State Survey Agency, and staff training was based on outdated CMS regulations. The Administrator, who was the Abuse Coordinator, was unavailable during the survey.

A Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted due to multiple complaints filed against the facility, investigating allegations of abuse and neglect.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to ensure current and implemented abuse policies, failure to report allegations of abuse to the State Survey Agency, lack of care plan for ostomy care for one resident, and failure of the Quality Assurance committee to effectively address abuse prevention and reporting. Multiple resident complaints of abuse, neglect, and poor care were substantiated.

The complaint investigation involved multiple allegations of abuse and neglect for three residents (R "A", R5, and R12). Allegations included verbal and physical abuse, failure to report abuse to the State Survey Agency, poor care such as not being cleaned or changed, rude and disrespectful staff behavior, and failure to respond timely to call lights. The facility failed to report 11 occurrences of abuse allegations to the State Survey Agency. The Director of Nursing was unaware of updated regulatory requirements and believed only 'willful' abuse needed reporting. The Administrator, who was the Abuse Coordinator, was out of the country during the survey.

An abbreviated survey was conducted to investigate complaint #GA00237027.

The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00237027 was unsubstantiated with no deficiencies cited.

The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.

The report contains initial comments but does not provide specific findings or deficiencies.

A revisit survey was conducted from 10/4/22 to 10/6/22 to verify correction of deficiencies cited during the 7/22/22 Recertification Survey.

All deficiencies cited as a result of the 7/22/22 Recertification Survey were found to be corrected.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

The follow-up survey noted that all previously cited deficiencies had been corrected.

The Life Safety Code Survey was conducted to assess compliance with fire safety and related construction, repair, and improvement operations standards at Budd Terrace at Wesley Woods.

The facility was found not in substantial compliance with the Life Safety Code requirements due to a temporary zip wall isolation barrier on the second floor for COVID assessment that did not meet NFPA 241 standards, potentially placing seven residents and staff at risk in case of fire.

The inspection was a Licensure Survey conducted from July 18, 2022 through July 22, 2022 to assess compliance with state regulations and facility licensure requirements.

The facility was found deficient in multiple areas including failure to follow CDC guidance on PPE use in the COVID-19 unit, inadequate care related to indwelling urinary catheter management, failure to assess resident safety for medication self-administration, incomplete and inaccurate care plans for multiple residents, failure to provide restorative nursing services, inadequate shower and bathing services, and failure to provide proper nail care.

A standard survey was conducted in conjunction with complaint investigations to assess compliance with Medicare/Medicaid regulations and facility requirements.

The facility was found not in substantial compliance with multiple regulatory requirements including medication self-administration assessment, visitation rights, physical restraint use, timely MDS assessments, comprehensive care planning, ADL care provision, quality of care related to diabetes and congestive heart failure management, fall prevention interventions, dietary staffing, and infection control practices.

Complaint Intake Numbers GA000225780, GA000224510, GA00221079 and GA00220789 were investigated in conjunction with this standard survey.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.

All complaints investigated during the survey were unsubstantiated and no regulatory violations were cited.

Complaints #GA00219646, #GA00218106, #GA00217508, #GA00213063, #GA00212067, #GA00211421, #GA00210852, and #GA00207988 were investigated and found unsubstantiated.

A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal regulations and preparedness for COVID-19.

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.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.

The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.

The survey investigated complaints #GA00199835, GA00200863, GA00201099, GA00207163, and GA00207470, all of which were found to be unsubstantiated.

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.

The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.

An investigation by desk review of complaint #GA00203868 was conducted on 3/25/2020, with onsite activities postponed due to lack of access. Additionally, a COVID-19 Focused Infection Control Survey was conducted on June 23-24, 2020.

No abuse, neglect, or immediate jeopardy concerns were noted. The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. No deficiencies were cited.

Investigation of complaint #GA00203868 was conducted by desk review with no abuse, neglect, or immediate jeopardy concerns noted at this time. Onsite investigation was deferred due to facility access restrictions.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with COVID-19 related regulations.

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 preparation.

A follow-up survey was conducted to verify that all previously cited deficiencies had been corrected.

The follow-up survey noted that all previously cited tags had been corrected.

A revisit survey was conducted from 5/30/19 through 5/31/19 in conjunction with the investigation of Complaint Intake Number GA00196579.

All deficiencies cited in the 4/4/19 recertification survey were found to be corrected. The complaint investigation was substantiated but no deficiencies were cited.

Complaint Intake Number GA00196579 was investigated and found substantiated with no deficiencies cited.

A revisit survey was conducted on 5/30/19 to verify correction of deficiencies cited in the 4/4/19 recertification survey and to investigate Complaint Intake Number GA#00196579.

All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was substantiated but found no deficiencies.

Complaint Intake Number GA#00196579 was investigated and substantiated with no deficiencies found.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

The facility failed to maintain a continuous seal of the smoke compartments above multiple floors near the wall, with improper mixing of different caulk to seal penetrations in multiple telecommunication rooms, placing residents and staff at risk of smoke migration.

The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements.

The facility was found not in substantial compliance due to failure to maintain eight sprinkler heads in the kitchen area which were loaded with grease and lint, one damaged sprinkler head above the 6th floor galley, and failure to maintain continuous smoke barrier seals across multiple floors with improper sealing in telecommunication rooms, placing residents and staff at risk.

A revisit survey was conducted to verify correction of deficiencies cited during the prior standard survey on 2018-02-15.

All deficiencies cited as a result of the 2/15/18 standard survey were found to be corrected.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan was also in substantial compliance with Appendix Z requirements.

A complaint survey was conducted to investigate complaints (GA 00184809) by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiency was cited during the complaint investigation survey.

Complaint survey conducted related to complaint GA 00184809; no deficiencies were found.

The inspection was conducted to investigate complaint #GA00182370 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Budd Terrace at Wesley Woods.

Complaint #GA00182370 was investigated and found to have no deficiencies.

An Abbreviated Survey was conducted on 8/22/17 to investigate Complaint GA 00178070.

The complaint was found to be unsubstantiated and no citations were issued.

Complaint GA 00178070 was investigated and found to be unsubstantiated.

An unannounced abbreviated survey was conducted to investigate complaint GA00177092.

The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.

Investigation of complaint GA00177092; facility found in substantial compliance.

A revisit survey was conducted to verify correction of deficiencies cited during the 4/14/17 Standard Recertification Survey.

All deficiencies cited in the prior 4/14/17 survey were found to be corrected during this revisit survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found to be in substantial compliance with the Life Safety Code requirements for fire safety and related NFPA standards.

The inspection was conducted to investigate complaints #GA 00159404 and #GA 00171974 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.

No deficiencies were cited during the complaint survey.

The visit was complaint-related, investigating two complaints (#GA 00159404 and #GA 00171974). No deficiencies were found.