Inspection Reports for
Cartersville Center for Nursing and Healing
78 OPAL STREET, CARTERSVILLE, GA, 30120
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
93% occupied
Based on a August 2024 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 5
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, food safety, and facility operations at Cartersville Center for Nursing and Healing.
Findings
The facility was found deficient in multiple areas including failure to provide privacy bags for urinary catheters, inaccurate resident discharge coding, medication administration errors with a 17.24% error rate, failure to provide timely and complete pharmaceutical services, and unsanitary food storage and preparation conditions in the kitchen.
Deficiencies (5)
F 0550: The facility failed to ensure residents with Foley catheters had privacy bags covering the urinary drainage bags, risking infection for two residents.
F 0641: The facility failed to properly code a resident discharge and did not send a correction transmittal to CMS for one resident.
F 0755: The facility failed to provide routine and emergency drugs timely, resulting in medication unavailability for one resident.
F 0759: The facility failed to maintain a medication error rate below 5%, with a 17.24% error rate observed during medication administration.
F 0812: The facility failed to ensure food was labeled, stored, and prepared under sanitary conditions, and kitchen equipment was not properly maintained, increasing risk of foodborne illness.
Report Facts
Medication administration error rate: 17.24
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse (LPN) | Named in catheter privacy bag deficiency and medication administration observations. |
| LL | Licensed Practical Nurse (LPN) | Interviewed regarding catheter privacy bag policy. |
| MM | Pharmacist | Interviewed regarding medication orders and pharmacy delivery issues. |
| KK | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and pharmacy communication. |
| NN | Unit Manager, Licensed Practical Nurse (LPN) | Interviewed regarding medication pass expectations and procedures. |
| GG | Registered Nurse (RN), Unit Manager | Interviewed regarding medication pass time limits and expectations. |
| EE | Certified Nursing Assistant (CNA) | Interviewed regarding food labeling and storage in pantry refrigerator. |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 18, 2025
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and medication administration policies at the nursing home.
Findings
The facility failed to provide routine and emergency drugs timely to residents, resulting in medication omissions and delays. The medication error rate was 17.24%, exceeding the acceptable threshold of 5%, with multiple errors observed during medication administration.
Deficiencies (2)
F 0755: The facility failed to provide routine and emergency drugs and biologicals timely to residents, including missing doses of apixaban and Spiriva for resident R82 due to pharmacy delays and insurance denial.
F 0759: The facility failed to maintain a medication error rate below 5%, with an observed error rate of 17.24% involving 5 errors in 29 medication opportunities across four residents, including omissions and improper administration.
Report Facts
Medication error rate: 17.24
Medication errors: 5
Medication opportunities: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | Observed medication pass and involved in medication omissions and administration for resident R82 |
| LPN KK | Licensed Practical Nurse | Interviewed regarding medication administration and pharmacy deliveries |
| Pharmacist MM | Pharmacist | Interviewed about medication orders and pharmacy delays |
| RN GG | Registered Nurse, Unit Manager | Interviewed about medication pass expectations and administration |
| LPN NN | Licensed Practical Nurse, Unit Manager | Interviewed about medication pass expectations and administration |
| Director of Nursing | Director of Nursing | Interviewed about medication pass expectations and pharmacy delivery timelines |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 24, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide written notice to residents or their representatives prior to room changes and failure to provide timely access to residents' medical records upon request.
Complaint Details
The complaint investigation was substantiated. The facility did not provide written notice of room changes to residents or their representatives as required. The facility also failed to provide timely access to medical records for three residents, despite multiple requests and legal representation involvement.
Findings
The facility failed to provide written notice to residents or their representatives before room changes affecting multiple residents. Additionally, the facility failed to provide timely access to medical records within the required timeframe for three residents, resulting in delays of up to 116 days.
Deficiencies (2)
F 0559: The facility failed to provide written notice of room changes prior to moving residents, affecting four residents reviewed. Documentation and interviews confirmed no written notifications were given before multiple room changes.
F 0573: The facility failed to provide timely access to residents' medical records within two working days of the initial request for three residents reviewed. Delays ranged from 30 to 116 calendar days.
Report Facts
Residents affected by room change notice deficiency: 4
Residents affected by medical records access deficiency: 3
Days delay for Resident #2 medical records: 39
Days delay for Resident #9 medical records: 35
Days delay for Resident #10 medical records: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Named in findings related to room change notifications and telephone call attempts |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding room transfer procedures and documentation |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding room transfer procedures and documentation |
| RN #4 | Registered Nurse, Unit Manager | Interviewed regarding room transfer procedures and documentation |
| Certified Nurse Aide #5 | Certified Nurse Aide | Interviewed regarding room transfer procedures and notification |
| Certified Nurse Aide #6 | Certified Nurse Aide | Interviewed regarding room transfer procedures and notification |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for room transfers and notification |
| Administrator | Administrator | Interviewed regarding facility policies on room transfers and medical record requests |
| Senior Compliance Officer | Senior Compliance Officer (SCO) | Interviewed regarding medical records request processing and compliance |
Inspection Report
Routine
Census: 110
Deficiencies: 11
Date: Aug 22, 2024
Visit Reason
Routine inspection of Cartersville Center for Nursing and Healing to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility operations.
Findings
The facility had multiple deficiencies including failure to notify responsible parties of medication changes, inaccurate resident assessments, inadequate assistance with activities of daily living, failure to provide activities programming, improper medication and wound care, unsafe oxygen tank storage, inadequate pain management, unsecured medication storage, poor food safety practices, inaccurate medical documentation, and lapses in infection control protocols.
Deficiencies (11)
F 0552: The facility failed to notify the responsible party of new medication orders for one resident, risking uninformed care decisions.
F 0641: The facility failed to ensure accurate assessments for two residents, potentially leading to inaccurate care planning.
F 0677: The facility failed to provide scheduled showers/baths for two residents dependent on staff, risking hygiene and wellbeing.
F 0679: The facility failed to develop and introduce an activities program for one resident, risking diminished quality of life.
F 0684: The facility failed to follow physician orders for ointment and compression stockings for one resident, risking medical complications.
F 0695: The facility failed to ensure oxygen tanks were securely stored for one resident, creating potential safety hazards.
F 0697: The facility failed to provide appropriate pain management for one resident, resulting in prolonged pain and delayed medication administration.
F 0761: The facility failed to lock a medication cart and had expired, used, and new items co-mingled in medication storage, risking unauthorized access and contamination.
F 0812: The facility failed to discard expired food, ensure proper labeling and storage, follow puree recipes, and maintain sanitary ice machines, risking food safety for residents.
F 0842: The facility failed to maintain accurate documentation of care and services for one resident, including wound care and compression stocking application.
F 0880: The facility failed to maintain infection control during male catheter insertion, hand hygiene during medication administration, and to keep contact isolation doors closed for residents with infections.
Report Facts
Residents sampled: 63
Facility census: 110
Medication orders not notified: 1
Residents with inaccurate assessments: 2
Residents missing scheduled showers: 2
Residents without activities program: 1
Residents with improper wound/medication care: 1
Residents with unsafe oxygen tank storage: 1
Residents with inadequate pain management: 1
Medication carts unsecured: 1
Expired food items found: 30
Residents with inaccurate documentation: 1
Residents with infection control breaches: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Named in catheter insertion infection control deficiency |
| LPN II | Licensed Practical Nurse | Named in pain management and medication preparation deficiencies |
| RN LL | Registered Nurse | Named in pain management and documentation deficiencies |
| LPN JJ | Licensed Practical Nurse | Named in pain management deficiency |
| RN KK | Unit Manager | Named in medication storage and oxygen tank storage deficiencies |
| LPN MM | Licensed Practical Nurse | Named in medication storage deficiency |
| LPN GG | Regional Skin Specialist | Named in catheter insertion infection control deficiency |
Inspection Report
Routine
Census: 110
Deficiencies: 11
Date: Aug 22, 2024
Visit Reason
Routine inspection of Cartersville Center for Nursing and Healing to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to notify responsible parties of medication changes, inaccurate resident assessments, inadequate assistance with activities of daily living, failure to provide scheduled showers, lack of activities programming, failure to follow physician orders for wound care and compression stockings, unsafe oxygen tank storage, inadequate pain management, improper medication storage, food safety violations, inaccurate medical record documentation, infection control breaches including improper catheterization technique and failure to maintain isolation precautions.
Deficiencies (11)
F 0552: Facility failed to notify the responsible party of new medication orders for one resident, risking uninformed care decisions.
F 0641: Facility failed to ensure accurate assessments for two residents, potentially leading to inaccurate care planning.
F 0677: Facility failed to provide scheduled showers for two residents dependent on staff, risking hygiene and wellbeing.
F 0679: Facility failed to develop and implement an activities program for one resident, risking diminished quality of life.
F 0684: Facility failed to follow physician orders for ointment application and compression stockings for one resident, risking medical complications.
F 0695: Facility failed to ensure oxygen tanks were securely stored, creating potential hazards for one resident using oxygen.
F 0697: Facility failed to provide adequate pain management for one resident, resulting in prolonged pain and discomfort.
F 0761: Facility failed to lock medication cart and found expired, used, and new items co-mingled in medication storage, risking contamination and unauthorized access.
F 0812: Facility failed to discard expired food, ensure proper food labeling and storage, follow puree recipe, and maintain sanitary ice machines, risking food safety for residents.
F 0842: Facility failed to maintain accurate documentation of care and services for one resident, including wound care and compression stocking application.
F 0880: Facility failed to maintain infection control during male catheterization, hand hygiene during medication administration, and to keep isolation doors closed for residents on contact precautions, risking infection spread.
Report Facts
Residents sampled: 63
Facility census: 110
Deficiencies cited: 11
Medication orders not notified: 1
Residents with inaccurate assessments: 2
Residents with missed showers: 2
Residents without activities program: 1
Residents with wound care noncompliance: 1
Residents with unsafe oxygen tank storage: 1
Residents with pain management issues: 1
Residents with infection control breaches: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Named in catheter insertion infection control breach |
| LPN II | Licensed Practical Nurse | Named in pain management and medication preparation findings |
| RN LL | Registered Nurse | Named in pain management and documentation findings |
| LPN JJ | Licensed Practical Nurse | Named in pain management and medication availability findings |
| RN KK | Unit Manager | Named in medication storage and oxygen tank storage findings |
| CNA AA | Certified Nursing Assistant | Named in bathing schedule documentation findings |
| Regional Director of Clinical Services | Provided statements on expectations for notification, infection control, and staff education | |
| Administrator | Provided statements on activities programming and oxygen tank storage | |
| Dietitian | Named in food safety and kitchen observations | |
| Dietary Manager | Named in food safety and kitchen observations | |
| Infection Preventionist | Provided statements on isolation precautions and infection control expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to follow proper infection control practices in a nursing home facility.
Complaint Details
The complaint investigation found substantiated failure to follow infection control procedures for a resident with MRSA on contact isolation.
Findings
The facility failed to implement proper infection prevention and control measures for a resident on contact isolation. Staff did not wash or sanitize hands or wear required personal protective equipment before and after contact with the resident.
Deficiencies (1)
F 0880: The facility failed to follow proper infection control practices to prevent disease spread for one resident on contact isolation. Staff entered the resident's room without washing hands or wearing gloves and a gown as required by facility policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Named in infection control deficiency for failing to wash hands and wear PPE when caring for resident R1. |
| CC | Infection Control Preventionist | Interviewed and confirmed infection control expectations and staff noncompliance. |
| DON | Director of Nursing | Interviewed regarding facility infection control signage and PPE placement. |
Inspection Report
Deficiencies: 4
Date: Jun 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, abuse reporting, investigation of alleged abuse, and provision of medical orders upon admission.
Findings
The facility failed to provide written notice to a resident regarding a room move, failed to timely report and thoroughly investigate an allegation of misappropriation of resident property, and failed to obtain physician orders for surgical wound care at admission for one resident.
Deficiencies (4)
F 0559: The facility failed to provide written notification to a resident and family explaining a required room move for one resident.
F 0609: The facility failed to timely report an allegation of misappropriation of resident property to the State Survey Agency or law enforcement.
F 0610: The facility failed to thoroughly investigate an allegation of misappropriation of resident property and did not reimburse the resident for the missing item.
F 0635: The facility failed to obtain physician orders for surgical wound care at the time of admission for one resident with a surgical wound.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Inspection Report
Routine
Deficiencies: 15
Date: Jul 16, 2022
Visit Reason
Routine state inspection survey of Cartersville Center for Nursing and Healing to assess compliance with healthcare regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, medication administration, resident care plans, ADL assistance, respiratory care, food service quality, pest control, and documentation of advance directives and code status.
Deficiencies (15)
F 0550: The facility failed to ensure three residents were treated with dignity and respect, including improper clothing, exposure, and lack of privacy.
F 0554: One resident self-administered medication without a physician's order and nursing staff failed to monitor nebulizer treatments as required.
F 0558: The facility failed to ensure one resident's call light was within reach and bed footboard was broken, and failed to provide basic accommodations.
F 0584: The facility failed to maintain a clean, comfortable, and homelike environment, with multiple maintenance and sanitation issues including holes in walls, dirty bathrooms, and excessive noise.
F 0609: The facility failed to report an allegation of neglect to the State Survey Agency and failed to thoroughly investigate the allegation involving a resident's call light being taken away and toileting needs unmet for five hours.
F 0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, including failure to address dementia care needs.
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for two residents with dementia, lacking interventions to address behavioral symptoms.
F 0677: The facility failed to provide scheduled showers and nail care for four residents, resulting in poor hygiene and resident complaints.
F 0678: The facility failed to consistently document residents' code status and advance directives in the electronic medical record, risking inappropriate emergency care.
F 0684: The facility failed to ensure residents received prescribed medications appropriately, including missed doses of an antibiotic and pain medication without proper notification to providers.
F 0688: The facility failed to provide appropriate respiratory care including failure to bag respiratory equipment, label and date oxygen tubing and humidifiers, clean oxygen concentrator filters, and ensure oxygen flow rates matched physician orders.
F 0804: The facility failed to provide nutrition management for a resident on dialysis, including failure to adjust meal schedule to provide nutrition prior to dialysis appointments.
F 0806: The facility failed to ensure palatable food was served to nine residents and resident council attendees, with complaints of cold, burnt, poorly prepared food, lack of condiments, and limited beverage choices.
F 0812: The facility failed to maintain the kitchen in a sanitary manner, including inadequate sanitizer concentrations, thawing food at room temperature, improper glove use, and ice scoop contamination.
F 0925: The facility failed to maintain an effective pest control program, with sightings of live and dead cockroaches in resident rooms and staff areas, and delayed response to pest control recommendations.
Report Facts
Missed antibiotic doses: 18
Oxygen flow rate: 3
Sanitizer concentration: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Named in medication administration and ADL care findings. |
| RN Supervisor | Registered Nurse Supervisor | Named in neglect allegation investigation. |
| DON | Director of Nursing | Named in multiple interviews regarding care expectations and deficiencies. |
| Administrator | Facility Administrator | Named in interviews regarding oversight and corrective actions. |
| Pharmacist | Pharmacist | Named in medication order and administration findings. |
| Dietary Manager | Dietary Manager | Named in kitchen sanitation and food quality findings. |
| Social Services Director | Social Services Director | Named in care plan and advance directive findings. |
| Ecolab Representative | Pest Control Representative | Named in pest control findings. |
| Maintenance Director | Maintenance Director | Named in pest control and maintenance findings. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Intake Numbers Ga#00196958 and GA#00197561 were investigated and found to be unsubstantiated.
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Intake Numbers Ga#00196958 and GA#00197561 were investigated and found to be unsubstantiated.
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (4)
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.
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.
Facility failed to ensure smoke detectors were properly installed; two detectors were located within 36 inches of an HVAC air supply vent.
Facility failed to provide audible and visual fire alarm notification devices in the large interior courtyard accessible to residents, staff, and visitors.
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
Date: 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.
Complaint Details
Complaint #GA00190914 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Census: 113
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Deficiencies (4)
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.
Failed to ensure cleanliness of one of two kitchen pantries and maintain a temperature log for one of two kitchen pantry refrigerators.
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.
Failed to use personal protective equipment (PPE) gown when sorting soiled laundry to prevent contamination of personal clothing.
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
Date: 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)
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
Date: 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.
Deficiencies (3)
Egress access corridor near basement access door was obstructed and used for storage, blocking a required means of egress.
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.
Smoking debris (cigarette butts) were observed being placed in the general trash receptacle, violating smoking regulations.
Report Facts
Census: 112
Certified beds: 118
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Deficiencies (5)
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.
Commercial cooking equipment hood suppression nozzles did not cover all equipment as required by NFPA 96.
Fire/Smoke barrier doors at corridor separations were missing screws in hinges, compromising door integrity.
Smoking areas were not properly maintained; cigarette butts were discarded around smoking areas and ashtrays/butt cans were not emptied regularly.
Portable space heater with heating element exceeding 212 degrees Fahrenheit was used in a non-sleeping area (Nurse Education Office).
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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