Inspection Report Summary
The most recent inspection on May 29, 2025, identified multiple deficiencies related to care planning for oxygen therapy and pain management, inadequate assistance with activities of daily living, pain management issues, and environmental sanitation concerns such as dirty air conditioner filters and broken mirrors. Earlier inspections showed a pattern of similar issues, including medication administration errors, failure to provide PASARR Level II screenings, and unsafe living conditions, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Complaint investigations included several substantiated complaints mostly without cited deficiencies, with one prior substantiated complaint involving missed call light responses and unmet resident shower preferences. Life Safety Code surveys consistently found the facility in substantial compliance, though earlier reports noted some fire safety maintenance deficiencies that were later corrected. The overall trend suggests ongoing challenges with resident care and environmental maintenance, with no clear improvement in the most recent survey cycle.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
15.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
218% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
160% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 7
May 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, mental health screening, activities of daily living, medication administration, oxygen therapy, pain management, and medication error rates at Parkside at Budd Terrace Operating Company LLC.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, incomplete PASARR Level II screenings for residents with mental disorders, inadequate assistance with activities of daily living for some residents, unsafe medication storage and self-administration practices, improper oxygen therapy management, inadequate pain management for some residents, and a medication error rate exceeding 5 percent.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure residents' living areas were safe, clean, and comfortable; dirty PTAC unit filters and broken mirror stored on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide PASARR Level II screening for two residents with qualifying mental health diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate assistance with activities of daily living including showers, baths, and grooming for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately assess residents for self-administration of medication and failed to ensure medication was stored safely; medication found unsecured in an unoccupied room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders for oxygen therapy were followed for two residents; oxygen flow rates inconsistent with orders and residents not wearing nasal cannulas as prescribed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate pain management for two residents; pain medication dosages were inadequate or medications were not administered as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 7.5 percent, exceeding the acceptable threshold of 5 percent; medications were unavailable and not administered as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Deficiency count: 7
Medication error rate: 7.5
Oxygen flow rate: 3
Oxygen flow rate: 2
Pain level: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| OO | Regional Maintenance Director | Confirmed environmental deficiencies including dirty fans, broken mirror, and dirty PTAC units |
| VV | Licensed Practical Nurse | Confirmed PASARR referral process and missed church attendance for resident R75 |
| WW | Social Worker | Confirmed PASARR Level II referrals were not submitted timely for residents R54 and R75 |
| NN | Licensed Practical Nurse | Confirmed shower schedules and missed showers for residents R36 and R61 |
| MM | Certified Nursing Assistant | Provided information on ADL care and grooming practices |
| DON | Director of Nursing | Provided expectations for ADL care, medication storage, oxygen therapy, pain management, and medication administration |
| CC | Licensed Practical Nurse | Confirmed resident R56 was not assessed for self-administration of medication and medication was improperly stored |
| RR | Licensed Practical Nurse | Confirmed no self-medication allowed and described medication administration process |
| EE | Licensed Practical Nurse | Acknowledged oxygen therapy inconsistencies and lack of training on oxygen concentrator use |
| AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosage for resident R371 |
| BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving corrected pain medication based on pain scale |
| FF | Unit Manager Licensed Practical Nurse | Described ongoing issues with timely medication delivery from pharmacy |
| GG | Registered Nurse | Observed medication pass with missing medications for resident R12 |
| DD | Licensed Practical Nurse | Removed unidentified pill from unassigned bed and acknowledged safety risk |
| UU | Certified Nursing Assistant | Familiar with resident R75's care plan and participation in activities |
Inspection Report
Routine
Deficiencies: 6
May 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide required PASARR Level II screenings for residents with qualifying diagnoses, inadequate assistance with activities of daily living for some residents, unsafe medication storage and self-administration practices, improper oxygen therapy management, inadequate pain management for some residents, and a medication error rate exceeding 5 percent.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide Preadmission Screening and Resident Review (PASARR) Level II for two of six residents with qualifying diagnoses. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure activities of daily living care was provided for three of 59 sampled residents related to not receiving showers/baths, fingernails care and ADLs care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to adequately assess two residents for self-administration of medication and failed to ensure one room was free from accident hazards due to unsecured medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders for oxygen therapy were followed for two residents receiving oxygen. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate pain management for two residents, including failure to administer scheduled pain medications and inadequate dosage adjustments. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate was 7.5 percent, exceeding the acceptable rate of less than 5 percent, including failure to administer prescribed medications due to unavailability. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.5
Residents sampled: 59
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| VV | Licensed Practical Nurse (LPN) | Interviewed regarding PASARR screening and resident care |
| WW | Social Worker | Interviewed regarding PASARR referral process |
| NN | Licensed Practical Nurse (LPN) | Confirmed shower schedules and resident care |
| MM | Certified Nursing Assistant (CNA) | Interviewed about ADL care and grooming |
| DON | Director of Nursing | Provided expectations on care, medication, and oxygen therapy |
| CC | Licensed Practical Nurse (LPN) | Confirmed medication storage and self-administration issues |
| RR | Licensed Practical Nurse (LPN) | Confirmed no self-medication policy and medication administration practices |
| DD | Licensed Practical Nurse (LPN) | Removed unsecured pill from unassigned bed |
| EE | Licensed Practical Nurse (LPN) | Adjusted oxygen flow rates and assisted residents with oxygen therapy |
| AA | Licensed Practical Nurse (LPN) | Administered pain medication and assessed pain levels |
| BB | Licensed Practical Nurse (LPN) | Commented on pain medication administration |
| FF | Unit Manager, Licensed Practical Nurse (LPN) | Discussed medication delivery issues |
| GG | Registered Nurse (RN) | Observed medication pass and confirmed medication unavailability |
Inspection Report
Annual Inspection
Deficiencies: 4
May 29, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Failure to develop and implement a person-centered comprehensive care plan addressing oxygen therapy and pain management for residents R152 and R43. |
| Failure to ensure ADL care was provided for residents R36, R61, and R75, including missed showers, inadequate fingernail care, and lack of assistance with personal hygiene. |
| Failure to ensure adequate pain management for residents R371 and R43, including missed pain medication doses and ineffective pain control. |
| Failure to maintain a safe, clean, and comfortable living environment in rooms 515, 624, 702, and 703, including dirty PTAC unit filters and a broken mirror stored on the floor in a central bath area. |
Report Facts
Residents sampled: 59
Rooms with environmental deficiencies: 4
Residents with ADL care issues: 3
Residents with pain management issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Reported pharmacy delays and failure to check oxygen concentrators |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and ADL care issues for residents |
| LPN VV | Licensed Practical Nurse | Confirmed resident R75 missed church due to not being dressed and out of bed |
| LPN AA | Licensed Practical Nurse | Administered pain medication and assessed pain levels for resident R371 |
| LPN BB | Licensed Practical Nurse | Stated resident R371 was not receiving correct pain medication based on pain scale |
| LPN FF | Unit Manager | Reported ongoing pharmacy medication delivery issues |
| CNA MM | Certified Nursing Assistant | Reported no broken shower beds and described shower and grooming routines |
| CNA UU | Certified Nursing Assistant | Familiar with resident R75's care plan and participation in activities |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for nursing staff on oxygen therapy monitoring and pain management |
| Administrator | Facility Administrator | Stated expectations for resident grooming, dressing, and participation in activities |
| Regional Maintenance Director | Regional Maintenance Director (RMD) | Confirmed environmental sanitation issues including dirty fans, broken mirror, and dirty PTAC units |
Inspection Report
Routine
Census: 169
Capacity: 165
Deficiencies: 8
May 29, 2025
Visit Reason
A standard survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.
Findings
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 Details
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.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents' living areas were safe, clean, and comfortable; dirty PTAC unit filters and broken mirror stored on floor. | SS= D |
| Failed to provide PASARR Level II screening for two residents with qualifying diagnoses. | SS= D |
| Failed to develop and implement comprehensive care plans addressing oxygen therapy and pain management for two residents. | SS= D |
| Failed to provide adequate ADL care including showers, fingernail care, and assistance for three residents. | SS= D |
| Failed to adequately assess residents for self-administration of medication and failed to ensure medication was not left unsecured in an unoccupied room. | SS= D |
| Failed to ensure physician orders for oxygen therapy were followed for two residents; oxygen flow rates incorrect and oxygen equipment improperly used. | SS= D |
| Failed to ensure adequate pain management for two residents; pain medications not administered timely or in adequate dosages. | SS= D |
| Medication error rate of 7.5% observed, exceeding the acceptable rate of less than 5%. | SS= D |
Report Facts
Residents present: 169
Total licensed capacity: 165
Medication error rate: 7.5
Pain medication doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| WW | Social Worker | Described PASARR screening process and confirmed delays in PASARR Level II referrals |
| VV | Licensed Practical Nurse | Described process for identifying mental disorders and confirmed missing PASARR Level II for resident R75 |
| DON | Director of Nursing | Provided expectations for oxygen therapy monitoring, pain management, medication availability, and nursing staff responsibilities |
| LPN EE | Licensed Practical Nurse | Acknowledged oxygen therapy flow rate errors and pharmacy delays in medication delivery |
| RN GG | Registered Nurse | Observed medication pass and confirmed medication unavailability for resident R12 |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosing for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving correct pain medication based on pain scale |
| LPN FF | Unit Manager | Described pharmacy delays and lack of alternative procedures for medication shortages |
| CNA MM | Certified Nursing Assistant | Discussed ADL care and shower schedules for residents R36 and R61 |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and lack of care for resident R61's fingernails |
| CNA UU | Certified Nursing Assistant | Familiar with resident R75's care plan and participation in activities |
Inspection Report
Life Safety
Census: 173
Capacity: 250
Deficiencies: 0
May 29, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Inspection Report
Annual Inspection
Deficiencies: 4
May 29, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Failure to develop and implement a person-centered comprehensive care plan addressing oxygen therapy and pain management for residents R152 and R43. |
| Failure to ensure ADL care was provided including showers, fingernail care, and personal hygiene for residents R36, R61, and R75. |
| Failure to ensure adequate pain management for residents R371 and R43, including missed medications and ineffective pain control. |
| Failure to maintain a safe, clean, and comfortable living environment in rooms 515, 624, 702, and 703, including dirty PTAC unit filters and broken mirrors stored unsafely. |
Report Facts
Residents sampled: 59
Rooms with environmental deficiencies: 4
Residents with ADL care deficiencies: 3
Residents with pain management deficiencies: 2
Residents with care plan deficiencies for oxygen therapy: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for nursing staff monitoring oxygen therapy and pain management |
| LPN EE | Licensed Practical Nurse | Interviewed about pharmacy delays and medication reorder process |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and grooming care issues for residents |
| Certified Nursing Assistant MM | Certified Nursing Assistant | Interviewed about shower and grooming care provision |
| LPN VV | Licensed Practical Nurse | Confirmed resident R75 missed church due to care issues |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Familiar with resident R75's care plan and activities participation |
| LPN AA | Licensed Practical Nurse | Interviewed about pain medication administration and assessment |
| LPN BB | Licensed Practical Nurse | Interviewed about pain medication adequacy for resident R371 |
| Unit Manager LPN FF | Licensed Practical Nurse | Discussed ongoing pharmacy medication delivery issues |
| Regional Maintenance Director OO | Regional Maintenance Director | Confirmed environmental sanitation deficiencies including dirty fans, broken mirrors, and damaged PTAC units |
| Administrator | Administrator | Interviewed about expectations for resident grooming, dressing, and participation in activities |
Inspection Report
Annual Inspection
Census: 169
Capacity: 165
Deficiencies: 8
May 29, 2025
Visit Reason
A standard annual survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.
Findings
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 Details
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.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' living areas were unsafe, unclean, and uncomfortable in four rooms; PTAC unit filters were dirty; broken mirror stored on floor in a bath area. | SS= D |
| Failure to provide PASARR Level II screening for two residents with qualifying diagnoses. | SS= D |
| Failure to develop and implement comprehensive care plans addressing oxygen therapy and pain management for two residents. | SS= D |
| Failure to provide adequate ADL care including showers, fingernail care, and assistance for three residents. | SS= D |
| Failure to adequately assess two residents for self-administration of medication; medication found unsecured in an unoccupied room. | SS= D |
| Failure to ensure oxygen therapy followed physician orders for two residents; oxygen concentrators improperly set or not in use. | SS= D |
| Failure to ensure adequate pain management for two residents; missed doses and ineffective pain control documented. | SS= D |
| Medication error rate of 7.5% observed, exceeding the acceptable rate of less than 5%. | SS= D |
Report Facts
Residents present: 169
Total licensed capacity: 165
Medication error rate: 7.5
Pain medication doses: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| WW | Social Worker | Described PASARR screening process and confirmed delays in PASARR Level II submissions for residents R54 and R75 |
| VV | Licensed Practical Nurse | Confirmed PASARR referral responsibilities and acknowledged lack of PASARR Level II for R75 |
| DON | Director of Nursing | Provided expectations for oxygen therapy monitoring, pain management, medication administration, and ADL care |
| LPN EE | Licensed Practical Nurse | Acknowledged oxygen concentrator flow rate errors and pharmacy delays in medication delivery |
| RN GG | Registered Nurse | Reported medication unavailability during medication pass |
| LPN RR | Licensed Practical Nurse | Confirmed no self-medication at facility and described medication administration process |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosing for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving correct pain medication based on pain scale |
| LPN FF | Unit Manager | Discussed pharmacy delays and medication delivery issues |
| CNA MM | Certified Nursing Assistant | Discussed ADL care and shower schedules |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and ADL care deficiencies |
| CNA UU | Certified Nursing Assistant | Familiar with resident R75's care plan and activity participation |
| LPN DD | Licensed Practical Nurse | Removed unsecured pill from unoccupied room |
Inspection Report
Life Safety
Census: 173
Capacity: 250
Deficiencies: 0
May 29, 2025
Visit Reason
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.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Report Facts
Stories: 7
Construction year: 1994
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 4
May 29, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Failure to develop and implement a person-centered comprehensive care plan addressing oxygen therapy and pain management for residents R152 and R43. |
| Failure to ensure ADL care was provided including showers, fingernail care, and assistance with activities of daily living for residents R36, R61, and R75. |
| Failure to ensure adequate pain management for residents R371 and R43, including inconsistent medication administration and inadequate pain control. |
| Failure to maintain a safe, clean, and comfortable living environment in rooms 515, 624, 702, and 703, including dirty PTAC unit filters, dirty oscillating fans, and broken mirrors stored on the floor in shower areas. |
Report Facts
Residents sampled: 59
Rooms with environmental deficiencies: 4
Residents with care plan deficiencies: 2
Residents with ADL care deficiencies: 3
Residents with pain management deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for nursing staff monitoring oxygen therapy and pain management |
| LPN EE | Licensed Practical Nurse | Interviewed about pharmacy delays and medication reorder issues |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and ADL care issues |
| Certified Nursing Assistant MM | Certified Nursing Assistant | Interviewed about shower and grooming care provision |
| LPN VV | Licensed Practical Nurse | Confirmed resident R75 missed church due to care issues |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Familiar with resident R75's care plan and activities participation |
| LPN AA | Licensed Practical Nurse | Interviewed about pain medication administration and assessment |
| LPN BB | Licensed Practical Nurse | Interviewed about pain medication adequacy for resident R371 |
| Unit Manager LPN FF | Licensed Practical Nurse | Discussed ongoing pharmacy medication delivery issues |
| Regional Maintenance Director OO | Regional Maintenance Director | Confirmed environmental sanitation deficiencies during walking rounds |
| Administrator | Facility Administrator | Interviewed regarding expectations for resident grooming and participation in activities |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 4
May 29, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Failure to develop and implement person-centered comprehensive care plans addressing oxygen therapy and pain management for residents R152 and R43. |
| Failure to ensure ADL care was provided, including showers, baths, and fingernail care for residents R36, R61, and R75. |
| Failure to ensure adequate pain management for residents R371 and R43, including missed medications and ineffective pain control. |
| Failure to maintain a safe, clean, and comfortable living environment in four rooms and one central bath area, including dirty PTAC unit filters, dirty personal fans, and a broken mirror stored on the floor. |
Report Facts
Residents sampled: 59
Rooms with environmental issues: 4
Rooms with cognitive impairment residents: 5
Pain medication administration records: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Mentioned regarding pharmacy delays and failure to check oxygen concentrators |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and missed grooming for residents |
| CNA MM | Certified Nursing Assistant | Interviewed about shower and grooming care provision |
| LPN VV | Licensed Practical Nurse | Confirmed missed church attendance for resident R75 |
| CNA UU | Certified Nursing Assistant | Familiar with resident R75's care plan and activities participation |
| LPN AA | Licensed Practical Nurse | Administered pain medication and assessed pain levels for resident R371 |
| LPN BB | Licensed Practical Nurse | Stated resident R371 was not receiving correct pain medication |
| LPN FF | Unit Manager | Discussed ongoing pharmacy medication delivery issues |
| DON | Director of Nursing | Provided expectations for nursing staff regarding oxygen therapy monitoring and pain management |
| Administrator | Stated expectations for residents to be well-groomed, dressed, out of bed, and participating in activities | |
| RMD OO | Regional Maintenance Director | Confirmed environmental sanitation issues including dirty fans and broken mirror |
Inspection Report
Routine
Census: 169
Capacity: 165
Deficiencies: 8
May 29, 2025
Visit Reason
A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.
Findings
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 Details
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.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' living areas were unsafe, unclean, and uncomfortable in four rooms; PTAC unit filters were dirty; broken mirror stored on floor in bath area. | SS= D |
| Failed to provide PASARR Level II screening for two residents with qualifying diagnoses. | SS= D |
| Failed to develop and implement comprehensive care plans addressing oxygen therapy and pain management for two residents. | SS= D |
| Failed to provide adequate ADL care including showers, fingernail care, and assistance for three residents. | SS= D |
| Failed to adequately assess two residents for self-administration of medication; medication found unsecured in unoccupied room. | SS= D |
| Failed to ensure oxygen therapy followed physician orders for two residents; oxygen flow rates incorrect and concentrators improperly used. | SS= D |
| Failed to ensure adequate pain management for two residents; pain medication not administered timely or in correct dosages. | SS= D |
| Medication error rate of 7.5% observed, exceeding acceptable threshold of 5%. | SS= D |
Report Facts
Residents present: 169
Total licensed capacity: 165
Medication error rate: 7.5
Pain medication doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| WW | Social Worker | Described PASARR screening process and confirmed delays in Level II referrals |
| VV | Licensed Practical Nurse | Discussed mental disorder identification and oxygen concentrator monitoring |
| DON | Director of Nursing | Provided expectations for oxygen therapy monitoring, pain management, medication availability, and nursing staff responsibilities |
| LPN EE | Licensed Practical Nurse | Acknowledged oxygen therapy discrepancies and pharmacy delays |
| RN GG | Registered Nurse | Observed medication pass and confirmed medication unavailability |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosing for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving correct pain medication |
| LPN FF | Unit Manager | Discussed pharmacy delays and medication refill issues |
Inspection Report
Routine
Census: 169
Capacity: 165
Deficiencies: 8
May 29, 2025
Visit Reason
A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.
Findings
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.
Complaint Details
Multiple complaint intake numbers were investigated; some were substantiated without deficiencies, others unsubstantiated. The standard survey included complaint investigations.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' living areas were unsafe, unclean, and uncomfortable in four rooms; PTAC unit filters were dirty; broken mirror stored on floor in bath area. | SS= D |
| Failure to provide PASARR Level II screening for two residents with qualifying diagnoses. | SS= D |
| Failure to develop and implement person-centered comprehensive care plans addressing oxygen therapy and pain management for two residents. | SS= D |
| Failure to provide adequate ADL care including showers, fingernail care, and assistance with activities for three residents. | SS= D |
| Failure to adequately assess two residents for self-administration of medication; medication found unsecured in unoccupied room. | SS= D |
| Failure to ensure oxygen therapy followed physician orders for two residents; oxygen concentrators improperly set or not in use. | SS= D |
| Failure to ensure adequate pain management for two residents; pain medications not administered timely or at appropriate dosages. | SS= D |
| Medication error rate of 7.5% observed, exceeding acceptable threshold, including missed medication administrations due to unavailability. | SS= D |
Report Facts
Residents present: 169
Total licensed capacity: 165
Medication error rate: 7.5
Pain medication doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| WW | Social Worker | Described PASARR screening process and confirmed delays in PASARR Level II referrals |
| VV | Licensed Practical Nurse | Described process for identifying mental disorders and confirmed missing PASARR Level II for resident R75 |
| DON | Director of Nursing | Provided expectations for oxygen therapy monitoring, pain management, medication administration, and ADL care |
| MM | Certified Nursing Assistant | Interviewed regarding ADL care and shower schedules |
| EE | Licensed Practical Nurse | Confirmed oxygen therapy discrepancies and pharmacy delays for pain medications |
| RR | Licensed Practical Nurse | Confirmed no self-medication at facility and described medication administration process |
| LPN DD | Licensed Practical Nurse | Confirmed unsecured medication found in unoccupied room |
| RN GG | Registered Nurse | Reported medication unavailability for resident R12 |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosing for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving correct pain medication dosage |
| LPN FF | Unit Manager | Described pharmacy delays and medication ordering issues |
Inspection Report
Life Safety
Census: 173
Capacity: 250
Deficiencies: 0
May 29, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Stories: 7
Construction year: 1994
Inspection Report
Life Safety
Census: 173
Capacity: 250
Deficiencies: 0
May 29, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Stories: 7
Construction year: 1994
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 4
May 29, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
| Description |
|---|
| Failure to develop and implement person-centered comprehensive care plans addressing oxygen therapy and pain management for residents R152 and R43. |
| Failure to ensure ADL care was provided, including missed showers/baths and inadequate fingernail care for residents R36, R61, and R75. |
| Failure to ensure adequate pain management for residents R371 and R43, including missed pain medication doses and inadequate medication administration. |
| Failure to maintain a safe, clean, and comfortable living environment in rooms 515, 624, 702, and 703, including dirty PTAC unit filters, dirty personal fans, and broken mirrors in shower areas. |
Report Facts
Residents sampled: 59
Rooms with environmental deficiencies: 4
Residents with care plan deficiencies: 2
Residents with ADL care deficiencies: 3
Residents with pain management deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for nursing staff monitoring oxygen therapy and pain management |
| LPN EE | Licensed Practical Nurse | Interviewed about pharmacy delays and medication reorder process |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and ADL care issues for residents |
| Certified Nursing Assistant MM | Certified Nursing Assistant | Interviewed about shower and grooming care provision |
| LPN VV | Licensed Practical Nurse | Confirmed missed activities and care plan for resident R75 |
| Certified Nursing Assistant UU | Certified Nursing Assistant | Familiar with resident R75's care plan and activities participation |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication administration for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed pain medication issues for resident R371 |
| Unit Manager LPN FF | Licensed Practical Nurse | Discussed ongoing pharmacy medication delivery issues |
| Regional Maintenance Director OO | Regional Maintenance Director | Confirmed environmental deficiencies including dirty fans, broken mirrors, and dirty PTAC units |
Inspection Report
Routine
Census: 169
Deficiencies: 8
May 29, 2025
Visit Reason
A standard routine survey was conducted from May 27, 2025 through May 29, 2025, including investigation of multiple complaint intake numbers.
Findings
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 Details
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.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Residents' living areas were unsafe, unclean, and uncomfortable in four rooms; PTAC unit filters were dirty; broken mirror stored on floor in bath area. | SS= D |
| Failure to provide PASARR Level II screening for two residents with qualifying diagnoses. | SS= D |
| Failure to develop and implement comprehensive care plans addressing oxygen therapy and pain management for two residents. | SS= D |
| Failure to provide adequate ADL care including showers, fingernail care, and assistance for three residents. | SS= D |
| Failure to adequately assess residents for self-administration of medication and medication found unsecured in unoccupied room. | SS= D |
| Failure to ensure oxygen therapy orders were followed for two residents, including incorrect flow rates and equipment misuse. | SS= D |
| Failure to ensure adequate pain management for two residents, including inconsistent medication administration and unresolved pain complaints. | SS= D |
| Medication error rate of 7.5% observed, exceeding the acceptable rate of less than 5%. | SS= D |
Report Facts
Residents present: 169
Medication error rate: 7.5
Medication error threshold: 5
Pain medication doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| WW | Social Worker | Described PASARR screening process and confirmed delayed referrals for residents R54 and R75 |
| VV | Licensed Practical Nurse | Described mental disorder identification process and confirmed missing PASARR Level II for resident R75 |
| DON | Director of Nursing | Provided expectations for oxygen therapy monitoring, pain management, medication administration, and ADL care |
| MM | Certified Nursing Assistant | Interviewed regarding ADL care and shower schedules |
| LPN NN | Licensed Practical Nurse | Confirmed shower schedules and lack of care for residents R36 and R61 |
| LPN EE | Licensed Practical Nurse | Acknowledged oxygen therapy flow rate errors and pharmacy delays in medication delivery |
| RN GG | Registered Nurse | Observed medication pass and confirmed medication unavailability for resident R12 |
| LPN DD | Licensed Practical Nurse | Removed unsecured pill from unoccupied room |
| LPN RR | Licensed Practical Nurse | Confirmed no self-medication allowed at facility |
| LPN AA | Licensed Practical Nurse | Confirmed inadequate pain medication dosing for resident R371 |
| LPN BB | Licensed Practical Nurse | Confirmed resident R371 was not receiving correct pain medication dosing |
| LPN FF | Unit Manager | Discussed ongoing pharmacy delays and lack of alternative procedures for medication shortages |
| CNA UU | Certified Nursing Assistant | Familiar with resident R75's care plan and participation in activities |
Inspection Report
Life Safety
Census: 173
Capacity: 250
Deficiencies: 0
May 29, 2025
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety and related regulations.
Findings
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.
Report Facts
Stories: 7
Construction year: 1994
Inspection Report
Abbreviated Survey
Census: 111
Deficiencies: 0
Dec 18, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00252782.
Findings
The complaint GA00252782 was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00252782 was investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Dec 9, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report page; only initial comments are noted without further elaboration.
Inspection Report
Follow-Up
Census: 102
Deficiencies: 0
Dec 9, 2024
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the October 30, 2024 Complaint Investigation survey.
Findings
All deficiencies cited in the October 30, 2024 Complaint Investigation survey were found to be corrected as of November 30, 2024.
Complaint Details
The visit was a follow-up to a Complaint Investigation survey conducted on October 30, 2024. All deficiencies were corrected by November 30, 2024.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 30, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to ensure call lights were answered and care provided, and failure to honor resident choice for shower times for one of three residents (R1).
Findings
The facility failed to ensure R1's care needs were met after call light activation, resulting in episodes of incontinence and inadequate peri care. Additionally, the facility failed to honor R1's preferred shower times, with missed showers and lack of documentation for missed care.
Complaint Details
The complaint investigation revealed substantiated issues including staff ignoring call lights, inadequate peri care, and failure to honor shower preferences for resident R1.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered and care provided for one resident, resulting in episodes of incontinence. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure resident choice of time and preference for showers was honored, with missed showers and inadequate documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Documented showers: 3
Scheduled showers: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Interviewed regarding peri care protocol and observations of resident R1 |
| RN CC | Registered Nurse, Unit Manager | Interviewed regarding documentation expectations for missed showers |
Inspection Report
Renewal
Deficiencies: 0
Oct 30, 2024
Visit Reason
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.
Findings
No State Health deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 2
Oct 30, 2024
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure call lights were answered and care provided for one resident after initiation of the call light system. | SS= D |
| Failure to ensure one resident's choice of time and preference for showers was honored. | SS= D |
Report Facts
Complaints investigated: 9
Complaints substantiated: 1
Resident census: 113
Documented showers: 3
Scheduled showers: 7
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse | Interviewed regarding peri care protocol and observed resident care |
| CC | Registered Nurse, Unit Manager | Interviewed about documentation and shower scheduling |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 8, 2024
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The Emergency Preparedness Program was reviewed and found to be in substantial compliance with regulatory requirements. All previously cited deficiencies have been corrected.
Inspection Report
Deficiencies: 0
Feb 1, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 125
Deficiencies: 0
Feb 1, 2024
Visit Reason
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.
Findings
All deficiencies cited in the prior December 21, 2023 recertification survey and complaint investigation were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a complaint investigation associated with the December 21, 2023 survey.
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 5
Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, treatment and care according to orders, accident prevention, respiratory care, medication storage, and other regulatory requirements at the nursing facility.
Findings
The facility was found deficient in multiple areas 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 failure to secure medications in locked compartments during transport.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR) for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a telephone order was transcribed into the Electronic Medication Administration Record (EMAR) system resulting in a resident not receiving the ordered medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision for a resident requiring two-person assistance during ADL care, resulting in a fall and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper storage of a CPAP mask when not in use; mask was found unbagged on bedside table. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store physician ordered medications in locked compartments when unattended for two medication carts in the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 118
Residents affected: 26
Residents affected: 31
Residents affected: 4
Residents affected: 1
Medication carts observed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Named in medication transfer and medication transcription deficiencies and respiratory care finding |
| Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to medication orders, supervision, and medication storage |
| Licensed Practical Nurse 5 | Licensed Practical Nurse (LPN) | Named in medication storage deficiency |
| Licensed Practical Nurse 6 | Licensed Practical Nurse (LPN) | Named in medication storage deficiency |
| Certified Nurses' Aide 1 | Certified Nurses' Aide (CNA) | Named in resident fall supervision deficiency |
| Certified Nurses' Aide 2 | Certified Nurses' Aide (CNA) | Named in resident fall supervision deficiency |
| Certified Nurses' Aide 4 | Certified Nurses' Aide (CNA) | Named in resident fall supervision deficiency |
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 5
Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, treatment and care according to orders, accident prevention, respiratory care, medication storage, and other regulatory requirements at the nursing facility.
Findings
The facility was found deficient in multiple areas 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 failure to secure medications in locked compartments during transport.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR) for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a telephone order was transcribed into the Electronic Medication Administration Record (EMAR) system resulting in a resident not receiving the ordered medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision for a resident requiring two-person assistance during ADL care, resulting in a fall and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain proper storage of a CPAP mask when not in use; mask was found unbagged on bedside table. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to store physician ordered medications in locked compartments when unattended for two of six medication carts in the facility. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 118
Residents affected: 26
Residents affected: 31
Residents affected: 4
Residents affected: 1
Residents affected: 2
Fall Risk Assessment score: 9
BIMS score: 15
BIMS score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Named in medication transfer and CPAP mask storage deficiencies |
| Director of Nursing | Director of Nursing | Confirmed medication order processes and deficiencies, supervision expectations, and medication storage requirements |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Acknowledged medication cart locking deficiency |
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Acknowledged medication cart locking deficiency |
| CNA1 | Certified Nurses' Aide | Involved in resident fall incident |
| CNA2 | Certified Nurses' Aide | Involved in resident fall incident |
| CNA4 | Certified Nurses' Aide | Involved in resident fall incident |
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 1
Dec 21, 2023
Visit Reason
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.
Findings
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).
Deficiencies (1)
| Description |
|---|
| Failure to transfer a physician ordered medication to the EMR system and MAR for one resident. |
Report Facts
Resident census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Licensed Practical Nurse | Stated she transferred medications but did not transfer the Trelegy inhaler to the EMR system or MAR. |
| Director of Nursing | Director of Nursing | Confirmed all orders should be placed in the EMR system to generate on the MAR. |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 5
Dec 21, 2023
Visit Reason
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.
Findings
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 Details
Complaint Intake Numbers GA00240721 and GA00241101 were substantiated with no deficiencies; GA00241851, GA00240804, and GA00239910 were unsubstantiated.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to transfer a physician ordered medication to the Electronic Medical Record (EMR) system and to the Medication Administration Record (MAR) for one resident. | SS= D |
| Failed to ensure a telephone order for one resident was transcribed into the EMAR system, resulting in the resident not receiving the ordered medication. | SS= D |
| Failed to ensure a resident requiring two-person assistance received adequate supervision during ADL care, resulting in a fall and injury. | SS= D |
| Failed to maintain proper storage of a CPAP mask when not in use for one resident. | SS= D |
| Failed to store physician ordered medications in a locked compartment when unattended for two medication carts. | SS= D |
Report Facts
Residents sampled: 26
Residents sampled: 31
Residents reviewed for accidents: 4
Facility census: 118
Fall Risk Assessment score: 9
Medication carts with unlocked medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)1 | Admitted failure to transfer medication orders to EMR and MAR; unit manager who confirmed missed transcription of orders | |
| Director of Nursing (DON) | Confirmed all orders should be placed in EMR; confirmed missed medication orders and supervision failures; confirmed medication carts should be locked | |
| Licensed Practical Nurse (LPN)5 | Acknowledged medication carts did not lock and medications should have been moved | |
| Licensed Practical Nurse (LPN)6 | Confirmed medications should have been kept in locked container | |
| Certified Nurses' Aides (CNA1, CNA2, CNA4) | Involved in resident fall incident due to inadequate supervision |
Inspection Report
Life Safety
Census: 116
Capacity: 270
Deficiencies: 4
Dec 19, 2023
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety and related regulations for Medicare/Medicaid participation.
Findings
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.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Kitchen hood suppression rubber spray head covers were missing and the system was past due for the six-month suppression service. | D |
| Fire alarm system testing and maintenance were not maintained as required; bi-annual smoke detector sensitivity testing was not updated. | D |
| Fire sprinkler system had not been maintained to minimum standards; five-year sprinkler inspection was last done in August 2018. | D |
| Resident Room #708 door would not latch when closed, failing to resist smoke passage. | D |
Report Facts
Census: 116
Total Capacity: 270
Date of last six-month suppression service: 2023
Date of last five-year sprinkler inspection: 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 29, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Budd Terrace at Wesley Woods, indicating a regulatory inspection was completed.
Findings
The document contains an initial comment section but does not provide specific findings or deficiencies within the text or image.
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Nov 29, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 29, 2023 Complaint Survey.
Findings
All deficiencies cited as a result of the September 29, 2023 Complaint Survey were found to be corrected.
Complaint Details
The revisit survey was conducted following a complaint survey on September 29, 2023. All deficiencies from that complaint survey were corrected.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 2
Sep 29, 2023
Visit Reason
The inspection was conducted due to allegations and complaints of abuse, neglect, and failure to report suspected abuse at the facility.
Findings
The facility failed to ensure that abuse policies were current and implemented, resulting in multiple unreported allegations of abuse affecting several residents. Interviews and record reviews revealed staff misconduct, inadequate reporting to the State Survey Agency, and outdated abuse training.
Complaint Details
The complaint investigation involved three residents (R A, R5, and R12) with multiple allegations of abuse including verbal and physical abuse, neglect in care such as not being cleaned or changed, rude staff behavior, and failure to report these allegations to the State Survey Agency. The Director of Nursing was unaware of updated regulatory requirements and only reported willful abuse allegations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Level of Harm - Minimal harm or potential for actual harm |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Allegations of abuse: 11
Grievances filed by resident R A: 21
Residents affected: Described as 'Many' for F607 and 'Some' for F609 deficiencies.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 5
Sep 29, 2023
Visit Reason
The inspection was conducted due to allegations and complaints of abuse, neglect, and failure to report abuse at the facility, as well as concerns about care planning and quality assurance processes.
Findings
The facility failed to ensure abuse policies were current and implemented, resulting in multiple unreported allegations of abuse affecting several residents. Deficiencies were found in timely reporting of suspected abuse, development of care plans (specifically ostomy care), and the effectiveness of the Quality Assessment and Assurance committee in addressing abuse and customer service concerns.
Complaint Details
The complaint investigation revealed multiple allegations of abuse for three residents (R A, R5, and R12) that were not reported to the State Survey Agency. Complaints included verbal and physical abuse, neglect in care such as not being cleaned or changed timely, rude and disrespectful staff behavior, and failure to provide adequate assistance. The Director of Nursing was unaware of updated regulatory requirements and only reported willful abuse allegations. The facility's grievance and complaint processes were inadequate, and abuse training was based on outdated regulations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan that meets all the resident's needs, specifically for ostomy care for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to administer the facility in a manner that enables effective and efficient use of resources, including failure to maintain an up-to-date and effective Abuse Prevention Program. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to set up an ongoing quality assessment and assurance group that effectively identifies, develops, implements, and monitors corrective action plans related to abuse prevention and reporting. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Census: 115
Grievances: 11
Grievances: 21
QAPI Concerns: 26
QAPI Concerns: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Director of Nursing | Provided regulatory guidance, involved in abuse investigations, unaware of updated abuse reporting regulations, and interviewed multiple times regarding abuse reporting and training. |
| Administrator | Administrator and Abuse Coordinator | Responsible for abuse reporting and policy oversight but was out of the country and unavailable during the survey. |
| RN OO | MDS Coordinator/Registered Nurse | Interviewed regarding care plan development and ostomy care plan absence. |
| RN GG | Registered Nurse | Interviewed regarding ostomy care and care plan documentation. |
Inspection Report
Renewal
Census: 115
Deficiencies: 1
Sep 29, 2023
Visit Reason
The inspection was a Licensure Survey conducted from September 26, 2023 through September 29, 2023 to assess compliance with state licensure requirements.
Findings
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.
Deficiencies (1)
| Description |
|---|
| Failure to ensure an up-to-date and effective Abuse Prevention Program and consistent reporting of abuse allegations to the State Survey Agency. |
Report Facts
Census: 115
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting and training; revealed Administrator was out of the country and unavailable |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 5
Sep 29, 2023
Visit Reason
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.
Findings
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.
Complaint Details
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.
Severity Breakdown
SS=F: 3
SS=E: 1
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure that the Abuse Policy and Procedures were current and implemented, affecting all residents. | SS=F |
| Failure to report allegations of abuse to the State Survey Agency for three sampled residents. | SS=E |
| Failure to develop a care plan for ostomy care for one resident. | SS=D |
| Failure to maintain an up-to-date and effective Abuse Prevention Program and to educate staff on current CMS regulations. | SS=F |
| Failure to have a Quality Assessment and Assurance committee that effectively identified, developed, implemented, and monitored corrective action plans related to Abuse Prevention Policy and Procedure and reporting. | SS=F |
Report Facts
Resident census: 115
Number of abuse allegations not reported: 11
Number of grievances filed by resident R "A": 21
Number of sampled residents: 22
Number of staff educated on customer service: 9
Number of concerns noted in QAPI meetings: 26
Number of concerns noted in QAPI meetings: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times; unaware of updated abuse reporting regulations; involved in abuse investigations; stated abuse allegations were only reported if 'willful' |
| RN OO | MDS Coordinator/Registered Nurse | Interviewed regarding care plan development and ostomy care plan absence |
| RN GG | Registered Nurse | Interviewed regarding ostomy care provided by staff and documentation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 13, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00237027.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00237027 was unsubstantiated with no deficiencies cited.
Inspection Report
Deficiencies: 0
Oct 6, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 136
Deficiencies: 0
Oct 6, 2022
Visit Reason
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.
Findings
All deficiencies cited as a result of the 7/22/22 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 27, 2022
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 142
Capacity: 270
Deficiencies: 1
Aug 1, 2022
Visit Reason
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.
Findings
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.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility put up a zip wall on the second floor as a temporary/isolation barrier for COVID assessment that did not meet NFPA 241 standards, risking fire safety for seven residents and staff. | SS= D |
Report Facts
Census: 142
Certified Beds: 270
Number of residents and staff at risk: 7
Number of patients behind zip wall: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during tour on 8/1/2022 |
Inspection Report
Routine
Deficiencies: 10
Jul 22, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey of Parkside at Budd Terrace Operating Company LLC to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including medication self-administration assessment, visitation rights, restraint use and monitoring, timely completion of Minimum Data Set (MDS) assessments, comprehensive care planning, assistance with activities of daily living, adherence to physician orders, fall prevention interventions, staffing in the food and nutrition department, and infection prevention and control practices related to COVID-19 and catheter care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to assess and determine if a resident was safe to self-administer medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident was allowed to have a visitor of his/her choosing at the time of his/her choosing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physical restraints were used only when medically necessary and failed to conduct required assessments and evaluations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to complete quarterly Minimum Data Set (MDS) assessments timely for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plans addressing all resident needs including psychotropic medication use, dialysis care, side rails, diabetes, and congestive heart failure. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to consistently provide assistance with activities of daily living including showers and nail care for dependent residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and services according to physician orders including neurological checks after falls, blood glucose monitoring and insulin administration, laboratory testing for potassium levels, and use of compression stockings and weekly weights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide a safe environment and proper supervision to prevent falls and failed to consistently implement care planned fall prevention interventions. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to employ sufficient kitchen staff to ensure resident meals were served on regular dishware, resulting in use of disposable dishware. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure staff followed CDC guidance for PPE use on the COVID-19 unit and failed to keep indwelling urinary catheter drainage bag and tubing off the floor. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Fall risk score: 13
BIMS score: 1
BIMS score: 10
BIMS score: 15
BIMS score: 7
BIMS score: 2
Weight: 208
Potassium level: 3
Potassium level: 3.3
Blood Urea Nitrogen (BUN): 31
Blood Urea Nitrogen (BUN): 33
Staff shortage: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse (RN) | Confirmed resident had not been assessed to self-administer medication |
| TT | Unit Manager (UM) | Involved in visitation and medication self-administration interviews |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| OO | Certified Nurse Assistant (CNA) | Provided interviews related to restorative services and fall prevention |
| NN | Licensed Practical Nurse (LPN) | Provided interviews related to neurological checks, medication administration, and care plans |
| Licensed Practical Nurse (LPN) | Provided interviews related to neurological checks and restorative program | |
| ADON | Assistant Director of Nursing | Provided interviews related to restorative program and fall prevention |
| CC | Certified Nurse Assistant (CNA) | Provided interview related to compression stocking care |
| DD | Licensed Practical Nurse (LPN) | Provided interview related to compression stocking care |
| MM | Certified Nurse Assistant (CNA) | Provided interview related to fall prevention |
| AA | Assistant Food Service Director (AFSD) | Provided interview related to kitchen staffing and use of disposable dishware |
| BB | Assistant Food Service Director (AFSD) | Provided interview related to kitchen staffing and use of disposable dishware |
| FF | Certified Nurse Assistant (CNA) | Provided interview related to catheter care and nail care |
| YY | Certified Nursing Assistant (CNA) | Observed and interviewed regarding PPE use on COVID-19 unit |
| XX | Housekeeper | Observed and interviewed regarding PPE use on COVID-19 unit |
| EE | Unit Manager | Provided interview related to psychotropic medication care planning |
Inspection Report
Annual Inspection
Deficiencies: 6
Jul 22, 2022
Visit Reason
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.
Findings
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.
Deficiencies (6)
| Description |
|---|
| Failure to ensure staff followed CDC guidance regarding PPE use on the COVID-19 unit and failure to keep indwelling urinary catheter drainage bag and tubing off the floor for one resident. |
| Failure to assess and determine if a resident was safe to self-administer medication. |
| Failure to develop comprehensive care plans addressing individual resident needs, including psychotropic medication use, dialysis care, and use of side rails. |
| Failure to provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living, including failure to follow through with therapy plans for a restorative nursing program. |
| Failure to provide showers as scheduled or as requested, with documentation lacking for showers provided and some residents reporting not receiving showers. |
| Failure to provide proper nail care, resulting in a resident having dark colored, dry substance under fingernails. |
Report Facts
Dates of survey: 5
Resident ID: 71
Resident ID: 184
Resident ID: 95
Resident ID: 67
Resident ID: 452
Resident ID: 120
Resident ID: 6
BIMS score: 10
BIMS score: 15
BIMS score: 7
BIMS score: 3
BIMS score: 13
BIMS score: 15
Medication dosage: 25
Medication dosage: 12.5
Medication dosage: 300
Medication dosage: 60
Medication dosage: 20
Shower frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager TT | Unit Manager | Confirmed urinary catheter tubing on floor was infection control issue and responsible for ensuring tubing was off floor |
| Certified Nursing Assistant FF | CNA | Confirmed urinary catheter bags and tubing on floor was infection control issue |
| Director of Nursing | DON | Provided multiple interviews regarding PPE guidance, catheter care, care plan expectations, restorative program, and showering |
| Assistant Director of Nursing | ADON | Explained need to keep catheter bags off floor and restorative program guidance |
| Administrator | Administrator | Stated expectations for PPE use, catheter care, medication self-administration assessment, care plan accuracy, and showering |
| Registered Nurse VV | RN | Confirmed resident had not been assessed to self-administer medication |
| Licensed Practical Nurse NN | LPN | Provided interviews on care plan use, showering, and restorative program |
| Licensed Practical Nurse QQ | LPN | Provided interviews on care plan use and showering |
| Certified Nurse Assistant OO | CNA | Described showering schedule and resident refusals |
| Unit Manager EE | Unit Manager | Discussed psychotropic medication care planning |
| Director of Rehabilitation | DOR | Discussed restorative services and therapy screening |
Inspection Report
Routine
Census: 150
Deficiencies: 9
Jul 22, 2022
Visit Reason
A standard survey was conducted in conjunction with complaint investigations to assess compliance with Medicare/Medicaid regulations and facility requirements.
Findings
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 Details
Complaint Intake Numbers GA000225780, GA000224510, GA00221079 and GA00220789 were investigated in conjunction with this standard survey.
Severity Breakdown
SS= D: 5
SS= E: 4
SS= F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to assess and determine if a resident was safe to self-administer medication. | SS= D |
| Failed to ensure a resident was allowed to have a visitor of his/her choosing at the time of his/her choosing. | SS= D |
| Failed to ensure physical restraints were used only when medically necessary and properly assessed and monitored. | SS= D |
| Failed to complete quarterly Minimum Data Set (MDS) assessments timely for two residents. | SS= D |
| Failed to develop comprehensive care plans addressing specific resident needs including dialysis care, use of side rails, diabetes management, and psychotropic medication use. | SS= E |
| Failed to consistently provide assistance with activities of daily living (ADLs) including showers and nail care for dependent residents. | SS= E |
| Failed to provide care and services according to accepted nursing standards including neurological checks after falls, blood glucose monitoring and insulin administration, laboratory testing for potassium levels, and following physician orders for weights and compression stockings. | SS= E |
| Failed to ensure sufficient kitchen staff to wash dishes, resulting in meals being served on disposable dishware. | SS= E |
| Failed to ensure staff followed CDC guidance for PPE use on the COVID-19 unit and failed to keep indwelling urinary catheter drainage bag and tubing off the floor. | SS= F |
Report Facts
Resident census: 150
Fall risk score: 13
BIMS score: 1
BIMS score: 10
BIMS score: 15
BIMS score: 3
Weight: 208
Potassium level: 3
Potassium level: 3.3
Blood glucose: 440
Blood glucose: 414
Blood glucose: 444
Blood glucose: 477
Blood glucose: 433
Blood glucose: 412
Blood glucose: 448
Blood glucose: 403
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN VV | Registered Nurse | Confirmed resident had not been assessed to self-administer medication |
| UM TT | Unit Manager | Informed family about medication bedside policy and visitation rules |
| DON | Director of Nursing | Provided statements on medication, visitation, restraint, MDS, care plans, and fall prevention |
| Administrator | Provided statements on medication self-administration, visitation, care plans, staffing, and infection control | |
| CNA OO | Certified Nurse Assistant | Provided statements on restraint use and shower schedule |
| LPN NN | Licensed Practical Nurse | Provided statements on restraint use, neurological checks, and blood sugar monitoring |
| LPN QQ | Licensed Practical Nurse | Provided statements on restraint use, blood sugar monitoring, and neurological checks |
| ADON | Assistant Director of Nursing | Provided statements on restraint use, care plans, lab orders, and fall prevention |
| AFSD AA | Assistant Food Service Director | Reported use of disposable dishware due to kitchen staffing shortages |
| AFSD BB | Assistant Food Service Director | Reported kitchen staffing shortages and use of disposable dishware |
| RD | Registered Dietitian | Reported kitchen staffing shortages and use of disposable dishware |
| Housekeeper XX | Observed not wearing full PPE when exiting COVID-19 unit | |
| CNA YY | Certified Nursing Assistant | Observed wearing multiple surgical masks instead of N-95 on COVID-19 unit |
| UM UU | Unit Manager | Provided statements on PPE use on COVID-19 unit |
| CNA FF | Certified Nursing Assistant | Provided statements on catheter care and nail care |
| CNA MM | Certified Nursing Assistant | Provided statements on fall prevention interventions |
| LPN DD | Licensed Practical Nurse | Provided statements on compression stocking use and resident weighing |
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 0
Dec 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Findings
All complaints investigated during the survey were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00219646, #GA00218106, #GA00217508, #GA00213063, #GA00212067, #GA00211421, #GA00210852, and #GA00207988 were investigated and found unsubstantiated.
Report Facts
Complaints investigated: 8
Inspection Report
Routine
Census: 119
Deficiencies: 0
Dec 29, 2020
Visit Reason
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.
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 the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 119
Inspection Report
Routine
Census: 139
Deficiencies: 0
Dec 9, 2020
Visit Reason
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.
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: 139
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
The survey investigated complaints #GA00199835, GA00200863, GA00201099, GA00207163, and GA00207470, all of which were found to be unsubstantiated.
Inspection Report
Routine
Census: 159
Deficiencies: 0
Aug 26, 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.
Findings
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.
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 0
Jun 24, 2020
Visit Reason
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.
Findings
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.
Complaint Details
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.
Report Facts
Total census: 167
Inspection Report
Routine
Census: 167
Deficiencies: 0
Jun 24, 2020
Visit Reason
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.
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 preparation.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 8, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited deficiencies had been corrected.
Findings
The follow-up survey noted that all previously cited tags had been corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
May 31, 2019
Visit Reason
A revisit survey was conducted from 5/30/19 through 5/31/19 in conjunction with the investigation of Complaint Intake Number GA00196579.
Findings
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 Details
Complaint Intake Number GA00196579 was investigated and found substantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Deficiencies: 0
May 30, 2019
Visit Reason
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.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was substantiated but found no deficiencies.
Complaint Details
Complaint Intake Number GA#00196579 was investigated and substantiated with no deficiencies found.
Inspection Report
Follow-Up
Deficiencies: 1
May 21, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
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.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain a continuous seal of the Smoke Compartments above multiple floors near the wall; multiple telecommunication rooms have improper mixing of different caulk to seal penetrations. | SS=F |
Report Facts
Residents at risk: 250
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings at the time of discovery. |
Inspection Report
Life Safety
Census: 195
Capacity: 250
Deficiencies: 3
Apr 1, 2019
Visit Reason
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.
Findings
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.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Eight fire sprinkler heads in the kitchen area were loaded with dust and grease and needed cleaning. | D |
| One damaged sprinkler head on the ceiling above the 6th floor galley area. | D |
| Failure to maintain a continuous seal of smoke compartments above multiple floors near the wall, with improper mixing of different caulk to seal penetrations in multiple telecommunication rooms. | F |
Report Facts
Number of sprinkler heads loaded with dust and grease: 8
Certified beds: 250
Census: 195
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff interviewed and confirmed findings during facility tour |
Inspection Report
Re-Inspection
Census: 196
Deficiencies: 0
Mar 30, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the prior standard survey on 2018-02-15.
Findings
All deficiencies cited as a result of the 2/15/18 standard survey were found to be corrected.
Inspection Report
Life Safety
Census: 171
Capacity: 270
Deficiencies: 0
Feb 13, 2018
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 in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan was also in substantial compliance with Appendix Z requirements.
Report Facts
Stories: 7
Construction Type: 222
Certified Beds: 270
Census: 171
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2018
Visit Reason
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.
Findings
No deficiency was cited during the complaint investigation survey.
Complaint Details
Complaint survey conducted related to complaint GA 00184809; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 27, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00182370 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Budd Terrace at Wesley Woods.
Complaint Details
Complaint #GA00182370 was investigated and found to have no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 22, 2017
Visit Reason
An Abbreviated Survey was conducted on 8/22/17 to investigate Complaint GA 00178070.
Findings
The complaint was found to be unsubstantiated and no citations were issued.
Complaint Details
Complaint GA 00178070 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 11, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00177092.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Complaint Details
Investigation of complaint GA00177092; facility found in substantial compliance.
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 0
Jun 13, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/14/17 Standard Recertification Survey.
Findings
All deficiencies cited in the prior 4/14/17 survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 196
Capacity: 250
Deficiencies: 0
Apr 12, 2017
Visit Reason
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.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements for fire safety and related NFPA standards.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 11, 2017
Visit Reason
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.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The visit was complaint-related, investigating two complaints (#GA 00159404 and #GA 00171974). No deficiencies were found.
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