Inspection Report Summary
The most recent inspection on March 18, 2025, found no deficiencies after a revisit survey confirmed correction of prior issues. Earlier inspections showed a pattern of deficiencies primarily related to kitchen sanitation and food storage, as well as life safety code concerns such as emergency lighting, exit signage, self-closing doors, and sprinkler system maintenance. Prior complaint investigations were mostly unsubstantiated, with one substantiated complaint in late 2023 that did not result in deficiencies. The facility previously had multiple care-related deficiencies in 2023, including issues with dental care, restorative services, documentation, and staff training, but these were followed by corrective actions. The recent clean inspection suggests improvement in addressing earlier cited deficiencies and compliance concerns.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
56 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Cherry Blossom Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide any detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: Mar 18, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 13, 2025 Recertification Survey.
Findings
All deficiencies cited in the prior February 13, 2025 Recertification Survey were found to be corrected during the March 18, 2025 revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 57
Capacity: 84
Deficiencies: 4
Date: Feb 18, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with emergency lighting, exit signage, hazardous area enclosure, self-closing doors, and sprinkler system maintenance requirements. Specific deficiencies included non-functioning emergency lights, exit signs without backup power, propped open self-closing doors, loose sprinkler escutcheon plates, corroded pipes, and a non-functioning exterior bell.
Deficiencies (4)
Failed to maintain emergency lighting outside kitchen and laundry exits; lights did not function when tested.
Failed to maintain exit signage in the main dining room; exit sign failed to operate on emergency backup power.
Failed to maintain self-closing door between kitchen and dining room; door was propped open and lacked magnetic catch tied to fire alarm.
Failed to maintain sprinkler system and escutcheon plates; loose plates in closets, corroded pipes, and non-functioning exterior bell.
Report Facts
Census: 57
Total Capacity: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitation standards in the kitchen, including proper sanitation of equipment, removal of outdated food, and proper storage of open food.
Findings
The facility failed to ensure proper sanitation of kitchen equipment, removal of outdated food, and proper storage of open food, which posed a potential risk of foodborne illness to residents receiving an oral diet. Observations included expired and opened food items, food particles on kitchen machines, and a dirty ice machine handle.
Deficiencies (1)
Failure to ensure proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen.
Report Facts
Use-by date: Feb 7, 2025
Use product date: Jan 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed expired and improperly stored food items and stated facility policies should be followed in the kitchen. |
Inspection Report
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
A State Licensure survey was conducted at Cherry Blossom Health and Rehabilitation from February 11, 2025, through February 13, 2025, to assess compliance with state health regulations.
Findings
The facility failed to ensure proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen, which had the potential to place residents at risk of foodborne illnesses. Observations included expired and undated food items, food particles on kitchen equipment, and contamination on the ice machine handle.
Deficiencies (1)
Failure to ensure proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen.
Report Facts
Number of bags of chips past use product date: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook | Confirmed pureed food was left in the puree blender sitting on the counter and stated it should not be left at room temperature. | |
| Dietary Manager | DM | Confirmed out-of-date and undated food items, verified contamination on ice machine handle, and stated facility policies should be followed in the kitchen. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: Feb 11, 2025
Visit Reason
A Standard survey was conducted from February 11 through February 13, 2025, including investigation of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA00252684, GA00242453, GA00243834, GA00245462, GA00246955, GA00247156, GA00249665, GA00251786 were investigated in conjunction with the Standard survey.
Findings
The facility failed to ensure proper sanitation of kitchen equipment, removal of outdated food, and proper storage of open food, which posed a risk of foodborne illnesses to residents receiving oral diets.
Deficiencies (1)
Failure to ensure proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen.
Report Facts
Complaint Intake Numbers: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook | Confirmed pureed food was left in the puree blender on the counter and stated it should not be left at room temperature. | |
| Dietary Manager | DM | Confirmed out-of-date and improperly stored food items and verified the ice machine had a black, flaky substance on the inside handle. |
Inspection Report
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Cherry Blossom Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide any detailed findings or deficiencies.
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
A complaint survey was conducted from November 14, 2023, through November 17, 2023, in conjunction with a revisit survey to investigate Complaint Intake Numbers GA00239755 and GA00240309.
Complaint Details
Complaint Intake Number GA00239755 was substantiated without deficiency cited; GA00240309 was unsubstantiated without deficiency cited.
Findings
The complaint investigation found that complaint GA00239755 was substantiated without deficiency cited and complaint GA00240309 was unsubstantiated without deficiency cited.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Nov 17, 2023
Visit Reason
A revisit survey was conducted from November 14, 2023, through November 17, 2023, including investigation of two complaint intake numbers GA00239755 and GA00240309.
Complaint Details
Complaint Intake Number GA00239755 was substantiated without deficiency cited; Complaint Intake Number GA00240309 was unsubstantiated without deficiency cited.
Findings
All deficiencies cited in the prior Standard/Complaint survey concluded on September 21, 2023, were found to be corrected. Complaint GA00239755 was substantiated without deficiency cited, and complaint GA00240309 was unsubstantiated without deficiency cited.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Life Safety
Census: 65
Capacity: 82
Deficiencies: 1
Date: Nov 13, 2023
Visit Reason
An unannounced Emergency Preparedness survey was conducted on 11/13/2023 following a State Agency Annual Emergency Preparedness Survey conducted on 9/19/2023. Additionally, a Life Safety Code Federal Monitoring Survey was conducted by CMS on 11/13/2023 following a state agency survey on 9/19/2023.
Findings
The facility was found in substantial compliance with emergency preparedness requirements but was found NOT in substantial compliance with Life Safety Code requirements, specifically failing to maintain the smoke and ½ hour fire resistance of the smoke barriers. One smoke barrier was affected due to a 2" metal sleeve penetration that was not completely fire stopped.
Deficiencies (1)
Failed to maintain the smoke and ½ hour fire resistance of the smoke barriers; A hall smoke barrier was penetrated by a 2" metal sleeve with interior not completely fire stopped.
Report Facts
Census: 65
Total Capacity: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present when deficiency was identified and identified the wall as a smoke barrier |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 21, 2023
Visit Reason
A State Licensure survey was conducted at Cherry Blossom Health and Rehabilitation from September 18, 2023 through September 21, 2023 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to assist residents with dental care, inadequate equipment for resident mobility, failure to provide nail care, lack of restorative services for limited range of motion, and inaccurate documentation of medical conditions and medication diagnoses.
Deficiencies (5)
Facility failed to assist two of eight residents reviewed for dental services in obtaining routine dental care.
Facility failed to ensure one resident had equipment required to exit their room to attend activities.
Facility failed to provide assistance with nail care to preserve and promote dignity of two residents.
Facility failed to ensure one resident with limited range of motion received restorative services as needed.
Facility failed to ensure accurate documentation of medical conditions for three residents, potentially contributing to inappropriate care or medication use.
Report Facts
Residents reviewed for dental services: 20
Residents failed dental assistance: 2
Residents reviewed for activities of daily living: 20
Residents failed nail care assistance: 2
Residents reviewed for limited range of motion: 20
Residents failed restorative services: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Interviewed regarding dental services and resident assistance |
| Director of Nursing | Director of Nursing (DON) | Interviewed and observed resident care and facility practices |
| Activities Director | Activities Director (AD) | Interviewed regarding resident participation in activities |
| Certified Nurse Aide 1 | Certified Nurse Aide (CNA) 1 | Interviewed regarding nail care practices |
| Certified Nurse Aide 2 | Certified Nurse Aide (CNA) 2 | Observed assisting resident with wheelchair |
| Certified Nurse Aide 5 | Certified Nurse Aide (CNA) 5 | Interviewed regarding restorative services for resident R27 |
| Division Regional Nurse | Division Regional Nurse (DRN) | Interviewed regarding wheelchair delivery and facility policies |
| Occupational Therapist | Occupational Therapist (OT) | Interviewed regarding restorative program for resident R27 |
| Administrator | Administrator | Interviewed regarding wheelchair orders and facility policies |
Inspection Report
Routine
Census: 61
Deficiencies: 14
Date: Sep 21, 2023
Visit Reason
A standard survey was conducted from September 18, 2023 through September 21, 2023, including complaint investigations which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00236365 and GA00239043 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to provide appropriate equipment, timely reporting of abuse, comprehensive care plans, fall prevention interventions, nail care, restorative services, bed rail assessments, staff training, accurate medication documentation, antibiotic stewardship, and behavioral health training.
Deficiencies (14)
Failure to ensure one resident had equipment to exit their room due to bariatric wheelchair not fitting through door.
Failure to report resident-to-resident physical abuse to State Agency within required two hours.
Failure to develop and implement comprehensive person-centered care plans for three residents.
Failure to review and revise care plan interventions for one resident reviewed for fall prevention.
Failure to provide assistance with nail care to preserve dignity of two residents.
Failure to provide restorative services as needed to address limited range of motion for one resident.
Failure to ensure appropriate fall interventions were implemented resulting in continued falls for one resident.
Failure to ensure documented safety assessment and resident or representative advisement of risks/benefits for bed rail use for six residents.
Failure to complete annual performance reviews for two Certified Nurse Aides.
Failure to assist two residents in obtaining routine dental care.
Failure to ensure accurate documentation of medical conditions for three residents with medication orders.
Failure to identify trends in antibiotic use, maintain documentation for clinical indication, and implement protocols to monitor and reduce inappropriate antibiotic use.
Failure to implement and maintain dementia training for one Certified Nurse Aide and emergency evacuation training for bariatric residents for all staff.
Failure to implement and maintain training program regarding prevention of abuse and neglect for one Certified Nurse Aide and one Licensed Practical Nurse.
Report Facts
Resident census: 61
Deficiencies cited: 13
BIMS scores: 15
BIMS scores: 12
BIMS scores: 11
BIMS scores: 12
BIMS scores: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Aide | Named in findings related to lack of annual performance review, lack of dementia, behavioral health, and abuse/neglect prevention training |
| CNA 4 | Certified Nurse Aide | Named in findings related to lack of annual performance review and lack of behavioral health training |
| LPN 1 | Licensed Practical Nurse | Named in findings related to lack of abuse/neglect prevention and behavioral health training |
| LPN 2 | Licensed Practical Nurse | Named in findings related to lack of behavioral health training |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies, including restorative services, medication order documentation, and training |
| Division Regional Nurse | Division Regional Nurse | Interviewed regarding policies, training, and antibiotic stewardship |
| Administrator | Facility Administrator | Interviewed regarding training expectations and wheelchair equipment issue |
| Social Services Director | Social Services Director | Interviewed regarding dental care coordination |
| Certified Nurse Aide 5 | Certified Nurse Aide | Interviewed regarding restorative services for resident |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed regarding bariatric resident evacuation training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report an allegation of resident-to-resident physical abuse involving one resident.
Complaint Details
The complaint involved one resident (R35) who was physically abused by another resident (R37). The facility's investigation found resident-to-resident mistreatment occurred on 08/03/2023. The Administrator did not consider the incident abuse and did not notify police, failing to follow federal regulatory requirements.
Findings
The facility failed to report an allegation of resident-to-resident physical abuse to the State Agency within the required two hours of discovery. The investigation revealed a physical altercation between two residents, which the Administrator did not consider abuse and did not notify police as required by federal regulations.
Deficiencies (1)
Failed to timely report suspected resident-to-resident physical abuse to the State Agency within the required two hours of discovery.
Report Facts
Residents reviewed for reporting: 20
Residents affected: 1
Date of incident: Aug 3, 2023
Date of investigative report: Aug 7, 2023
Brief Interview for Mental Status (BIMS) score: 13
Inspection Report
Routine
Census: 61
Deficiencies: 13
Date: Sep 21, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of Cherry Blossom Health and Rehabilitation to assess compliance with healthcare facility regulations, including resident care, safety, and staff training.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate equipment for resident mobility, timely reporting of abuse, comprehensive care planning, fall prevention interventions, assistance with activities of daily living, restorative services, accurate medical documentation, antibiotic stewardship, and staff training on dementia, behavioral health, and emergency evacuation of bariatric residents.
Deficiencies (13)
Failed to ensure one resident had equipment required to exit their room as desired to attend activities.
Failed to timely report an allegation of resident to resident physical abuse to the State Agency within the required two hours of discovery.
Failed to develop and implement comprehensive person-centered care plans for three residents addressing dental needs, vision, bed rails, restorative services, and pain management.
Failed to review and revise care plan interventions for one resident after falls, resulting in inadequate fall prevention.
Failed to provide assistance with nail care to preserve and promote dignity for two residents.
Failed to provide restorative services to one resident with limited range of motion, resulting in potential for worsening contracture.
Failed to ensure appropriate fall interventions were implemented for one resident with repeated falls.
Failed to assess safety risks, review risks and benefits, obtain informed consent, and maintain documentation for bed rail use for six residents.
Failed to ensure two Certified Nurse Aides had annual performance reviews to enable in-service education based on review outcomes.
Failed to assist two residents in obtaining routine dental care and to perform oral assessments as required.
Failed to ensure accurate documentation of medical conditions for three residents, leading to inappropriate medication orders.
Failed to implement an effective antibiotic stewardship program to monitor and reduce inappropriate antibiotic use.
Failed to implement and maintain training programs for dementia care, emergency evacuation of bariatric residents, abuse and neglect prevention, and behavioral health training for staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 6
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 61
Staff affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide 1 | Certified Nurse Aide | Named in nail care, training, and abuse prevention findings |
| Certified Nurse Aide 4 | Certified Nurse Aide | Named in behavioral health training and annual performance review findings |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Named in abuse prevention and behavioral health training findings |
| Licensed Practical Nurse 2 | Licensed Practical Nurse | Named in behavioral health training findings |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including restorative services, medication orders, fall prevention, and staff training |
| Administrator | Administrator | Interviewed regarding wheelchair equipment, staff training, and facility policies |
| Division Regional Nurse | Division Regional Nurse | Interviewed regarding policies and training |
| Social Services Director | Social Services Director | Interviewed regarding dental care assistance |
| Occupational Therapist | Occupational Therapist | Interviewed regarding restorative program for resident |
| Certified Nurse Aide 5 | Certified Nurse Aide | Interviewed regarding restorative services |
| Certified Nurse Aide 2 | Certified Nurse Aide | Observed assisting resident with wheelchair |
| Activities Director | Activities Director | Interviewed regarding resident activity participation |
Inspection Report
Life Safety
Census: 61
Capacity: 82
Deficiencies: 0
Date: Sep 19, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified Beds: 82
Census: 61
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An Abbreviated Survey was conducted to investigate complaints #GA00233616 and #GA00233793.
Complaint Details
Complaints #GA00233616 and #GA00233793 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: May 12, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Cherry Blossom Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations regarding dental services and oral health care for residents at Cherry Blossom Health and Rehabilitation.
Findings
The facility failed to identify and provide dental services for one resident with ongoing dental issues, including a loose tooth causing pain. Staff interviews revealed lack of awareness and communication about the resident's dental pain, and the resident was not scheduled for dental care during the facility's quarterly dentist visit.
Deficiencies (1)
Failure to provide or obtain dental services for one resident related to an ongoing dental issue.
Report Facts
Facility sample size: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Observed feeding resident and interviewed regarding resident's lunch and dental pain |
| FF | Certified Nursing Assistant (CNA) | Reported resident's mouth pain and loose tooth during telephone interview |
| EE | Licensed Practical Nurse (LPN) | Interviewed about communication regarding resident's complaint or mouth pain |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding awareness of resident's dental issues and facility dental services |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 3/15/2022 through 3/17/2022 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey conducted from 3/15/2022 through 3/17/2022.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 1
Date: Mar 17, 2022
Visit Reason
A standard survey was conducted from 3/15/2022 through 3/17/2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00222102, GA00217611, GA00215526, and GA00215285 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to dental services. Specifically, the facility failed to identify and provide dental services for one resident with an ongoing dental issue, including failure to refer the resident to a dentist despite known dental problems and complaints of pain.
Deficiencies (1)
Failure to identify and provide dental services for one resident related to an ongoing dental issue, including lack of referral to a dentist despite known dental problems and complaints of pain.
Report Facts
Resident census: 59
Facility sample size: 32
Resident age: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Observed feeding resident and interviewed regarding resident's eating and dental pain. |
| FF | Certified Nursing Assistant (CNA) | Reported resident's mouth pain to nurse within the last month but could not recall details. |
| EE | Licensed Practical Nurse (LPN) | Stated no CNA had informed her of resident's complaint or mouth pain. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding awareness of resident's dental problems and pain. |
Inspection Report
Life Safety
Census: 60
Capacity: 82
Deficiencies: 0
Date: Mar 17, 2022
Visit Reason
The visit was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey to ensure compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The Emergency Preparedness Program was found to be in compliance with 42 CFR 483.73, and the facility was found to be in compliance with the Life Safety Code requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Report Facts
Certified Beds: 82
Census: 60
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00206041 and GA00207394.
Complaint Details
Complaints #GA00206041 and GA00207394 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00206041 and GA00207394 were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
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, including implementation of CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on July 1-2, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with COVID-19 related regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Census: 62
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 23, 2020
Visit Reason
A revisit survey was conducted at Cherry Blossom Health and Rehabilitation from 1/22/20 to 1/23/20 in conjunction with investigation of Complaint Intake Number GA00201684.
Complaint Details
Complaint Intake Number GA00201684 was investigated and partially substantiated, with no deficiencies written.
Findings
All deficiencies cited in the prior standard survey from 12/2/19 through 12/5/19 were found to be corrected. The complaint was partially substantiated, with no deficiencies written.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 23, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted investigating complaint number GA00201684, along with a Revisit survey from a Standard survey with an exit date of 12/5/19.
Complaint Details
Complaint number GA00201684 was partially substantiated with no deficiencies.
Findings
The complaint was partially substantiated with no deficiencies identified during the survey.
Inspection Report
Life Safety
Census: 75
Capacity: 77
Deficiencies: 0
Date: Dec 4, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2019
Visit Reason
The inspection was conducted to investigate complaint #GA00196845 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00196845 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 7/15/19 through 7/16/19.
Inspection Report
Follow-Up
Census: 70
Deficiencies: 0
Date: Apr 30, 2019
Visit Reason
A follow-up survey was conducted at Cherry Blossom Health and Rehabilitation from April 29, 2019 through April 30, 2019 to verify compliance with Medicare/Medicaid regulations.
Findings
The follow-up survey revealed that 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.
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 5
Date: Feb 28, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194433, which was substantiated with deficiencies. Further investigation and re-entry were conducted to assess compliance and corrective actions.
Complaint Details
Complaint GA00194433 was substantiated with deficiencies related to resident fall, notification failures, and advance directive documentation.
Findings
The facility was found to have Immediate Jeopardy related to failure to timely notify the physician and family of a resident's fall and change in condition, failure to provide appropriate neuro-checks, and failure to follow professional standards of care. Additionally, deficiencies were found in updating advance directives and care plans, and in administration oversight of these processes. Immediate Jeopardy was removed after corrective actions including staff education, audits, and suspension of involved nurse.
Deficiencies (5)
Failure to timely notify physician and family of resident fall and change in condition, resulting in resident death.
Failure to provide neuro-checks at ordered times and failure to follow professional nursing standards after resident fall.
Failure to update advance directives care plan after change in resident's code status.
Failure to ensure valid Do Not Resuscitate (DNR) order with required physician signatures.
Failure of facility administration to ensure accurate advance directive documentation and oversight through QAPI.
Report Facts
Resident census: 64
Deficiency severity level J: 2
Deficiency severity level D: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assigned nurse at time of resident fall; failed to notify physician timely; suspended and terminated |
| LPN BB | Licensed Practical Nurse | Day shift nurse who failed to notify physician timely after observing resident condition post-fall |
| Director of Nursing | Director of Nursing | Informed of Immediate Jeopardy; involved in notification and corrective actions |
| Physician CC | Physician | Notified late after resident fall; expected immediate notification |
| Nurse Practitioner | Nurse Practitioner | Not contacted at time of resident fall; received report next day |
| Administrator | Facility Administrator | Oversight of facility operations; aware of deficiencies and corrective actions |
| Social Worker | Social Worker | Involved in advance directive process; lacked full understanding of POLST requirements |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: Feb 28, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to complaint GA00194433, which involved an unwitnessed fall and failure to notify the physician and family in a timely manner for one resident.
Complaint Details
Complaint GA00194433 was substantiated with deficiencies related to failure to notify physician and family timely after a resident's fall, resulting in Immediate Jeopardy from 1/24/19 to 2/27/19, which was removed on 2/28/19.
Findings
The facility failed to promptly notify the physician and responsible party about a resident's fall and change in condition, resulting in Immediate Jeopardy that was later removed. Additional deficiencies included inaccurate code status documentation and failure to verify physician signatures on POLST forms.
Deficiencies (3)
Failure to notify the physician and responsible party in a timely manner after a resident's unwitnessed fall.
Substandard Quality of Care related to neglect and failure to notify.
Failure to include accurate code status in the medical record and failure to verify a second physician's signature on a POLST form.
Report Facts
Resident census: 64
Sample size: 12
Number of residents with change in condition: 12
Number of LPN charge nurses educated: 10
Number of RN supervisors educated: 3
Number of LPN Resident Care Coordinators educated: 2
Number of LPN Wound Care Coordinators educated: 1
Number of RN Minimum Data Set Coordinators educated: 1
Number of LPN Minimum Data Set Coordinators educated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assessed resident after fall, failed to notify physician timely, suspended and terminated for poor judgment |
| LPN BB | Licensed Practical Nurse | Day shift nurse who observed resident's condition post-fall and called family instead of physician |
| Director of Nursing (DON) | Director of Nursing | Informed of Immediate Jeopardy, responsible for oversight of notification system and audits |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy, responsible for facility operations and aware of code status issues |
| Physician CC | Physician | Expected immediate notification after falls, was not notified timely |
| Nurse Practitioner (NP) | Nurse Practitioner | Not contacted at time of resident's fall, received report next day |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 6, 2018
Visit Reason
A revisit was conducted on 9/6/18 for the recertification survey of 7/26/18.
Findings
The revisit revealed that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 74
Capacity: 82
Deficiencies: 0
Date: Jul 25, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance with Appendix Z requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 18, 2018
Visit Reason
The inspection was conducted to investigate complaints #GA00189335 and #GA00189362 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The visit was complaint-related, investigating two complaints identified by numbers GA00189335 and GA00189362. No deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 9, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00186951 on 5/9/18.
Complaint Details
Complaint GA00186951 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2017
Visit Reason
A desk review was conducted on 09/13/2017 to follow up on the recertification survey of 07/20/2017.
Findings
The review revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 08/21/2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 28, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 66
Capacity: 76
Deficiencies: 1
Date: Jul 19, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to provide smoke barriers with at least a one half hour fire resistance rating. Observations revealed smoke barriers on multiple halls did not extend fully and had unsealed penetrations, placing all 66 residents at risk in the event of a fire.
Deficiencies (1)
Facility failed to provide smoke barriers with at least a one half hour fire resistance rating; smoke barriers did not extend fully and had unsealed penetrations.
Report Facts
Census: 66
Certified Beds: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding smoke barrier deficiencies during tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA171852 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA171852 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted at Cherry Blossom Health and Rehabilitation.
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