Inspection Reports for Canton Center for Nursing and Healing LLC
321 HOSPITAL ROAD, CANTON, GA, 30114
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 17, 2024, found no deficiencies and determined a complaint to be unsubstantiated. Earlier inspections showed a pattern of deficiencies related mainly to medication management, infection control, and environmental sanitation, including issues with psychotropic medication orders, incomplete care plans, and cleanliness concerns. Prior complaint investigations were mostly unsubstantiated, with one substantiated complaint in January 2024 that resulted in federal citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed previous deficiencies, showing improvement in recent surveys.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
88 residents
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00245792.
Complaint Details
Complaint #GA00245792 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint #GA00245792 was unsubstantiated and no deficiencies were cited during the survey.
Report Facts
Census: 88
Inspection Report
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Canton Center for Nursing and Healing LLC, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/5/2024 recertification and compliant survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies have been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 5, 2024
Visit Reason
A State Licensure survey was conducted at Canton Center for Nursing and Healing, LLC from January 2, 2024 through January 5, 2024 to assess compliance with State Health regulations.
Findings
The survey identified multiple deficiencies including failure to ensure psychotropic medications had proper physician rationale and stop dates, inadequate infection control practices affecting multiple residents, incomplete care plans regarding oxygen use, and environmental sanitation issues such as soiled ceiling vents and damaged bed frames.
Deficiencies (4)
Failure to ensure psychotropic medications were ordered for 14 days as needed with prescribing physician's rationale and stop date documented for one resident.
Failure to maintain effective infection control practices including improper hand hygiene, inadequate cleaning of glucometers and blood pressure cuffs, and improper use of PPE.
Failure to include specialty needs related to oxygen use on the care plan for one resident.
Failure to provide a safe, clean, comfortable, homelike environment due to soiled ceiling return air vents, stained floor tiles, and a damaged bed frame footboard in multiple resident rooms.
Report Facts
Sampled residents: 44
Residents affected by infection control deficiencies: 4
Resident rooms with environmental deficiencies: 4
Psychotropic medication order duration: 14
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding psychotropic medication order requirements and infection control expectations | |
| Licensed Practical Nurse (LPN) BB | Observed and interviewed regarding medication administration and hand hygiene practices | |
| Licensed Practical Nurse (LPN) CC | Observed and interviewed regarding PPE use, blood pressure cuff cleaning, and glucometer disinfection | |
| MDS Coordinator | Interviewed regarding care plan documentation processes | |
| Administrator | Interviewed during walking rounds confirming environmental deficiencies | |
| Maintenance Director | Interviewed during walking rounds confirming environmental deficiencies and tasked with repairs |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 7
Date: Jan 5, 2024
Visit Reason
A recertification survey was conducted from January 2 through January 5, 2024, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA231206, GA00230255, GA00227750, and GA00227707 were investigated. GA231206 was substantiated with federal citation; the others were unsubstantiated.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including unsafe and unclean environment, incomplete care plans, failure to provide necessary care such as fingernail care, medication administration errors, insufficient RN coverage, improper use of psychotropic medications, and inadequate infection control practices.
Deficiencies (7)
Facility failed to provide a safe, clean, comfortable, homelike environment in four resident rooms with soiled ceiling return air filter grilles, stained floor tile, and unsecured bed footboard.
Failed to ensure specialty needs related to oxygen use were included in the care plan for one resident.
Failed to provide fingernail care to one resident requiring extensive assistance.
Failed to provide care and services meeting professional standards for three residents including oxygen without order and signage, missed medication doses, and failure to obtain orthostatic vital signs as ordered.
Failed to provide RN coverage for at least eight consecutive hours a day, seven days a week on specified dates.
Failed to ensure psychotropic medications ordered PRN had physician's rationale and 14-day stop date documented.
Failed to maintain effective infection control practices including hand hygiene, cleaning of glucometers and blood pressure cuffs, proper PPE use, and mask use in COVID-19 positive rooms.
Report Facts
Residents present: 86
Medication doses missed: 12
RN coverage hours: 0
RN coverage hours: 4
Residents sampled: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed medication administration with improper hand hygiene |
| LPN CC | Licensed Practical Nurse | Observed improper PPE use and failure to clean blood pressure cuff between residents |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for oxygen orders, medication administration, RN coverage, psychotropic medication documentation, and infection control practices |
| LPN GG | Licensed Practical Nurse | Interviewed about medication reordering and documentation |
| LPN HH | Licensed Practical Nurse | Interviewed about medication reordering and administration |
| LPN FF | Licensed Practical Nurse | Interviewed about medication administration and backup pharmacy use |
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 3
Date: Dec 4, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to clean the kitchen hood per NFPA 96, failure to have annual inspection of portable fire extinguishers, and lack of approved oxygen storage signage on oxygen storage rooms.
Deficiencies (3)
Failed to clean the kitchen hood in accordance with NFPA 96, with grease buildup observed and last cleaning dated 8/2023.
Failed to have the annual inspection of portable fire extinguishers outside the kitchen area and in the kitchen, with out-of-date extinguishers observed.
Failed to provide approved oxygen storage signage on oxygen storage rooms.
Report Facts
Census: 92
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 3
Date: Dec 4, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to deficiencies including failure to clean the kitchen hood per NFPA 96, failure to have annual inspection and tagging of portable fire extinguishers, and failure to provide approved oxygen storage signage on oxygen storage rooms.
Deficiencies (3)
Failed to clean the kitchen hood in accordance with NFPA 96, evidenced by grease buildup on the hood and filters; last cleaning was in August 2023.
Failed to have annual inspection and tagging of portable fire extinguishers outside the kitchen area and in the kitchen; extinguishers were out of date.
Failed to provide approved oxygen storage signage on oxygen storage rooms.
Report Facts
Census: 92
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 information to the NHSN between 04/10/2023 and 04/16/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
An abbreviated survey was conducted to investigate three complaints identified as #GA00226698, #GA00226327, and #GA00225060.
Complaint Details
The survey investigated three complaints: #GA00226698 and #GA00226327 were substantiated with no regulatory violations cited; #GA00225060 was unsubstantiated with no regulatory violations cited.
Findings
Complaints #GA00226698 and #GA00226327 were substantiated but no regulatory violations were cited. Complaint #GA00225060 was unsubstantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 12, 2022
Visit Reason
A Follow-Up Desk Review Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the follow-up desk review.
Inspection Report
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/04/2022 and 07/10/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 81
Capacity: 100
Deficiencies: 3
Date: Jun 15, 2022
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program and compliance with federal regulations, including the annual review and update of the emergency preparedness plan.
Findings
The facility's Emergency Preparedness Program was found not in substantial compliance with 42 CFR 483.73 due to missing documentation of names and contact information in the communication plan, outdated training documentation, and lack of evidence of an annual update or governing body adoption of the emergency preparedness plan. The facility was found in compliance with Life Safety Code requirements.
Deficiencies (3)
Emergency Preparedness Plan did not include names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers.
Emergency Preparedness Training was conducted using an outdated plan revision (09/13/2018) rather than the current plan revision (12/13/2020).
No documentation available that the Emergency Preparedness Plan had an annual update or review as required, nor evidence that the plan was adopted by the facility's governing body.
Report Facts
Census: 81
Total Capacity: 100
Training Date: Dec 18, 2021
Plan Revision Date: Dec 13, 2020
Plan Revision Date: Sep 13, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed findings regarding missing documentation and outdated training |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 12, 2022
Visit Reason
Licensure Survey conducted from 2022-06-10 through 2022-06-12 to assess compliance for facility licensure.
Findings
No deficiencies were identified during the licensure survey.
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