Inspection Reports for The Center for Advanced Rehab at Parkside
110 PARK CITY ROAD, ROSSVILLE, GA, 30741
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 25, 2025, found that all previously cited deficiencies had been corrected. Prior inspections showed a range of issues, including medication administration errors, infection control lapses, inadequate assistance with activities of daily living, and multiple Life Safety Code violations related to fire safety and emergency preparedness. Complaint investigations were mostly unsubstantiated, except for a substantiated complaint in 2021 linked to infection control deficiencies and resident neglect during a COVID-19 outbreak that resulted in resident harm and deaths. No fines, license suspensions, or enforcement actions were listed in the available reports. The facility appears to have addressed recent deficiencies effectively, showing improvement in compliance over the latest inspection cycle.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
120 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the Center for Advanced Rehab at Parkside, 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: 120
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted on 2025-03-13.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during the revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 13, 2025
Visit Reason
A State Licensure survey was conducted at The Center for Advanced Rehab at Parkside from March 11, 2025, through March 13, 2025, to assess compliance with state health regulations and quality of care standards.
Findings
The facility was found deficient in medication administration practices, hand hygiene and infection control, and failure to provide adequate assistance with activities of daily living (ADLs) including showering for dependent residents. Specific issues included incorrect medication dosing, failure to prime insulin pens, lack of mouth rinsing after inhaler use, inconsistent hand hygiene, improper cleaning of shared equipment, and missed or undocumented showers for residents.
Deficiencies (3)
Failed to give correct dosage of medicated ointment, prime insulin pen, and have residents rinse mouth after inhaler use.
Failed to consistently perform hand hygiene and sanitize shared medical equipment between residents during medication pass.
Failed to provide adequate assistance with activities of daily living (ADLs) including bathing and showering for two residents dependent on staff.
Report Facts
Residents reviewed for medication administration deficiencies: 3
Residents sampled for hand hygiene and equipment sanitation: 42
Residents dependent on staff for ADLs with deficiencies: 2
BIMS score for R77: 15
BIMS score for R97: 14
Shower documentation missing: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed administering medication incorrectly and failing to instruct resident to rinse mouth after inhaler use |
| LPN AA | Licensed Practical Nurse | Observed not priming insulin pen and failing to perform hand hygiene |
| LPN CC | Licensed Practical Nurse | Observed failing to perform hand hygiene before and after donning gloves during blood glucose check and insulin administration |
| CNA DD | Certified Nursing Assistant | Confirmed shower schedule for resident R97 and assisted resident R77 with ADLs |
| RN EE | Registered Nurse, Unit Manager | Confirmed shower schedule and lack of documentation for showers |
| RN FF | Registered Nurse | Discussed expectations for shower documentation and resident care |
| Director of Nursing | Director of Nursing (DON) | Provided policy clarifications and confirmed expectations for medication administration, hand hygiene, equipment cleaning, and resident care |
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 6
Date: Mar 13, 2025
Visit Reason
A recertification survey was conducted from March 11 through March 13, 2025, including investigation of Complaint Intake Number GA00253238, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00253238 was investigated in conjunction with the recertification survey.
Findings
The facility was found not in substantial compliance with multiple deficiencies including medication administration errors, failure to provide adequate assistance with activities of daily living, failure to maintain medication error rates below 5%, failure to provide palatable and safe food to a resident with low BMI, inconsistent hand hygiene and equipment sanitation practices, and failure to properly implement an antibiotic stewardship surveillance program.
Deficiencies (6)
Failed to give correct dosage of medicated ointment, prime insulin pen, and have residents rinse mouth after inhaler use.
Failed to provide two of five residents dependent on staff for ADLs with necessary assistance.
Failed to maintain medication error rate below 5%, with 3 errors in 42 opportunities (7.14%).
Failed to provide one resident with food and drink that was palatable, attractive, and at safe temperature, risking worsening of abnormal weight loss and low BMI.
Failed to consistently perform hand hygiene and sanitize shared medical equipment between residents during medication passes.
Failed to properly establish and implement a surveillance plan for identifying, tracking, monitoring, and reporting infections and antibiotic use among residents and staff.
Report Facts
Medication errors: 3
Resident census: 120
BMI: 19.9
Shower refusals/documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication administration deficiencies including incorrect ointment dosage and failure to prime insulin pen. |
| LPN AA | Licensed Practical Nurse | Named in medication administration deficiencies including failure to prime insulin pen and medication pass errors. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and facility expectations. |
| CNA DD | Certified Nursing Assistant | Interviewed regarding resident shower schedules and meal refusals. |
| RN EE | Registered Nurse, Unit Manager | Interviewed regarding shower documentation and staffing. |
| LPN CC | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene failures during blood glucose check and insulin administration. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding failure to implement antibiotic stewardship surveillance program. |
| Registered Dietician | Registered Dietician | Interviewed regarding resident food preferences and complaints. |
Inspection Report
Life Safety
Census: 123
Capacity: 125
Deficiencies: 9
Date: Mar 12, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements, including failures to maintain smoke tight enclosures, clearance around sprinkler heads, sprinkler system maintenance, subdivision of building spaces, clearance around electrical panels, maintenance of rated doors, provision of emergency lighting, proper use of power cords, and proper oxygen storage signage.
Deficiencies (9)
Failed to maintain smoke tight enclosures with openings in the ceiling of Environmental Services and Mechanical rooms on Blue Hall.
Failed to maintain clearance around sprinkler heads; blocked sprinkler heads in upstairs storage room of Mauve Hall.
Failed to maintain sprinkler system; inadequate number of spare sprinkler heads in riser room.
Failed to maintain subdivision of building spaces; penetrations in smoke barriers on Green Hall and Brown Hall.
Failed to maintain clearance around electrical panels; multiple panels blocked with combustible storage in Mauve Hall, Rehab unit, and Kitchen janitor closet.
Failed to maintain rated doors; missing screws in hinges of rated door in Floor Tech room on Green Hall.
Failed to provide emergency lighting at the generator; no battery powered emergency lighting present.
Failed to maintain electrical system; extension cords used improperly in storage area above Mauve Hall.
Failed to maintain oxygen storage area; improper signage on O2 storage door.
Report Facts
Census: 123
Total Capacity: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Date: Nov 21, 2024
Visit Reason
An Abbreviated Survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaints GA00249916, GA00249217, GA00247896, GA00246399, GA00245358, GA00241787, GA00240389, GA00237222, and GA00234902 were investigated and found unsubstantiated.
Findings
All complaints investigated during the survey were found to be unsubstantiated and no regulatory violations were cited.
Inspection Report
Routine
Census: 117
Deficiencies: 0
Date: Sep 11, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Center for Advanced Rehab at Parkside, 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: 124
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
A revisit survey was conducted in conjunction with complaint investigations for Complaint Intake Numbers GA00230013 and GA00230029 to verify correction of previous deficiencies.
Complaint Details
Complaint Intake Numbers GA00230013 and GA00230029 were investigated in conjunction with the revisit survey; no citations resulted from the complaint investigation.
Findings
All deficiencies cited in the prior recertification survey on November 10, 2022 were found to be corrected. There were no citations resulting from the complaint investigation.
Report Facts
Census: 124
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Jan 13, 2023
Visit Reason
An unannounced complaint survey was initiated to investigate complaint numbers GA00230013 and GA00230029 in conjunction with a revisit survey.
Complaint Details
Complaint numbers GA00230013 and GA00230029 were investigated and found to have no deficiencies.
Findings
No deficiencies were cited as a result of the complaint investigations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
A Follow-Up 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 Survey.
Inspection Report
Original Licensing
Deficiencies: 3
Date: Nov 10, 2022
Visit Reason
A Licensure Survey was conducted from 11/8/22 through 11/10/22 to assess compliance with state and federal regulations for facility licensure.
Findings
The facility failed to ensure medication carts were secured when unattended, failed to date and label multiple open multi-dose ophthalmic medication containers, and failed to discard an expired ophthalmic medication container.
Deficiencies (3)
One of six medication carts (200 Hall Medication Cart) was unsecured when unattended.
Seven open multi-dose containers of ophthalmic drops in one medication cart (Mauve Hall) were not dated or labeled.
One expired multi-dose container of ophthalmic drops in the Mauve Hall medication cart was not discarded.
Report Facts
Number of medication carts inspected: 6
Number of open undated ophthalmic medication containers: 7
Number of expired ophthalmic medication containers: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Responsible for the unsecured medication cart on 200 Hall |
| LPN BB | Licensed Practical Nurse | Responsible for the medication cart on Mauve Hall containing undated and expired ophthalmic medications |
| Interim Director of Nursing | Interim Director of Nursing | Provided inservice on medication cart security and verified deficiencies |
Inspection Report
Annual Inspection
Census: 124
Deficiencies: 3
Date: Nov 10, 2022
Visit Reason
A recertification survey was conducted from November 8, 2022 through November 10, 2022, including investigation of Complaint Intake Number GA00220229 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00220229 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to medication storage and administration. Deficiencies included an unsecured medication cart left unattended, seven open multi-dose ophthalmic containers not dated or labeled, and one expired ophthalmic medication that was not discarded.
Deficiencies (3)
One of six medication carts (200 Hall Medication Cart) was unsecured when unattended.
Seven open multi-dose containers of ophthalmic drops in one medication cart (Mauve Hall) were not dated or labeled.
One expired multi-dose container of ophthalmic drops in one medication cart (Mauve Hall) was not discarded.
Report Facts
Resident census: 124
Number of medication carts: 6
Number of open undated ophthalmic containers: 7
Number of expired ophthalmic containers: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Verified responsibility for unsecured medication cart on 200 Hall |
| LPN BB | Licensed Practical Nurse | Verified undated ophthalmic medications and expired medication on Mauve Hall medication cart |
| Interim Director of Nursing | Provided expectations on medication cart security and verified medication labeling requirements | |
| Administrator | Verified medication cart deficiencies with Interim DON |
Inspection Report
Life Safety
Census: 124
Capacity: 125
Deficiencies: 5
Date: Nov 10, 2022
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including sprinkler system maintenance, smoke compartment integrity, electrical system readiness, generator operational status, and gas equipment storage safety.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and life safety codes. Deficiencies included lack of documentation for the emergency preparedness plan, failure to perform annual sprinkler system inspection, unsealed penetrations in rated walls affecting smoke compartments, faulty generator components with no fuel testing, and improper signage in the oxygen storage area.
Deficiencies (5)
Emergency Preparedness Program plan was not available and not in substantial compliance with 42 CFR 483.73.
Failure to perform the annual sprinkler system inspection and maintenance.
Unsealed penetrations in the rated walls of the electrical/mechanical room affecting two smoke compartments.
Generator had a faulty component not replaced and no fuel test performed on diesel fuel.
Failure to provide proper signage on the oxygen cylinder storage area.
Report Facts
Census: 124
Total Capacity: 125
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 22, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00218158 and #GA00218385.
Complaint Details
Complaints #GA00218158 and #GA00218385 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Dec 22, 2021
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 detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 0
Date: Dec 20, 2021
Visit Reason
A revisit survey was conducted to investigate complaints GA00218158 and GA00218385 and to verify correction of deficiencies cited in the extended Complaint and Focused Infection Control Survey conducted in September 2021.
Complaint Details
Complaints GA00218158 and GA00218385 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were found to be unsubstantiated, and all previously cited deficiencies were corrected.
Report Facts
Resident census: 69
Inspection Report
Abbreviated Survey
Census: 115
Deficiencies: 0
Date: Sep 30, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00217622 from September 27 to September 30, 2021.
Complaint Details
Complaint GA00217622 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 14
Date: Sep 30, 2021
Visit Reason
Complaint survey conducted on 9/15/21 and revisit from 9/27/21 through 9/30/21 to verify removal of Immediate Jeopardy related to COVID-19 outbreak and infection control deficiencies.
Complaint Details
Complaint survey triggered by COVID-19 outbreak with Immediate Jeopardy identified on 9/13/21 related to infection control failures causing resident harm and deaths. Immediate Jeopardy removal plan validated on 9/22/21.
Findings
The facility failed to implement effective infection prevention and control measures during a COVID-19 outbreak, resulting in 74 positive residents, 7 resident deaths, and multiple hospitalizations. Immediate Jeopardy was identified due to failures in outbreak testing, cohorting, staff screening, PPE use, and oversight. The facility submitted an Immediate Jeopardy Removal Plan which was validated on 9/22/21, but systemic deficiencies remained.
Deficiencies (14)
Failure to ensure an effective Infection Prevention Control Program to investigate and identify infection outbreaks.
Failure to implement outbreak testing of residents and staff after a staff member tested positive.
Failure to implement CDC, CMS, and GDPH outbreak guidance including isolation, cohorting, baseline testing, disinfectant use, and PPE.
Failure to have a Certified Infection Control Preventionist on staff.
Failure to properly and consistently screen staff and visitors for COVID-19 upon entrance.
Failure to consistently test staff twice weekly per county positivity rate.
Failure to designate positive COVID-19 areas and place signage to prevent cross contamination.
Failure to utilize dedicated staff for positive and negative residents.
Failure to educate staff and visitors on the use of Personal Protective Equipment (PPE).
Failure to ensure staff were trained and utilized appropriate PPE throughout the facility.
Failure to provide documentation of ongoing facility-wide surveillance including data collection and root-cause analysis.
Failure to use approved disinfectants listed on EPA N list and ensure staff awareness of dwell times.
Failure to have an effective Quality Assurance Performance Improvement Plan to address COVID-19 outbreak.
Failure to ensure Governing Body provided effective oversight to prevent or reduce spread of COVID-19.
Report Facts
COVID-19 positive residents: 74
Resident deaths: 7
Hospitalizations: 3
Staff COVID-19 positive: 38
Census: 115
Room changes: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to infection control deficiencies and Immediate Jeopardy notification and removal plan | |
| Assistant Administrator | Named in relation to infection control deficiencies and Immediate Jeopardy notification and removal plan | |
| Director of Nursing (DON) | Director of Nursing | Named in relation to infection control deficiencies and Immediate Jeopardy notification and removal plan |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing/Infection Control Preventionist | Named in relation to infection control deficiencies and Immediate Jeopardy notification and removal plan |
| Regional Vice President KK | Consultant | Provided education to Administrator on COVID-19 outbreak protocol |
| Licensed Practical Nurse AB | LPN | Interviewed regarding COVID-19 unit procedures and PPE use |
| Housekeeping Aide HHH | Interviewed regarding cleaning procedures and disinfectant use | |
| Housekeeper QQQ | Interviewed regarding cleaning procedures and disinfectant use | |
| Respiratory Therapist | RT | Attended QAPI meetings and completed CDC Infection Control Preventionist course |
Inspection Report
Abbreviated Survey
Census: 89
Capacity: 115
Deficiencies: 15
Date: Sep 30, 2021
Visit Reason
An abbreviated survey was conducted to verify the removal of Immediate Jeopardy related to a Covid-19 outbreak and to investigate complaint #GA00217622.
Complaint Details
Complaint #GA00217622 was investigated and found to be unsubstantiated.
Findings
The facility failed to implement an effective Infection Prevention Control Program, including outbreak testing, isolation, cohorting, staff screening, and use of appropriate disinfectants and PPE, resulting in 74 residents and 38 staff testing positive for Covid-19, with 7 resident deaths and 3 hospitalizations. The facility lacked a Certified Infection Control Preventionist and failed to ensure proper oversight and Quality Assurance Performance Improvement (QAPI) activities. Immediate Jeopardy was removed after corrective actions but the facility remained out of compliance with ongoing systematic changes.
Deficiencies (15)
Failure to ensure an effective Infection Prevention Control Program to prevent or reduce the spread of Covid-19.
Failure to implement outbreak testing of residents and staff when a staff member tested positive for Covid-19 on August 20, 2021.
Failure to implement outbreak guidance for isolation, cohorting, baseline testing, consistent staff testing, disinfectants, and PPE use during Covid-19 outbreak.
Failure to have a Certified Infection Control Preventionist on staff.
Failure to properly and consistently screen staff and visitors for Covid-19 upon entrance.
Failure to consistently test staff twice weekly per County positivity rate since August 9, 2021.
Failure to designate positive Covid-19 areas and place signage to alert staff and visitors to prevent cross contamination.
Failure to utilize dedicated staff for positive Covid-19 and negative residents.
Failure to educate staff and visitors on the use of Personal Protective Equipment (PPE).
Failure to ensure staff were trained and utilized appropriate PPE throughout the facility once Covid-19 outbreak was identified.
Failure to provide documentation of ongoing facility-wide surveillance including data collection, root-cause analysis, interpretation, and dissemination of surveillance information.
Failure to use approved disinfectants listed on EPA N list and ensure staff were trained and aware of dwell times.
Failure to have an effective Quality Assurance Performance Improvement Plan (QAPI) to address Covid-19 outbreak.
Failure of the Governing Body to provide effective oversight to prevent or reduce the spread of Covid-19 infection.
Failure to designate a qualified Infection Preventionist who completed specialized training in infection prevention and control.
Report Facts
Resident census: 89
Total capacity: 115
Residents tested positive: 74
Staff tested positive: 38
Resident deaths: 7
Resident hospitalizations: 3
Staff testing frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN FFF | Infection Control Preventionist | Hired temporarily to assist in Infection Control processes and make recommendations |
| RN GGG | Director of Clinical Services | Hired to assist clinical management to meet compliance |
| KK | Regional Vice President | Provided education to Administrator and QAPI committee |
| Administrator | Named in Immediate Jeopardy notification and QAPI meetings | |
| DON | Director of Nursing | Named in Immediate Jeopardy notification and QAPI meetings |
| ADON | Assistant Director of Nursing | Named in Immediate Jeopardy notification and QAPI meetings |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 15
Date: Sep 15, 2021
Visit Reason
An abbreviated/extended survey was conducted to investigate complaints GA00214887, GA00216725, and GA00217348, and to complete a Focused Infection Control Survey from September 7 to September 15, 2021.
Complaint Details
The investigation was triggered by complaints GA00214887, GA00216725, and GA00217348. Complaint GA00217348 was substantiated with deficiencies related to infection control and resident neglect.
Findings
The facility failed to implement effective infection prevention and control measures during a Covid-19 outbreak, resulting in 74 Covid-19 positive residents, 7 resident deaths, and multiple hospitalizations. Deficiencies included lack of a Certified Infection Control Preventionist, failure to cohort positive and negative residents, inconsistent staff testing, improper PPE use, inadequate environmental cleaning, and failure of the governing body to provide oversight. Immediate Jeopardy was identified and remains ongoing as of the exit date.
Deficiencies (15)
Failure to ensure an effective Infection Prevention Control Program to prevent or reduce the spread of Covid-19.
Failure to implement outbreak testing of residents and staff when a staff member tested positive for Covid-19.
Failure to implement outbreak guidance for isolation, cohorting, baseline testing, consistent staff testing, use of disinfectants, and PPE use.
Failure to have a Certified Infection Control Preventionist on staff.
Failure to screen staff and visitors properly and consistently for Covid-19 upon entrance.
Failure to consistently test staff twice weekly per county positivity rate.
Failure to designate positive Covid-19 areas and place signage to prevent cross contamination.
Failure to utilize dedicated staff for positive and negative residents.
Failure to educate staff and visitors on the use of Personal Protective Equipment (PPE).
Failure to ensure staff were trained and utilized appropriate PPE throughout the facility.
Failure to provide documentation of ongoing facility-wide surveillance including data collection and analysis.
Failure to use approved EPA N-list disinfectants and ensure staff awareness of dwell times.
Failure to have an effective Quality Assurance Performance Improvement Plan to address the Covid-19 outbreak.
Failure of the Governing Body to provide effective oversight to prevent or reduce the spread of Covid-19 infection.
Neglect of resident R#12 related to lack of documentation of adequate care and monitoring after testing positive for Covid-19.
Report Facts
Covid-19 positive residents: 74
Resident deaths: 7
Hospitalizations: 3
Staff positive for Covid-19: 38
Census: 115
Deficiency citations: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R#12 | Resident | Named in neglect finding related to lack of monitoring and care after Covid-19 positive test |
| Administrator | Named in multiple findings including failure to ensure infection control program, oversight, and neglect | |
| Assistant Administrator | Notified of Immediate Jeopardy and involved in infection control deficiencies | |
| Director of Nursing (DON) | Director of Nursing | Named in infection control and oversight deficiencies |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing/Infection Control Preventionist | Named in infection control deficiencies and lack of certification |
| Medical Director (MD) | Medical Director | Interviewed regarding Covid-19 protocols and outbreak management |
| Consultant KK | Member of Governing Body interviewed about oversight | |
| Consultant LL | Member of Governing Body interviewed about oversight | |
| Housekeeping Supervisor (HS) | Housekeeping Supervisor | Interviewed about cleaning products and procedures |
| Environmental Services Technician (EST) AA | Environmental Services Technician | Interviewed about cleaning products and PPE use |
| Licensed Practical Nurse (LPN) CC | Licensed Practical Nurse | Interviewed about resident cohorting and infection control practices |
| Certified Nursing Assistant (CNA) GG | Certified Nursing Assistant | Observed and interviewed about PPE and hand hygiene practices |
| Certified Nursing Assistant (CNA) BB | Certified Nursing Assistant | Interviewed about PPE use and Covid-19 status knowledge |
| Licensed Practical Nurse (LPN) EE | Licensed Practical Nurse | Interviewed about Covid-19 resident status communication |
| Certified Nursing Assistant (CNA) FF | Certified Nursing Assistant | Interviewed about PPE use and confusion regarding PPE changes |
| Family member of resident A | Interviewed about visitation and lack of Covid-19 outbreak notification | |
| Registered Nurse (RN) JJ | Registered Nurse | Interviewed about resident cohorting and PPE use |
| Certified Nursing Assistant (CNA) II | Certified Nursing Assistant | Interviewed about PPE use and cohorting practices |
| Certified Nursing Assistant (CNA) OO | Certified Nursing Assistant | Interviewed about staff testing frequency |
| Licensed Practical Nurse (LPN) PP | Licensed Practical Nurse | Interviewed about staff testing frequency |
| Respiratory Therapist (RT) | Respiratory Therapist | Interviewed about outbreak testing and staff movement |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 15
Date: Sep 15, 2021
Visit Reason
An abbreviated/extended survey was conducted to investigate complaints GA00214887, GA00216725, and GA00217348, and to complete a Focused Infection Control Survey. Complaint GA00217348 was substantiated with deficiencies.
Complaint Details
Complaint GA00217348 was substantiated with deficiencies related to infection control and neglect.
Findings
The facility failed to implement an effective Infection Prevention Control Program, including outbreak testing, isolation, cohorting, staff and visitor screening, consistent staff testing, use of appropriate disinfectants, PPE use, and staff education. The facility lacked a Certified Infection Control Preventionist and failed to provide adequate oversight and quality assurance. As a result, 74 residents and 38 staff tested positive for Covid-19, with 7 resident deaths and 3 hospitalizations.
Deficiencies (15)
Failure to ensure an effective Infection Prevention Control Program to prevent or reduce the spread of Covid-19.
Failure to implement outbreak testing of residents and staff when a staff member tested positive for Covid-19 on August 20, 2021.
Failure to implement outbreak guidance of CDC, CMS, and GDPH for isolation, cohorting, baseline testing, consistent staff testing, disinfectants, PPE use during Covid-19 outbreak.
Failure to have a Certified Infection Control Preventionist on staff.
Failure to properly and consistently screen staff and visitors for Covid-19 upon entrance.
Failure to consistently test staff twice weekly per County positivity rate since August 9, 2021.
Failure to designate positive Covid-19 areas and place signage to alert staff and visitors to prevent cross contamination.
Failure to utilize dedicated staff for positive Covid-19 and negative residents.
Failure to educate staff and visitors on the use of Personal Protective Equipment (PPE).
Failure to ensure staff were trained and utilized appropriate PPE throughout the facility once the Covid-19 outbreak was identified.
Failure to provide documentation of ongoing facility-wide surveillance including data collection, root-cause analysis, interpretation, and dissemination of surveillance information.
Failure to use approved disinfectants listed on the EPA N list throughout the facility and failure to ensure staff were trained and aware of dwell times for disinfectants.
Failure to have an effective Quality Assurance Performance Improvement Plan (QA/PI) to address a Covid-19 outbreak.
Failure of the Governing Body to provide effective oversight to prevent or reduce the spread of Covid-19 infection.
Failure to designate a qualified Infection Preventionist who completed specialized training in infection prevention and control.
Report Facts
Resident deaths: 7
Resident hospitalizations: 3
Residents tested positive: 74
Staff tested positive: 38
Facility census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Infection Control Preventionist | Assumed role after previous ICP quit on 6/22/21; not certified; no official training; did not provide outbreak education. |
| Administrator | Accountable for facility operations; unaware of severity of outbreak until 9/13/21; failed to ensure adequate oversight. | |
| Medical Director | Provided Covid-19 protocol; unaware of cohorting issues and infection control failures. |
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
An initial walk-through licensure survey was conducted for the 10 bed mechanical ventilator unit at the Center for Advanced Rehab at Parkside.
Findings
The facility was determined to be in compliance with state requirements.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 29, 2021
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags had been corrected.
Inspection Report
Renewal
Deficiencies: 0
Date: May 6, 2021
Visit Reason
The inspection was conducted as a Licensure Survey to assess compliance for renewal of the facility's license.
Findings
No deficiencies were identified during the Licensure Survey conducted on 5/6/2021.
Inspection Report
Routine
Census: 121
Deficiencies: 0
Date: May 6, 2021
Visit Reason
A standard survey was conducted from May 3, 2021 through May 7, 2021, including investigation of Complaint Intake Number GA00213777 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00213777 was investigated in conjunction with this standard survey.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Annual Inspection
Census: 122
Capacity: 125
Deficiencies: 1
Date: May 4, 2021
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program for compliance with federal regulations and to conduct a Life Safety Code Survey.
Findings
The facility's Emergency Preparedness Program was found not in substantial compliance due to lack of evidence of the required annual review. However, the facility was found in compliance with Life Safety Code requirements.
Deficiencies (1)
Emergency Preparedness Program did not meet the requirements of 42 CFR 483.73 due to no evidence of the required annual review.
Report Facts
Certified beds: 125
Census: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed findings regarding Emergency Preparedness Program |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00211151, #GA00210719, and #GA00210690.
Complaint Details
Complaint #GA00211151, #GA00210719, and #GA00210690 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
An initial walk-through for the new wing was conducted at The Center for Advanced Rehab at Parkside to determine compliance with state requirements.
Findings
The facility was found to be in compliance with state requirements during the initial walk-through.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted in conjunction with a Covid-19 Infection Control Survey to investigate cases GA00208650 and GA00208971.
Findings
The investigation found that GA00208650 and GA00208971 were unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 117
Deficiencies: 0
Date: Aug 6, 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
Abbreviated Survey
Census: 116
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were 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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Report Facts
Total census: 116
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for 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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 110
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations identified by codes GA00196096, GA00195598, GA00197667, GA00200157, and GA00196506.
Complaint Details
Complaints GA00200157 and GA00195598 were substantiated without deficiencies; GA00197667, GA00196506, and GA00196096 were not substantiated.
Findings
The investigation concluded with substantiation of complaints GA00200157 and GA00195598 without deficiencies, while complaints GA00197667, GA00196506, and GA00196096 were not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 13, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegation GA00195324 related to accidents and hazards.
Complaint Details
One allegation related to accidents and hazards was substantiated with no deficiencies.
Findings
One allegation related to accidents and hazards was substantiated with no deficiencies identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate allegations identified as GA00194859 and GA00194581.
Complaint Details
The investigation was complaint-related but the allegations were unsubstantiated.
Findings
The allegations were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: Oct 18, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the recertification survey dated 2018-08-23.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 18, 2018
Visit Reason
A complaint survey was conducted to investigate complaints # GA00191823 and GA00191780 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation of complaints # GA00191823 and GA00191780; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 10, 2018
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.
Inspection Report
Life Safety
Census: 108
Capacity: 125
Deficiencies: 2
Date: Aug 20, 2018
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to perform a Life Safety Code Survey related to construction, repair, and improvement operations.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with Appendix Z requirements, with missing elements and staff unfamiliarity. Additionally, a Life Safety Code Survey identified that an exit and exit discharge area was obstructed by construction materials, placing 60 residents at risk during an emergency.
Deficiencies (2)
Emergency Preparedness Plan was not complete, up to date, and staff were not properly familiar with the plan details.
Construction area exit and exit discharge was obstructed with materials and equipment, compromising emergency egress.
Report Facts
Residents at risk: 60
Census: 108
Certified beds: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed findings related to Emergency Preparedness Plan | |
| Staff M | Confirmed findings related to Emergency Preparedness Plan and construction obstruction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186424 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186424 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: Nov 9, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 21, 2017 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 8, 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 at the time of the follow-up survey.
Inspection Report
Life Safety
Census: 109
Capacity: 125
Deficiencies: 1
Date: Sep 19, 2017
Visit Reason
The 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 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to properly maintain smoke barrier walls, with numerous unsealed or improperly sealed penetrations observed throughout the facility, posing a risk to residents in the event of a fire emergency.
Deficiencies (1)
Facility failed to ensure that all smoke barrier walls are properly maintained, with numerous unsealed or improperly sealed penetrations using sheetrock tape and joint compound.
Report Facts
Census: 109
Certified beds: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unsealed smoke barrier penetrations during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 11, 2017
Visit Reason
A complaint survey was conducted on June 10, 2017 to investigate Complaint # GA00170433.
Complaint Details
Complaint # GA00170433 was investigated and found the facility in substantial compliance.
Findings
The survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
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