Inspection Reports for Christian City Assisted Living Center
7290 Lester Rd, Union City, GA 30291, GA, 30291
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Inspection Report
Deficiencies: 0
Jun 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Christian City Rehabilitation Center, 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: 171
Deficiencies: 0
Jun 25, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 30, 2025, Recertification Survey.
Findings
All deficiencies cited in the April 30, 2025, Recertification Survey were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 177
Capacity: 200
Deficiencies: 0
May 9, 2025
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 Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Routine
Deficiencies: 6
Apr 30, 2025
Visit Reason
A State Licensure survey was conducted at Christian City Rehabilitation Center from April 27, 2025, through April 30, 2025, to assess compliance with state health regulations and facility policies.
Findings
The survey revealed multiple deficiencies including failure to timely report abuse allegations, medication management issues with unavailable medications, inadequate infection control during blood glucose monitoring, incomplete care planning for pressure ulcers, failure to provide appropriate call devices for residents with physical impairments, and environmental sanitation concerns including mold and room disrepair.
Complaint Details
The complaint investigation included allegations of abuse and neglect for Resident R197, including a fall, force feeding, weight loss, and lack of hygiene care. The facility's investigation was unsubstantiated, but the failure to timely report was cited as a deficiency.
Deficiencies (6)
| Description |
|---|
| Failure to timely report allegations of abuse for two residents, increasing risk of continued abuse. |
| Failure to ensure medication refills and availability, resulting in missed medication administrations for multiple residents. |
| Failure to follow infection control practices during blood glucose check and insulin administration, risking transmission of infectious diseases. |
| Failure to develop a comprehensive care plan reflecting actual pressure ulcers and related interventions for one resident. |
| Failure to provide call devices tailored to residents' physical needs and failure to respond promptly to call system for two residents. |
| Failure to maintain a homelike environment due to room disrepair and presence of mold in resident rooms and bathrooms. |
Report Facts
Residents reviewed for abuse: 6
Total sample residents: 51
Weight loss: 30
Medication administration dates with 'Not Administered: Drug/Item Unavailable': 15
BIMS score: 14
BIMS score: 10
BIMS score: 5
Mold affected area size: 4
Mold remediation invoice date: Nov 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA10 | Certified Nursing Assistant | Named in investigation of alleged rough care and abuse for Resident R202. |
| UM3 | Unit Manager | Reported abuse allegation to Administrator and documented complaint for Resident R202. |
| LPN2 | Licensed Practical Nurse | Observed during medication administration and blood glucose check with infection control deficiencies. |
| UM2 | Unit Manager | Confirmed medication availability procedures and observed medication administration. |
| DON | Director of Nursing | Reviewed medication administration records and confirmed deficiencies; provided statements on care planning and call device issues. |
| WN1 | Wound Nurse | Reported care plan for pressure ulcers was not updated correctly for Resident R194. |
| UM5 | Unit Manager | Observed call device placement and resident ability to use call system for Resident R25. |
| CNA5 | Certified Nursing Assistant | Confirmed Resident R25 could not use call bell. |
| CNA6 | Certified Nursing Assistant | Confirmed Resident R25 had no ability to use call bell. |
| HSKS | Housekeeping Supervisor | Observed mold in resident bathroom. |
| MD | Maintenance Director | Verified room disrepair and mold issues; provided statements on remodeling and mold inspection. |
| Administrator | Provided statements on abuse investigation, mold remediation, and remodeling plans. |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 18
Apr 30, 2025
Visit Reason
A recertification survey was conducted at Christian City Rehab Center from April 27, 2025, through April 30, 2025, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure call devices met residents' needs, failure to maintain a homelike environment, failure to report abuse allegations timely, failure to complete significant change and discharge MDS assessments, failure to code pressure ulcers accurately, failure to create baseline and comprehensive care plans, failure to provide restorative nursing services, failure to have physician orders for indwelling catheter, failure to obtain and document resident weight, failure to document dialysis assessments and communication, failure to ensure timely medication refills, failure to label insulin pens properly, improper disposal of expired medications, and failure to follow infection control during blood glucose monitoring.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Specific substantiation status was not stated.
Severity Breakdown
Level D: 15
Level E: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to ensure call devices were tailored to residents' physical needs and failed to respond promptly to call system for two residents. | Level D |
| Failed to create a homelike environment by ensuring resident rooms were clean or in good repair for four residents. | Level D |
| Failed to report allegations of abuse in a timely manner for two residents. | Level D |
| Failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in a resident's status. | Level D |
| Failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of discharge for two residents. | Level D |
| Failed to code pressure ulcers on MDS assessment for two residents. | Level D |
| Failed to ensure a baseline care plan was created within 48 hours of admission for one resident. | Level D |
| Failed to develop a comprehensive care plan for one resident with pressure ulcers. | Level D |
| Failed to ensure two residents received nail care, increasing risk of infection and nail damage. | Level D |
| Failed to administer long-acting insulin in accordance with physician orders for two residents. | Level D |
| Failed to identify pressure ulcers and initiate treatment orders timely for one resident. | Level D |
| Failed to provide restorative nursing services for one resident, risking decline in ADLs. | Level D |
| Failed to have physician orders and indication for indwelling catheter for one resident. | Level D |
| Failed to obtain and document weight for one resident, risking unmonitored weight loss. | Level D |
| Failed to ensure documentation of assessment prior to and upon return from dialysis and failed to complete dialysis communication forms for one resident. | Level D |
| Failed to ensure medication was refilled before running out and over-the-counter medication was available for three residents. | Level E |
| Failed to adequately label insulin pens and properly dispose of expired medication in designated disposal container. | Level D |
| Failed to ensure infection control practices during blood glucose check for one resident, placing residents at risk of infectious diseases. | Level D |
Report Facts
Residents sampled: 51
Residents with call device deficiency: 2
Residents with homelike environment deficiency: 4
Residents with abuse reporting deficiency: 2
Residents with significant change MDS deficiency: 1
Residents with discharge MDS deficiency: 2
Residents with pressure ulcer coding deficiency: 2
Residents with baseline care plan deficiency: 1
Residents with comprehensive care plan deficiency: 1
Residents with nail care deficiency: 2
Residents with insulin administration deficiency: 2
Residents with pressure ulcer treatment deficiency: 1
Residents with restorative nursing deficiency: 1
Residents with catheter order deficiency: 1
Residents with weight documentation deficiency: 1
Residents with dialysis documentation deficiency: 1
Residents with medication refill deficiency: 3
Insulin pens observed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Administered insulin and performed blood glucose check; involved in medication administration deficiencies and infection control failure |
| UM2 | Unit Manager | Provided information on medication availability, nail care responsibility, and dialysis communication |
| DON | Director of Nursing | Provided multiple clarifications on policies, deficiencies, and expectations |
| CNA5 | Certified Nursing Assistant | Confirmed resident R25 could not use call bell |
| CNA6 | Certified Nursing Assistant | Confirmed resident R25 could not use call bell |
| UM5 | Unit Manager | Observed call bell placement for resident R25 and R238 |
| LPN1 | Licensed Practical Nurse | Reported resident R120's decline in mobility after fall |
| MDSC | MDS Coordinator | Reported on MDS assessment deficiencies |
| WN1 | Wound Nurse | Reported on pressure ulcer care deficiencies |
| WN2 | Wound Nurse | Reported on dialysis communication and wound care |
| UM1 | Unit Manager | Reported on dialysis communication and medication availability |
| LPN8 | Licensed Practical Nurse | Withheld or reduced insulin doses without physician orders |
| LPN4 | Registered Nurse | Verified lack of catheter orders |
| LPN2 | Licensed Practical Nurse | Observed with unlabeled insulin pens and improper disposal of expired medication |
Inspection Report
Abbreviated Survey
Census: 171
Deficiencies: 0
Dec 10, 2024
Visit Reason
An abbreviated/partial extended survey was conducted at Christian City Rehabilitation Center to investigate Complaint Intake Number GA00252984.
Findings
The complaint was found unsubstantiated and no federal deficiencies were cited during the investigation.
Complaint Details
Complaint Intake Number GA00252984 was investigated and found unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 174
Deficiencies: 0
Oct 31, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00252092 and GA00252017.
Findings
The complaints GA00252092 and GA00252017 were substantiated with no regulatory violations cited.
Complaint Details
Complaints GA00252092 and GA00252017 were substantiated with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Apr 23, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Christian City Rehabilitation Center, 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
Re-Inspection
Deficiencies: 0
Apr 23, 2024
Visit Reason
A revisit survey was conducted on 4/22/2024 through 4/23/2024 to investigate Complaint Intake Number GA00245354 and to verify correction of citations from the 3/3/2024 recertification survey.
Findings
The complaint investigation was found to be unsubstantiated, and all citations related to the prior 3/3/2024 recertification survey were found to be corrected.
Complaint Details
Complaint Intake Number GA00245354 was investigated and found to be unsubstantiated.
Report Facts
Complaint Intake Number: GA00245354
Previous survey date: 3/3/2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 23, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00245354.
Findings
No deficiencies were cited related to complaint number GA00245354.
Complaint Details
Complaint number GA00245354 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 22, 2024
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 by the surveyor.
Inspection Report
Routine
Census: 174
Deficiencies: 2
Mar 3, 2024
Visit Reason
A State Licensure survey was conducted at Christian City Rehabilitation Center from March 1, 2024 through March 3, 2024 to assess compliance with state health regulations.
Findings
The facility failed to properly thaw frozen foods by not allowing running water to overflow, and failed to ensure resident nourishment refrigerators and freezers were clean, with resident foods labeled, dated, and discarded past use-by dates. These deficiencies had the potential to affect 170 residents receiving an oral diet.
Deficiencies (2)
| Description |
|---|
| Failed to properly thaw frozen foods by not allowing running water to overflow to prevent potential harmful particles/bacteria to run freely. |
| Resident nourishment refrigerators and freezers were not clean, with food items not labeled or dated, and food items discarded past the use-by date. |
Report Facts
Facility census: 174
Residents potentially affected: 170
Expired yogurt containers: 12
Expired milk cartons: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DC AA | Dietary Cook | Observed thawing frozen fish filets improperly |
| DM | Dietary Manager | Confirmed thawing procedures and food labeling responsibilities |
| BB | Housekeeper | Stated housekeeping was not responsible for cleaning resident nourishment refrigerators/freezers |
| CC | Registered Nurse Unit Manager | Confirmed nursing responsibility for cleaning resident nourishment refrigerators/freezers |
| DD | Licensed Practical Nurse | Confirmed nursing staff responsibility for labeling and discarding resident foods |
| EDD | Executive Dining Director | Explained dietary staff responsibilities for stocking and discarding expired food items |
Inspection Report
Routine
Census: 174
Deficiencies: 3
Mar 3, 2024
Visit Reason
A standard survey was conducted from March 1 through March 3, 2024, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Christian City Rehabilitation Center.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to submit a proper PASRR Level I screening for a resident with schizophrenia and multiple food safety violations such as improper thawing of frozen foods, unclean nourishment refrigerators/freezers, and unlabeled or expired resident food items.
Complaint Details
Complaint Intake Numbers GA00242767, GA00244229, and GA00241875 were unsubstantiated with no deficiencies; complaint GA00243672 was substantiated with deficiencies.
Severity Breakdown
SS= D: 1
SS= F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an application for PASRR Level I including diagnosis of schizophrenia was submitted prior to or on admission for one resident. | SS= D |
| Failed to properly thaw frozen foods by not allowing running water to overflow to prevent harmful particles/bacteria. | SS= F |
| Failed to ensure resident nourishment refrigerators and freezers were clean, resident foods were labeled and dated, and food items past use by date were discarded. | SS= F |
Report Facts
Residents sampled: 43
Facility census: 174
Expired yogurt containers: 6
Expired milk cartons: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EE | Social Service Director | Interviewed regarding PASRR screening process and admitted resident without proper Level II PASRR |
| AA | Dietary Cook | Observed thawing frozen fish improperly without running water overflow |
| DM | Dietary Manager | Confirmed thawing procedure issues and responsibility for food expiration and labeling |
| BB | Housekeeper | Interviewed about cleaning responsibilities of nourishment refrigerators/freezers |
| CC | Registered Nurse Unit Manager | Confirmed nursing responsibility for cleaning nourishment refrigerators/freezers |
| DD | Licensed Practical Nurse | Confirmed nursing responsibility for labeling and discarding resident foods |
| EDD | Executive Dining Director | Interviewed about dietary staff responsibilities for stocking and discarding food items |
Inspection Report
Life Safety
Census: 165
Capacity: 200
Deficiencies: 6
Mar 2, 2024
Visit Reason
The inspection 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 obstructions in egress corridors, malfunctioning self-closing doors, lack of bi-annual kitchen hood suppression system inspection, improper use of power strips, missing annual elevator inspection, and missing approved signage for the outside oxygen storage area.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain an obstruction free egress corridor on the 5th floor near the vertical opening door; equipment and carts found in the corridor. | D |
| Failed to maintain rated door assemblies on the 2nd and 4th floors at elevator lobbies; doors missing parts and will not latch properly. | E |
| Failed to have the required bi-annual inspection of the kitchen hood suppression system; blue inspection tag is out-of-date. | D |
| Failed to properly use multiple outlet power strips in resident room 309 and electrical room behind the 3rd floor nurses station. | E |
| Failed to have the required annual elevator inspection; elevator did not have a current annual inspection card inside the car. | D |
| Failed to provide approved signage for the outside oxygen storage area. | D |
Report Facts
Census: 165
Total Capacity: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 187
Deficiencies: 0
Sep 8, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaint intake numbers at Christian City Rehabilitation Center.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices. All complaints investigated were found to be unsubstantiated.
Complaint Details
Multiple complaint intake numbers were investigated and all were found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Aug 26, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Christian City Rehabilitation Center, 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: 177
Deficiencies: 0
Aug 26, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/23/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 6/23/22 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 8, 2022
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
Life Safety
Census: 174
Capacity: 200
Deficiencies: 2
Jun 27, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failures in emergency lighting and sprinkler system maintenance. Specifically, emergency lighting in the laundry wash area failed to illuminate during testing, and sprinkler system deficiencies included visible loaded sprinkler heads and a missing escutcheon plate.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Emergency lighting unit in the wash area of the laundry would not illuminate during a test. | SS= D |
| Loaded sprinkler heads visible in the laundry room and a missing escutcheon plate in the therapy room. | SS= D |
Report Facts
Smoke Compartments affected: 1
Stories: 5
Certified beds: 200
Census: 174
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting and sprinkler system deficiencies during the tour. |
Inspection Report
Original Licensing
Deficiencies: 2
Jun 23, 2022
Visit Reason
A Licensure Survey was conducted from 6/21/2022 through 6/23/2022 to assess compliance with licensure requirements.
Findings
The facility failed to provide adequate Activities of Daily Living care related to incontinence for one resident and failed to maintain the kitchen in a clean and sanitary condition, posing potential risk to all residents receiving oral diets.
Deficiencies (2)
| Description |
|---|
| Failure to provide adequate incontinence care to one of 16 sampled residents, resulting in resident being changed only once per shift despite total dependence on staff for toileting. |
| The kitchen was observed to have multiple unsanitary conditions including stained floors and walls, debris, leaking water, broken garbage disposal, and accumulation of thick substances on appliances and walls. |
Report Facts
Number of sampled residents: 16
Brief Interview for Mental Status (BIMS) score: 15
Date of last inspection: May 29, 2019
Number of dietary staff in attendance: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Named in progress notes for providing incontinence care to resident #35 |
| Unit Manager | Interviewed regarding staff rounding and incontinence care frequency | |
| Dietary Manager | Responsible for kitchen cleanliness and cleaning schedules; resigned during survey | |
| Administrator | Interviewed regarding kitchen conditions and facility oversight | |
| Corporate Clinical Nurse | Interviewed with Administrator regarding kitchen conditions |
Inspection Report
Routine
Census: 170
Deficiencies: 3
Jun 23, 2022
Visit Reason
A standard survey was conducted from June 21 through June 23, 2022, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to provide adequate incontinence care to a resident, lack of physician orders for oxygen use, and unsanitary kitchen conditions posing potential risk to all residents.
Complaint Details
Complaint Intake Numbers GA00219871, GA00222438, GA00220772, GA00221671, GA00220070, GA00224230, and GA00222507 were investigated in conjunction with this standard survey.
Severity Breakdown
Level D: 2
Level F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide Activities of Daily Living (ADL) care related to incontinence for one resident (R#35). | Level D |
| Failure to obtain a Physician's Order for oxygen use, including frequency and flow rate, for one resident (R#281). | Level D |
| Failure to maintain the kitchen in a clean and sanitary condition, including stained floors, walls, appliances, leaking water, broken garbage disposal, and presence of mold and debris. | Level F |
Report Facts
Resident census: 170
Number of sampled residents for ADL deficiency: 16
Number of sampled residents for oxygen order deficiency: 57
Date range of survey: 2022-06-21 to 2022-06-23
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 4, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00218564, #GA00218549, and #GA00217803.
Findings
Complaints #GA00218564 and #GA00218549 were unsubstantiated without regulatory violations cited. Complaint #GA00217803 was substantiated but without regulatory violations cited.
Complaint Details
Complaints #GA00218564 and #GA00218549 were unsubstantiated. Complaint #GA00217803 was substantiated but no regulatory violations were cited.
Inspection Report
Routine
Census: 172
Deficiencies: 0
Oct 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Total census: 172
Inspection Report
Abbreviated Survey
Census: 168
Deficiencies: 0
Sep 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00213295.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended practices for COVID-19. The complaint was unsubstantiated with no regulatory violations cited.
Complaint Details
Complaint #GA00213295 was unsubstantiated with no regulatory violations cited.
Report Facts
Total census: 168
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 23, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00209393 and #GA00213050.
Findings
The complaints investigated were unsubstantiated and no deficiencies were identified during the survey.
Complaint Details
Complaints #GA00209393 and #GA00213050 were investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Renewal
Census: 156
Deficiencies: 1
Feb 3, 2021
Visit Reason
A licensure survey was conducted from 2/1/2021 through 2/3/2021 to assess compliance with State regulations related to the facility's nurse call system functionality.
Findings
The facility failed to ensure that all components of the nurse call system on multiple floors were fully functional, with call lights not working in numerous rooms and no effective monitoring system in place. Residents reported reliance on alternative means such as bedside bells and personal phones due to the system failures. The facility was awaiting approval for replacement of the call light system.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure that all components of the nurse call system for the 2nd, 3rd, 4th, and 5th Floors were fully functional and lacked an effective monitoring system to identify call light issues in resident rooms. |
Report Facts
Census: 156
Rooms with call light issues: 17
Work order history timeframe: 159
Vendor invoice dates: 5
Number of times Maintenance Director called vendor: 3
Date range of licensure survey: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse (RN) | Interviewed regarding call light system not working and use of bedside bells |
| CC | Licensed Practical Nurse (LPN) | Interviewed about use of silver desk bells due to call light system failure |
| Interim Administrator | Interviewed about awareness of call light system problems and approval process for replacement | |
| Director of Nursing | DON | Interviewed about discussions with Corporate Nursing Consultant and Area Vice President regarding call light system replacement |
| Maintenance Director | Interviewed multiple times regarding call light system failures and vendor contacts |
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 1
Feb 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in addition to an Abbreviated/Partial Extended Survey investigating complaints GA00211569 and GA00211592, initiated on 2021-02-01 and concluded on 2021-02-03. The complaint GA00211569 was partially substantiated and GA00211592 was unsubstantiated.
Findings
The facility failed to ensure that all components of the nurse call system on multiple floors were fully functional and lacked an effective monitoring system to identify call light issues. Multiple observations and interviews confirmed non-functional call lights, black call light monitors, and reliance on bedside bells which were often ineffective. Vendor reports indicated significant hardware failures and recommended full system replacement, which was pending approval.
Complaint Details
Complaint GA00211569 was partially substantiated; complaint GA00211592 was unsubstantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure all components of the nurse call system on the 2nd, 3rd, 4th, and 5th floors were fully functional and lack of effective monitoring system for call light issues. |
Report Facts
Census: 156
Rooms with call light issues: 16
Work order history period: 159
Vendor service dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse (RN) | Interviewed regarding call light system non-functionality |
| CC | Licensed Practical Nurse (LPN) | Interviewed about use of bedside bells due to call light system failure |
| Interim Administrator | Interviewed about call light system issues and approval process for replacement | |
| Director of Nursing (DON) | Discussed call light system replacement and Capital Expenditure Request status | |
| Maintenance Director | Provided observations and interviews regarding call light system failures and vendor communications |
Inspection Report
Routine
Census: 78
Deficiencies: 0
Jan 20, 2021
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 had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Total census: 78
Inspection Report
Routine
Census: 159
Deficiencies: 0
Dec 18, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 159
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 16, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00209057 and #GA00210283.
Findings
The complaints #GA00210283 and #GA00209057 were unsubstantiated with no regulatory violations found.
Complaint Details
Complaints #GA00210283 and #GA00209057 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 14, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00208629 and GA00208495 and included an Infection Control Focused Survey.
Findings
The complaints #GA00208629 and GA00208495 were found to be unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00208629 and GA00208495 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 18, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint numbers including #GA00203632, #GA00204217, #GA00205568, #GA00206207, #GA00206475, #GA00206661, #GA00206686, #GA00206833, and #GA00207159.
Findings
Several complaints were investigated; complaints #GA00205568, #GA00206207, #GA00206661, #GA00206833, and #GA00207159 were unsubstantiated, while complaints #GA00203632, #GA00204217, #GA00206475, and #GA00206686 were substantiated but with no deficiencies found.
Complaint Details
Complaint numbers #GA00205568, #GA00206207, #GA00206661, #GA00206833, and #GA00207159 were unsubstantiated. Complaints #GA00203632, #GA00204217, #GA00206475, and #GA00206686 were substantiated with no deficiencies.
Inspection Report
Routine
Census: 169
Deficiencies: 0
Aug 11, 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
Routine
Census: 163
Deficiencies: 0
Jun 25, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 24-25, 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: 163
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 23, 2019
Visit Reason
A complaint survey was conducted to investigate complaint #GA00201537 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited and the complaint was not substantiated.
Complaint Details
Complaint #GA00201537 was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2019
Visit Reason
A complaint survey was conducted to investigate complaint #GA00200129 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00200129 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 22, 2019
Visit Reason
A complaint survey was conducted on 8/21/19 - 8/22/19 to investigate complaints #GA00198159 and GA00198001 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted in response to complaints #GA00198159 and GA00198001; no deficiencies were found, indicating no substantiated issues.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 30, 2019
Visit Reason
A complaint survey was conducted on 5/29/19 through 5/30/19 to investigate complaints GA00196322, GA00196904, and GA00196782 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted to investigate complaints GA00196322, GA00196904, and GA00196782; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 25, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00194777 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint GA00194777 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 6, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00194165 and GA00194452 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey investigated complaints GA00194165 and GA00194452 and found no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 6, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 189
Deficiencies: 0
Dec 20, 2018
Visit Reason
A standard survey was conducted at Christian City Rehabilitation Center from December 17, 2018 to December 20, 2018. Complaint Intake Numbers GA00193496 and GA00193482 were investigated in conjunction with this standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with Healthcare Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities. Some deficiencies related to the standard survey were identified.
Complaint Details
Complaint Intake Numbers GA00193496 and GA00193482 were investigated in conjunction with this standard survey.
Inspection Report
Life Safety
Census: 189
Capacity: 200
Deficiencies: 5
Dec 17, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards for Christian City Rehabilitation Center.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with cooking facility fire protection, missing smoke detectors, incomplete sprinkler system installation and maintenance, impaired fire pump, loaded sprinkler heads, and unauthorized portable space heaters.
Severity Breakdown
D: 3
F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Hood Suppression red rubber nozzle cap cover was off, potentially allowing grease accumulation and obstructing fire extinguishing capability around the kitchen stove top. | D |
| Missing smoke detectors near doors to the dining room that should have been installed during recent renovation. | D |
| Freezer located in pantry closet was not equipped with a fire sprinkler. | F |
| Facility fire pump was impaired with a yellow tag indicating need for repairs; loaded sprinkler heads noted in laundry and service hallway. | F |
| A space heater was observed in the MDS office on the 2nd floor (Memory Care Unit) without documentation that thermostat did not exceed 212 degrees Fahrenheit. | D |
Report Facts
Residents at risk: 60
Staff at risk: 6
Staff at risk: 8
Staff at risk: 3
Residents at risk: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA 00190180 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA 00190180 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 15, 2018
Visit Reason
A revisit survey was conducted on 2/15/18 to verify correction of deficiencies cited in the 12/22/17 Standard Survey and to investigate Complaint Intake Number GA00184877.
Findings
All deficiencies cited in the prior 12/22/17 Standard Survey were found to be corrected. The complaint investigation for GA00184877 was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00184877 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 15, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00184877.
Findings
The complaint was found to be unsubstantiated during the survey.
Complaint Details
Complaint GA00184877 was investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 6, 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 deficiencies had been corrected at the time of the follow-up survey.
Inspection Report
Complaint Investigation
Census: 180
Deficiencies: 0
Feb 6, 2018
Visit Reason
An unannounced Complaint Survey was conducted to investigate complaint GA 00184469 at Christian City Rehabilitation Center.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA 00184469; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2018
Visit Reason
The inspection was conducted to investigate complaint # GA00180716.
Findings
No health deficiencies were cited during the complaint survey.
Complaint Details
Complaint # GA00180716 was investigated and found to have no health deficiencies.
Inspection Report
Routine
Census: 191
Deficiencies: 4
Dec 22, 2017
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR 483 and 488, focusing on resident care, assessments, care plans, activities, and dialysis services.
Findings
The facility was found not in substantial compliance due to deficiencies including inaccurate resident assessments, failure to revise care plans timely, inadequate activity programs meeting resident interests and needs, and failure to ensure dialysis services were provided according to professional standards.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not have a process to ensure accurate activity assessments for one resident. | Level D |
| Failed to revise activity or dialysis care plans for two residents. | Level D |
| Failed to provide an activity program designed to meet the interests and physical limitations of one resident. | Level D |
| Failed to ensure dialysis services were provided in accordance with professional standards for one resident due to lack of communication documentation. | Level D |
Report Facts
Resident census: 191
Sampled residents: 35
Dialysis communication missing days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager (UM) "A" | Interviewed regarding resident activity participation and care plan updates | |
| Life Enhancement Director (LED) | Interviewed regarding activity assessments and care plan updates | |
| Life Enhancement Aide (LEA) | Interviewed regarding activity assessments and documentation | |
| MDS Backup Nurse | Interviewed regarding care plan oversight and updates |
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 22, 2017
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations, including nursing care and recreational activities, at Christian City Rehabilitation Center.
Findings
The facility failed to ensure proper dialysis communication and services for one resident, and failed to provide an activity program meeting the interests and physical limitations of another resident. Deficiencies were noted in nursing care communication and recreational activity planning.
Deficiencies (2)
| Description |
|---|
| Failure to ensure one resident received dialysis services in accordance with professional standards due to lack of communication between the facility and dialysis center for seven dialysis service days. |
| Failure to provide an activity program designed to meet the interests and physical limitations of one resident, including lack of management of behaviors during activities and omission of vision loss considerations. |
Report Facts
Sampled residents: 35
Dialysis service days without communication: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Interviewed regarding dialysis communication book availability |
Inspection Report
Life Safety
Census: 191
Capacity: 200
Deficiencies: 2
Dec 19, 2017
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with emergency preparedness communication plan requirements and life safety code standards. Deficiencies included lack of a backup communication plan for internet and cellular outages and non-illuminated exit signs in two locations, placing residents at risk.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Emergency preparedness communication plan did not include a backup alternative plan for internet and cellular phone service disruptions. | Level D |
| Exit signs were not illuminated in the kitchen exit corridor and on the 5th floor exit corridor. | Level E |
Report Facts
Stories: 5
Census: 191
Certified beds: 200
Number of exit sign deficiencies: 2
Residents at risk: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness communication plan and exit sign deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 5, 2017
Visit Reason
An Abbreviated Survey was conducted on 6/5/17 at Christian City Rehabilitation Center to investigate complaint GA00174666.
Findings
The complaint was not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.
Complaint Details
Complaint GA00174666 was investigated and found not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 15, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00171443, GA00173074, and GA00171602.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were identified.
Complaint Details
Complaints GA00171443, GA00173074, and GA00171602 were investigated and found to be unsubstantiated without deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 25, 2017
Visit Reason
An unannounced revisit survey was conducted from January 23, 2017 through January 25, 2017, including investigation of three complaint intake numbers in conjunction with the revisit survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities. No federal deficiencies were cited.
Complaint Details
Complaint Intake Numbers GA00170168, GA00170758, and GA00170956 were investigated in conjunction with the revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 25, 2017
Visit Reason
The visit was conducted to investigate complaints #GA00170168, GA00170758, and GA00170956 and to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the abbreviated survey conducted by a Registered Nurse at Christian City Rehabilitation Center.
Complaint Details
The survey was complaint-related, investigating three complaints, but no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 3, 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 survey.
Inspection Report
Life Safety
Census: 186
Capacity: 200
Deficiencies: 1
Nov 14, 2016
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2000 Edition.
Findings
The facility was found not in substantial compliance due to patient room doors failing to close and latch properly to limit smoke passage, placing 50 residents at risk in the event of fire. This deficiency was observed in three rooms across three floors.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Patient room doors to the corridor would not close properly or completely latch to provide limited passage of smoke. | SS= D |
Report Facts
Residents at risk: 50
Census: 186
Total capacity: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of door deficiencies at time of discovery |
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