Inspection Reports for Cartersville Center for Nursing and Healing
78 OPAL STREET, GA, 30120
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 20, 2019
Visit Reason
A revisit survey was conducted from 6/18/19 to 6/20/19 to verify correction of deficiencies from the 4/18/19 Standard Survey and to investigate two complaint intake numbers Ga#00196958 and GA#00197561.
Findings
All deficiencies cited in the 4/18/19 Standard Survey were found to be corrected. The complaint investigations for Ga#00196958 and GA#00197561 were found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers Ga#00196958 and GA#00197561 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 18, 2019
Visit Reason
A revisit survey was conducted from 6/18/19 to 6/20/19 to investigate Complaint Intake Numbers Ga#00196958 and GA#00197561 in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 4/18/19 Standard Survey were found to be corrected. The complaint investigation found Ga#00196958 and GA#00197561 to be unsubstantiated.
Complaint Details
Complaint Intake Numbers Ga#00196958 and GA#00197561 were investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 4, 2019
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies.
Findings
All previous citations were found to be corrected during the follow-up survey conducted by the Fire Safety Supervisor.
Inspection Report
Life Safety
Census: 111
Capacity: 118
Deficiencies: 4
Apr 16, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including abrupt changes in elevation on walking surfaces, lack of exit signage in the interior courtyard, improper installation of smoke detectors near HVAC vents, and absence of audible and visual fire alarm notification devices in the courtyard.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure all walking surfaces throughout the means of egress are maintained smooth and free of abrupt changes in elevations exceeding one inch in the interior courtyard. | SS= D |
| Facility failed to provide exit signs in the large interior courtyard where multiple doors exist but only two are required exits, and neither had exit signs. | SS= D |
| Facility failed to ensure smoke detectors were properly installed; two detectors were located within 36 inches of an HVAC air supply vent. | SS= D |
| Facility failed to provide audible and visual fire alarm notification devices in the large interior courtyard accessible to residents, staff, and visitors. | SS= D |
Report Facts
Residents at risk due to abrupt elevation changes: 50
Residents at risk due to lack of exit signage: 50
Residents at risk due to improper smoke detector installation: 42
Residents at risk due to lack of fire alarm notification devices: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00190914 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00190914 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Census: 113
Deficiencies: 0
May 3, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/22/18 Recertification Survey.
Findings
All deficiencies cited in the prior 3/22/18 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 27, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 112
Deficiencies: 4
Mar 22, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The facility was found noncompliant with food safety requirements related to dishwasher sanitization and kitchen pantry cleanliness, improper disposal of garbage and refuse, and failure to use proper personal protective equipment during laundry operations.
Severity Breakdown
F: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure proper sanitizing during operation and maintenance of a low temperature/chemical sanitizing dishwasher, and failed to maintain and monitor temperature and sanitizer concentration logs. | F |
| Failed to ensure cleanliness of one of two kitchen pantries and maintain a temperature log for one of two kitchen pantry refrigerators. | D |
| Failed to ensure that trash was disposed of in a sanitary manner; back-door area near kitchen, loading dock, and compactor areas had debris and litter. | D |
| Failed to use personal protective equipment (PPE) gown when sorting soiled laundry to prevent contamination of personal clothing. | D |
Report Facts
Resident census: 112
Chlorine sanitizer concentration: 0
Chlorine sanitizer concentration: 50
Chlorine sanitizer concentration: 100
Wash temperature: 120
Days missing refrigerator temperature recordings: 7
Total days in month: 21
Laundry barrels: 2
Facility census: 112
Sample size: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Laundry Assistant | Observed sorting soiled laundry without wearing a protective gown |
| Registered Dietitian (RD) | Present during kitchen observations and interviews | |
| Acting Dietary Manager (DM) | Responsible for kitchen operations and dishwasher maintenance | |
| Housekeeping Supervisor | Interviewed regarding cleaning responsibilities and PPE expectations | |
| Facility Administrator | Interviewed regarding kitchen operations and corrective actions |
Inspection Report
Routine
Census: 112
Deficiencies: 1
Mar 21, 2018
Visit Reason
The inspection was conducted to assess compliance with infection control procedures, specifically regarding the use of personal protective equipment (PPE) during laundry handling.
Findings
The facility failed to ensure that laundry staff wore the required protective gown while sorting soiled laundry, exposing staff to contamination risk. The only available apron was damaged and not functional, and staff acknowledged not wearing proper PPE despite knowing the requirement.
Deficiencies (1)
| Description |
|---|
| Failure to use personal protective equipment (PPE) gown when sorting soiled laundry to prevent contamination. |
Report Facts
Facility census: 112
Sample size: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Laundry Assistant | Observed and interviewed regarding failure to wear PPE gown while sorting soiled laundry |
| HealthCare Services Housekeeping Supervisor | Interviewed regarding expectations for staff to wear PPE and lack of notification about damaged apron |
Inspection Report
Life Safety
Census: 112
Capacity: 118
Deficiencies: 3
Mar 20, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed egress access corridors, failure to maintain hazardous areas with proper smoke-resistant construction, and failure to follow smoking regulations. These deficiencies could place residents at risk in the event of a fire emergency.
Severity Breakdown
E: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Egress access corridor near basement access door was obstructed and used for storage, blocking a required means of egress. | E |
| Hazardous areas such as the laundry room had damaged sheet-rock ceilings and walls that failed to resist smoke passage; storage room doors failed to close and latch properly. | E |
| Smoking debris (cigarette butts) were observed being placed in the general trash receptacle, violating smoking regulations. | D |
Report Facts
Census: 112
Certified beds: 118
Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2017
Visit Reason
A follow-up inspection was conducted on 5/9/17 to verify correction of deficiencies identified during the recertification survey of 3/16/17.
Findings
All deficiencies identified in the previous recertification survey had been corrected at the time of the follow-up inspection.
Inspection Report
Follow-Up
Deficiencies: 0
May 1, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 116
Capacity: 118
Deficiencies: 5
Mar 14, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in hazardous area enclosures, cooking facility fire protection, corridor door maintenance, smoking area maintenance, and portable space heater use.
Severity Breakdown
D: 3
E: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Hazardous areas are not properly sealed to prevent passage of smoke; specifically, a 4 inch by 16 inch opening in the ceiling of the Main Electrical room was unsealed. | D |
| Commercial cooking equipment hood suppression nozzles did not cover all equipment as required by NFPA 96. | D |
| Fire/Smoke barrier doors at corridor separations were missing screws in hinges, compromising door integrity. | E |
| Smoking areas were not properly maintained; cigarette butts were discarded around smoking areas and ashtrays/butt cans were not emptied regularly. | F |
| Portable space heater with heating element exceeding 212 degrees Fahrenheit was used in a non-sleeping area (Nurse Education Office). | D |
Report Facts
Census: 116
Total Capacity: 118
Opening size: 64
Number of smoking areas: 3
Time of discovery: 1045
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M interviewed and confirmed findings during inspection | ||
| Staff A interviewed regarding space heater in Nurse Education Office |
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