Inspection Reports for Coastal Manor
128 COASTAL MANOR DRIVE SE, LUDOWICI, GA, 31316
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 3, 2025, found no deficiencies during the revisit survey verifying correction of earlier cited issues. Prior inspections showed a pattern of deficiencies mainly related to food safety and emergency preparedness, including improper food storage, labeling, and sanitation, as well as multiple Life Safety Code violations such as obstructed exits and fire safety system maintenance. Complaint investigations were mostly unsubstantiated, except for one substantiated case in February 2025 involving failure to protect residents from abuse and related reporting deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, as indicated by the clean results in the most recent revisit survey.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
124% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
90 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Coastal Manor, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
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
Census: 90
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted on July 10, 2025.
Findings
All deficiencies cited as a result of the July 10, 2025 standard survey were found to be corrected during the revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Coastal Manor following a survey completed on July 2, 2025.
Findings
The report contains initial comments and references to deficiencies and plans of correction, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Life Safety
Capacity: 104
Deficiencies: 20
Date: May 28, 2025
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness requirements.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness, means of egress, self-closing doors, exit discharge, emergency lighting, hazardous area enclosures, cooking facilities, fire alarm system installation and maintenance, sprinkler system maintenance, smoke barrier construction, smoking regulations, portable space heaters, electrical systems, and power cord usage.
Deficiencies (20)
Emergency Preparedness Program was not in substantial compliance with 42 CFR § 483.73 due to missing components.
Exits were obstructed and inaccessible in the 600, 700, and therapy hall areas.
Self-closing doors were not operating correctly; doors in television room, activity room, and nurse administration office were propped open.
Exit discharge sidewalks from courtyards had elevation changes greater than 1/2 inch.
Emergency light in the SCU dining area was not operable.
Self-closing device on kitchen door was disabled.
Kitchen vent hood cleaning reports for the last 12 months and last 2 suppression system inspection reports were not available for review.
Fire alarm power circuit breaker was not labeled.
Fire alarm annual inspection test report was not available for review.
Fire alarm panel was showing a trouble/error condition.
Sprinkler heads were dirty with dust, paint, and sheetrock mud.
Sprinkler system inspection report was not available for review.
Five-year internal inspection report on sprinkler system was not available for review.
Backflow preventer test report was not available for review.
Fire wall penetrations were not properly sealed.
Facility smoking policy for residents and staff was not available for review.
Portable space heater was found in the medication room.
Generator test log and load bank test report were not available for review.
Battery powered emergency light for the generator was not operable.
Power strips were found on the floor in the medication room and administrator's office.
Report Facts
Certified beds: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the inspection |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: May 16, 2025
Visit Reason
A standard annual survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide written notification of hospital transfers to residents and their representatives, and multiple food safety violations in the kitchen such as improper food storage, unlabeled and undated food items, unclean equipment, and use of dented cans.
Deficiencies (2)
Failed to ensure written notification of hospital transfer was given to resident and resident representative for three residents.
Failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded.
Report Facts
Resident census: 82
Sampled residents reviewed: 27
Weight of food items: 4.54
Weight of food items: 20
Number of cardboard boxes on walk-in freezer floor: 12
Number of dented cans observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated that family is called and noted in chart but no written notice sent | |
| Social Services Coordinator | Uncertain about sending written transfer notices but sends list to ombudsman | |
| Administrator | Not aware of regulation requiring written notice of transfer | |
| Dietary Manager | Observed food storage issues and confirmed expectations for labeling and storage | |
| Registered Dietician | Confirmed food should not be stored on walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 1
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with state health and safety regulations.
Findings
The facility failed to ensure proper food storage in the walk-in freezer, including food being stored off the floor, proper labeling and dating of food, cleanliness of equipment, and proper handling of dented cans. These deficiencies had the potential to affect all 82 residents consuming food from the kitchen.
Deficiencies (1)
Food stored in the walk-in freezer was not properly stored off the floor; food was not properly labeled and dated; equipment was not properly cleaned; dented cans were not properly discarded.
Report Facts
Residents affected: 82
Number of cardboard boxes on walk-in freezer floor: 12
Weight of opened undated spicy chicken breast box: 4.54
Weight of opened undated beef patties box: 20
Weight of dented cans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed during kitchen tour and provided statements about food storage practices and deficiencies | |
| Registered Dietician | Interviewed and confirmed food should not be stored on the walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: May 16, 2025
Visit Reason
A standard annual survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide written notification of hospital transfers to residents and their representatives, and improper food storage and sanitation practices in the kitchen.
Deficiencies (2)
Failure to ensure written notification of transfer to the hospital was given or sent to the resident and resident representative for three residents.
Failure to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded.
Report Facts
Resident census: 82
Weight of food items: 4.54
Weight of food items: 20
Weight of dented cans: 6.375
Weight of dented cans: 6.625
Weight of dented cans: 6.5
Weight of dented cans: 6.75
Weight of dented cans: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated that family is called and noted in chart but no written notice sent for transfers |
| Social Services Coordinator | Social Services Coordinator | Uncertain about sending written transfer notices but sends list of transfers to ombudsman |
| Administrator | Administrator | Not aware of regulation requiring written notice of transfer; stated calls resident's representative |
| Dietary Manager | Dietary Manager | Observed food storage deficiencies and confirmed expectations for labeling and storage |
| Registered Dietician | Registered Dietician | Confirmed food should not be stored on walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 5
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with state health and safety regulations.
Findings
The facility failed to ensure proper food storage in the walk-in freezer, including food being stored off the floor, proper labeling and dating of food, cleanliness of equipment, and proper handling of dented cans. These deficiencies had the potential to affect all 82 residents consuming food from the kitchen.
Deficiencies (5)
Food stored in the walk-in freezer was improperly stored on the floor with approximately twelve large cardboard boxes covering the floor.
Opened food items in the reach-in freezer were undated and unlabeled.
Commercial can opener was observed with dirt and dried debris on the blade.
Large dry bin storage of flour had a lid that was ajar and did not fit properly to seal the container.
Multiple dented cans were found on pantry racks in the regular use section instead of the designated dented can area; one dented can was improperly placed on the floor holding a door open.
Report Facts
Weight of opened food items: 4.54
Weight of opened food items: 20
Number of cardboard boxes on walk-in freezer floor: 12
Resident census: 82
Weights of dented cans: 6.5
Weights of dented cans: 6.625
Weights of dented cans: 6.5
Weights of dented cans: 6.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed and confirmed food storage deficiencies and equipment cleanliness issues | |
| Registered Dietician | Confirmed that food should not be placed or stored on the walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: May 16, 2025
Visit Reason
A standard annual survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide written notification of hospital transfers to residents and their representatives, and improper food storage and sanitation practices in the kitchen that could affect all residents.
Deficiencies (2)
Failed to ensure written notification of transfer to hospital was given or sent to the resident and resident representative for three residents.
Failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded according to food service safety standards.
Report Facts
Resident census: 82
Number of sampled residents: 27
Number of residents with transfer notification deficiency: 3
Weight of undated food items: 4.54
Weight of undated food items: 20
Number of dented cans observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated that family is called and noted in chart but no written notification is sent for hospital transfers | |
| Social Services Coordinator | Uncertain about sending written transfer notices but sends list of transferred residents to ombudsman | |
| Administrator | Not aware of regulation requiring written notice of transfer; stated family is notified by phone | |
| Dietary Manager | Observed food storage deficiencies and confirmed expectations for labeling and storage | |
| Registered Dietician | Confirmed food should not be stored on walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 5
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with state health and safety regulations.
Findings
The facility failed to ensure proper food storage in the walk-in freezer, including food being stored off the floor, proper labeling and dating of food, cleanliness of equipment, and proper handling of dented cans. These deficiencies had the potential to affect all 82 residents consuming food from the kitchen.
Deficiencies (5)
Food stored in the walk-in freezer was not properly stored off the floor.
Food was not properly labeled and dated.
Equipment, including the commercial can opener, was not properly cleaned.
Dented cans were not properly discarded and were found in the regular use can section and on the floor holding a door open.
Flour storage container lid was ajar and did not fit properly, exposing contents to air.
Report Facts
Number of residents potentially affected: 82
Number of cardboard boxes on walk-in freezer floor: 12
Weight of undated food items: 4.54
Weight of undated food items: 20
Weights of dented cans: 6.5
Weights of dented cans: 6.625
Weights of dented cans: 6.5
Weights of dented cans: 6.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed during kitchen tour and provided statements about food storage and cleanliness | |
| Registered Dietician | Interviewed and confirmed food should not be stored on the walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 2
Date: May 16, 2025
Visit Reason
A standard annual survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide written notification of hospital transfers to residents and their representatives, and improper food storage and sanitation practices in the kitchen that could affect all residents.
Deficiencies (2)
Failed to ensure written notification of transfer to hospital was given or sent to the resident and resident representative for three residents.
Failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded.
Report Facts
Resident census: 82
Number of sampled residents reviewed: 27
Weight of opened food items: 4.54
Weight of opened food items: 20
Number of dented cans observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated that family is called and noted in chart but no written notice is sent |
| Social Services Coordinator | Social Services Coordinator | Uncertain about sending written transfer notices but sends list of transferred residents to ombudsman |
| Administrator | Administrator | Not aware of regulation requiring written notice of transfer |
| Dietary Manager | Dietary Manager | Observed food storage deficiencies and confirmed expectations for food labeling and storage |
| Registered Dietician | Registered Dietician | Confirmed food should not be stored on walk-in freezer floor |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 5
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with state health and safety regulations.
Findings
The facility failed to ensure proper food storage in the walk-in freezer, including food being stored off the floor, proper labeling and dating of food, cleanliness of equipment, and proper handling of dented cans. These deficiencies had the potential to affect all 82 residents consuming food from the kitchen.
Deficiencies (5)
Food stored in the walk-in freezer was improperly stored on the floor with approximately twelve large cardboard boxes.
Opened food items in the reach-in freezer were undated and unlabeled.
Commercial can opener had dirt and dried debris on the blade.
Large dry bin storage of flour had an improperly fitting lid that was ajar.
Multiple dented cans were found on pantry racks and one dented can was improperly placed on the floor holding a door open.
Report Facts
Resident census: 82
Weight of opened food items: 4.54
Weight of opened food items: 20
Number of cardboard boxes on walk-in freezer floor: 12
Weights of dented cans: 6.5
Weights of dented cans: 6.625
Weights of dented cans: 6.5
Weights of dented cans: 6.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed and confirmed food storage deficiencies and equipment cleanliness issues | |
| Registered Dietician | Confirmed food should not be stored on the walk-in freezer floor |
Inspection Report
Annual Inspection
Capacity: 82
Deficiencies: 5
Date: May 16, 2025
Visit Reason
A State Licensure survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with state health and safety regulations.
Findings
The facility failed to ensure proper food storage in the walk-in freezer, including food being stored off the floor, proper labeling and dating of food, cleanliness of equipment, and proper handling of dented cans. These deficiencies had the potential to affect all 82 residents consuming food from the kitchen.
Deficiencies (5)
Food stored in the walk-in freezer was improperly stored on the floor with approximately twelve large cardboard boxes.
Opened food items in the reach-in freezer were undated and unlabeled.
Commercial can opener was observed with dirt and dried debris on the blade.
Large dry bin storage of flour had a lid that was ajar and did not fit properly to seal the container.
Multiple dented cans were found on pantry racks and one dented can was improperly placed on the floor holding a door open.
Report Facts
Total residents potentially affected: 82
Weight of undated spicy chicken breast box: 4.54
Weight of undated beef patties box: 20
Number of cardboard boxes on walk-in freezer floor: 12
Weights of dented cans: 6 lb. 6.5 oz. diced tomatoes, 6 lb. 10 oz. mandarin oranges, 6 lb. 8 oz. marinara sauce, 6 lb. 12 oz. white hominy, plus one 6 lb. 8 oz. marinara sauce can on floor
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed food storage issues and confirmed shipment schedules and expectations for food storage and labeling | |
| Registered Dietician | Confirmed that food should not be placed or stored on the walk-in freezer floor |
Inspection Report
Routine
Census: 82
Deficiencies: 2
Date: May 16, 2025
Visit Reason
A standard survey was conducted at Coastal Manor from May 13, 2025, through May 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide written notification of hospital transfers to residents and their representatives, and food safety violations such as improper storage of food in the walk-in freezer, unlabeled and undated food items, unclean equipment, and improperly discarded dented cans.
Deficiencies (2)
Failed to ensure written notification of transfer to hospital was given or sent to resident and resident representative for three residents.
Failed to ensure food stored in walk-in freezer was properly stored off the floor, properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded.
Report Facts
Resident census: 82
Number of sampled residents reviewed: 27
Number of residents affected by transfer notification deficiency: 3
Weight of undated food items: 4.54
Weight of undated food items: 20
Number of dented cans observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Stated that family is called and noted in chart but no written notice sent | |
| Social Services Coordinator | Uncertain about sending written transfer notices but sends list of transferred residents to ombudsman | |
| Administrator | Not aware of regulation requiring written notice of transfer | |
| Dietary Manager | Observed food storage deficiencies and confirmed expectations for food labeling and storage | |
| Registered Dietician | Confirmed food should not be stored on walk-in freezer floor |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Coastal Manor, 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: 88
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the complaint survey conducted on 2025-02-22.
Complaint Details
The revisit survey was conducted following a complaint survey on 2025-02-22; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 2/22/2025 complaint survey were found to be corrected.
Report Facts
Census: 88
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 22, 2025
Visit Reason
A survey was conducted at Coastal Manor from February 18, 2025 to February 22, 2025 as part of the annual inspection process.
Findings
There were no deficiencies cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 22, 2025
Visit Reason
A complaint survey was conducted at Coastal Manor from February 18, 2025, through February 22, 2025, investigating multiple complaint intake numbers related to allegations of resident-to-resident abuse.
Complaint Details
Complaint Intake Numbers GA00239288, GA00239549, GA00248682, GA00249025, and GA00251893 were investigated. Four were unsubstantiated; GA00251893 was substantiated with deficiency related to resident-to-resident abuse.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to protect residents from physical abuse by another resident, failure to report and investigate allegations of abuse timely and properly, and failure to complete required PASARR screening for one resident.
Deficiencies (4)
Failure to protect residents from physical abuse perpetrated by Resident #2, including hitting, scratching, and grabbing other residents.
Failure to ensure staff reported allegations of abuse immediately to the Administrator/designee and to the state survey agency.
Failure to investigate 5 of 7 allegations of abuse perpetrated by Resident #2.
Failure to ensure a PASARR screening was completed on or before admission or after the resident remained in the facility past 30 days for Resident #2.
Report Facts
Number of sampled residents affected by abuse: 3
Number of allegations of abuse reviewed: 7
Dates of incidents: Incidents occurred on 05/28/2024, 08/08/2024, 08/16/2024, 09/22/2024, 10/09/2024, 10/16/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Interviewed regarding Resident #2 hitting Resident #11 |
| LPN #4 | Licensed Practical Nurse | Observed Resident #2 pinching another resident and interviewed about incidents |
| LPN #9 | Licensed Practical Nurse | Interviewed about Resident #2 scratching Resident #4 |
| DON | Director of Nursing | Interviewed about abuse investigations, reporting, and incidents involving Resident #2 |
| Administrator | Facility Administrator | Interviewed about abuse investigation responsibilities and reporting |
| LPN #13 | Licensed Practical Nurse | Stated incidents between Resident #2 and others would be considered abuse |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Considered Resident #2 hitting others as abuse |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
A Life Safety Code 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
Plan of Correction
Deficiencies: 0
Date: May 18, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Coastal Manor following a regulatory inspection.
Findings
The document provides a summary statement of deficiencies identified during the inspection and includes the provider's plan of correction.
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Date: May 18, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 10, 2023 Standard Survey.
Findings
All deficiencies cited in the March 10, 2023 Standard Survey were found to be corrected during this revisit survey.
Report Facts
Census: 81
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 11, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies related to the facility's emergency preparedness program.
Findings
The facility's emergency preparedness plan was found to be incomplete and not in substantial compliance with Appendix Z requirements, lacking documentation of drills beyond desktop discussions, which could place residents at risk during an emergency. However, all other previously cited deficiencies were corrected.
Deficiencies (1)
Emergency Preparedness Program did not meet the requirements of Appendix Z; plan was incomplete and missing several items, with no recorded drills other than desktop discussions.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Stated that on-site staff are trained on certain emergency requirements at the time of employment, but no drills were recorded other than desktop discussions. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 10, 2023
Visit Reason
A State Licensure survey was conducted from March 6, 2023 through March 10, 2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in medication administration with a medication error rate of 7.69%, exceeding the expected less than 5%. Additionally, the facility failed to develop and maintain comprehensive care plans and assessments related to the use of bed rails for multiple residents, including failure to assess risks, obtain consent, and complete evaluations properly.
Deficiencies (3)
The facility failed to ensure a medication error rate of less than 5%, with two medication errors out of 26 opportunities (7.69% error rate).
The facility failed to develop care plans describing the need for and use of bed rails for four of six residents reviewed.
The facility staff failed to assess risks associated with bed rail use, failed to complete bed rail assessments on admission and quarterly thereafter, failed to ensure assessments were fully completed, and failed to obtain consent from residents or representatives prior to installing bed rails for six residents.
Report Facts
Medication error rate: 7.69
Residents observed for medication administration: 6
Residents affected by medication errors: 2
Residents reviewed for care plans: 6
Residents with bed rail deficiencies: 6
Residents affected by bed rail failures: 53
Total residents with beds equipped with bed rails: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Confirmed medication error administering two acetaminophen tablets to Resident #25 |
| LPN #14 | Licensed Practical Nurse | Missed administering artificial tears to Resident #50 |
| Director of Nursing | Director of Nursing | Provided expectations on medication error rate and acknowledged deficiencies in bed rail assessments and care plans |
| RN Supervisor #5 | Registered Nurse Supervisor | Mentioned as responsible for care plans and bed rail assessments but stated not trained or instructed on bed rail assessments |
| MDS Coordinator | MDS Coordinator | Stated no care plans were developed for bed rails and care plans were primarily done by this role |
| LPN #4 | Licensed Practical Nurse | Stated not responsible for care plans and unaware of bed rail decision-making |
| Therapy Coordinator | Therapy Coordinator | Stated therapy department did not assess or recommend bed rails |
| CNA #1 | Certified Nursing Assistant | Stated bed rails used to prevent residents from rolling out of bed |
| CNA #2 | Certified Nursing Assistant | Stated bed rails used for fall prevention but unaware who initiated bed rails |
| LPN #3 | Licensed Practical Nurse | Stated no decision-making process for bed rails and bed rails not removed once placed |
| LPN #13 | Licensed Practical Nurse | Indicated bed rails used for resident positioning and safety |
| CNA #7 | Certified Nursing Assistant | Stated residents at fall risk or always falling needed bed rails |
| CNA #10 | Certified Nursing Assistant | Indicated residents needed bed rails if they leaned to one side |
| CNA #11 | Certified Nursing Assistant | Indicated knowledge of bed rail need based on resident convenience or fall risk |
Inspection Report
Routine
Census: 84
Deficiencies: 9
Date: Mar 10, 2023
Visit Reason
A standard survey was conducted from March 6, 2023 through March 10, 2023, including investigation of Complaint Intake Number GA00231792, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00231792 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop care plans for bed rail use, improper resident transfers resulting in injury, failure to assess risks and obtain consent for bed rails, medication administration errors, food safety violations, and lack of effective quality assurance related to bed rail assessments and inspections.
Deficiencies (9)
Failure to develop care plans describing the need for and use of bed rails for multiple residents.
Failure to ensure proper transfer of Resident #41, resulting in a left tibia fracture.
Failure to assess risks associated with bed rail use, complete assessments, and obtain consent for bed rails for multiple residents.
Medication error rate exceeded 5%, with two errors observed in medication administration.
Failure to store, prepare, distribute, and serve food in accordance with professional food safety standards.
Failure to develop and implement an effective plan of action to address the use of bed rails in the facility.
Failure to conduct regular inspection of bed frames, mattresses, and bed rails to ensure compatibility and identify entrapment risks.
Failure to follow infection prevention procedures during medication administration through a feeding tube.
Failure to process soiled laundry in a safe and sanitary manner and failure to wear appropriate protective equipment.
Report Facts
Medication errors: 2
Resident census: 84
Residents with bed rails: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication error for administering two acetaminophen tablets instead of one. |
| CNA #7 | Certified Nursing Assistant | Named in improper transfer of Resident #41 resulting in fracture. |
| LPN #3 | Licensed Practical Nurse | Responded during Resident #41 transfer incident. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, bed rail assessments, and quality assurance. |
| Administrator | Facility Administrator | Interviewed regarding facility expectations and quality assurance. |
| Laundry Aide #18 | Laundry Aide | Observed not wearing gown while handling soiled laundry. |
| LPN #13 | Licensed Practical Nurse | Observed improper infection control during medication administration through feeding tube. |
Inspection Report
Life Safety
Census: 84
Capacity: 104
Deficiencies: 8
Date: Mar 9, 2023
Visit Reason
The inspection was conducted to review Coastal Manor's Emergency Preparedness Program and to perform a Life Safety Code Survey to assess compliance with federal regulations and NFPA standards.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and Life Safety Code standards. Deficiencies included an incomplete emergency preparedness plan, improperly marked exit doors, hazardous areas not smoke tight, untested smoke detectors, sprinkler system installation and maintenance issues, and unsafe electrical connections.
Deficiencies (8)
Emergency Preparedness Program was incomplete and missing several required items, not in substantial compliance with 42 CFR § 483.73.
Exit doors leading to courtyard were not marked as NO EXIT.
Hazardous areas were not smoke tight; a cased opening between Financial Services office and copy room used for storage.
Janitor's closet door and kitchen dry storage doors were propped open by unapproved devices.
Required smoke detectors were not properly tested; no documentation of sensitivity testing by licensed contractor.
One of five covered alcoves outside exit doors was not sprinkler protected (covered alcove outside Coastal Cafe).
Sprinkler heads in one of two cooler/freezers were obstructed by storage boxes within 18 inches.
Electrical connections improperly made using an extension cord cut and hard wired into cooler fan motor.
Report Facts
Certified beds: 104
Census: 84
Residents at risk due to hazardous areas not smoke tight: 44
Residents at risk due to uncovered alcove: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and at time of discovery | |
| Maintenance director | Recently assigned emergency preparedness program; provided information on staff training and emergency preparedness plan |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00227903 and #GA00229320.
Complaint Details
Complaints #GA00227903 and #GA00229320 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints were found to be unsubstantiated and no regulatory violations were cited.
Inspection Report
Follow-Up
Census: 82
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
A revisit was conducted at Coastal Manor on 8/8/22 to verify correction of deficiencies cited as a result of a prior complaint survey.
Complaint Details
The revisit was conducted following a complaint survey; all cited deficiencies were corrected.
Findings
All deficiencies cited during the complaint survey were found to be corrected as of 7/24/22.
Inspection Report
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Coastal Manor, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 9, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint GA000218149.
Complaint Details
Complaint GA000218149 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated with no State deficiencies written.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jun 9, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint GA000218149. The complaint was found to be unsubstantiated, but deficiencies were cited unrelated to the complaint.
Complaint Details
Complaint GA000218149 was investigated and found to be unsubstantiated.
Findings
The facility failed to test staff for COVID-19 the required number of times per week based on CDC, CMS, and community transmission recommendations during an outbreak period from May 16, 2022 through June 9, 2022. Three staff members missed required COVID-19 tests despite the facility being in outbreak status and community transmission being high (Red level).
Deficiencies (1)
Facility failed to test staff for COVID-19 the required number of times per week during outbreak and high community transmission.
Report Facts
Staff members sampled: 8
Staff members affected: 3
COVID-19 tests missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Staff member who missed one COVID-19 test during week of 5/24/22-5/31/22 | |
| LL | Staff member who missed two COVID-19 tests during week of 6/1/22-6/8/22 | |
| OO | Staff member who missed one COVID-19 test during week of 5/24/22-5/31/22 | |
| DD | Infection Control Nurse | Confirmed high community transmission and testing requirements |
| Director of Nursing | Acknowledged outbreak status and twice weekly testing | |
| Administrator | Commented on new Infection Control Nurse and unknown reasons for missing tests |
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Date: Oct 5, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey to investigate complaint GA00217924 was initiated on October 4, 2021 and concluded on October 5, 2021.
Complaint Details
Complaint GA00217924 was substantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS and CDC recommended practices to prepare for COVID-19. The complaint GA00217924 was substantiated with no regulatory violations cited.
Report Facts
Census: 78
Inspection Report
Renewal
Census: 77
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
A Licensure Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health (DCH) at Coastal Manor from August 3, 2021 through August 6, 2021.
Findings
The facility was found to be in substantial compliance as a result of the Licensure Survey.
Inspection Report
Renewal
Census: 77
Deficiencies: 0
Date: Aug 6, 2021
Visit Reason
A Recertification Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health (DCH) at Coastal Manor from August 3, 2021 through August 6, 2021.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (CFR) Part 483.5-483.95, Subpart B Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 78
Capacity: 108
Deficiencies: 0
Date: Aug 4, 2021
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 Program was also in substantial compliance with LTC 42 CFR § 483.73.
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 0
Date: May 24, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00214618.
Complaint Details
Complaint #GA00214618 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated with no regulatory violations cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212173.
Complaint Details
Complaint #GA00212173 was investigated and found to be unsubstantiated with no deficiency cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 84
Deficiencies: 0
Date: Jan 5, 2021
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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209523.
Complaint Details
Complaint #GA00209523 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 3, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00209350.
Complaint Details
Complaint number GA00209350 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00201905.
Complaint Details
Complaint #GA00201905 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 94
Deficiencies: 0
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with emergency preparedness and infection control regulations 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, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 105
Deficiencies: 0
Date: Nov 7, 2019
Visit Reason
An unannounced, abbreviated survey visit was conducted to investigate complaints numbers GA00195772 and GA00197505.
Complaint Details
The visit was complaint-related with aspects of the complaints substantiated but no deficiencies cited.
Findings
Aspects of the complaints were substantiated; however, no deficiencies were cited during the survey.
Report Facts
Complaints investigated: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 25, 2019
Visit Reason
An unannounced visit was conducted to investigate complaint GA00195409 regarding Resident/Patient/Client Neglect.
Complaint Details
Complaint GA00195409 regarding Resident/Patient/Client Neglect was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 17, 2019
Visit Reason
A survey visit was conducted to investigate complaint #GA00194806.
Complaint Details
Complaint #GA00194806 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 22, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Date: Oct 19, 2018
Visit Reason
An abbreviated survey was conducted at Coastal Manor on October 19, 2018 to investigate complaint GA00192190.
Complaint Details
Investigation of complaint GA00192190; facility found in substantial compliance.
Findings
The facility was determined to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Re-Inspection
Census: 103
Deficiencies: 0
Date: Oct 17, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from August 27, 2018 through August 30, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 102
Deficiencies: 5
Date: Aug 30, 2018
Visit Reason
A standard survey was conducted at Coastal Manor from August 27, 2018 through August 30, 2018, including investigation of Complaints Intake Number GA00190434 which was unsubstantiated.
Complaint Details
Complaints Intake Number GA00190434 was investigated in conjunction with the standard survey and was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to submit Level II PASRR for a resident with mental illness, failure to follow nutrition care plan for a resident with significant weight loss, failure to update care plans after falls or pressure ulcers for multiple residents, failure to conduct root cause analysis for falls, and improper storage of insulin medications.
Deficiencies (5)
Failed to submit an application for Level II PASRR for a resident with mental illness and diagnoses of schizophrenia and major depressive disorder.
Failed to follow nutrition care plan to contact Registered Dietician and Physician for a resident with significant weight loss.
Failed to update care plans for four residents who experienced falls and one resident with a pressure ulcer.
Failed to conduct root cause analysis of falls and evaluate effectiveness of interventions for four residents with falls.
Failed to store insulin according to manufacturer's recommendations, storing unopened insulin in medication carts instead of refrigeration.
Report Facts
Resident census: 102
Weight loss percentage: 11.4
Weight loss percentage: 5.61
Falls goal: 250
Falls with major injury goal: 6
Fall risk assessment score: 8
Fall risk assessment score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maybel HH | LPN | Provided education on fall prevention and described fall risk interventions |
| LPN FF | MDS Staff | Described care plan update process |
| RN EE | MDS Staff | Described care plan update process |
| RN GG | MDS Staff | Described care plan update process |
| DON | Director of Nursing | Provided multiple interviews regarding care plan updates, falls root cause analysis, and nutrition care |
| RN Unit Manager | Described pharmacy policy on insulin storage | |
| Pharmacist | Described insulin storage policy and labeling | |
| Dietary Manager | Confirmed resident weight loss monitoring and dietician follow-up | |
| Social Worker | Responsible for resident admissions and PASRR documentation | |
| CNA BB | Certified Nursing Assistant | Described fall prevention practices and daily huddles |
| LPN CC | Provided wound care observation | |
| LPN DD | Provided wound care observation |
Inspection Report
Deficiencies: 1
Date: Aug 30, 2018
Visit Reason
The inspection was conducted to evaluate compliance with medical, dental, and nursing care requirements, specifically regarding adherence to a nutrition care plan for a resident with significant weight loss.
Findings
The facility failed to follow the nutrition care plan by not contacting the Registered Dietician and Physician for a resident (R#65) who experienced significant weight loss over six months. The Director of Nursing confirmed the Registered Dietician had not seen the resident in the last several months and up to 12 months.
Deficiencies (1)
Failure to follow a nutrition care plan to contact the Registered Dietician and Physician for one resident with significant weight loss.
Report Facts
Weight loss percentage: 11.4
Weight loss percentage: 5.61
Weight on 3/27/18: 114
Weight on 8/2/18: 101
Weight on 7/17/18: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed Registered Dietician had not seen the resident within the last few months and last 12 months |
Inspection Report
Life Safety
Census: 102
Capacity: 108
Deficiencies: 4
Date: Aug 27, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including sprinkler system installation and maintenance issues, corridor door latch failures, and improper outdoor oxygen cylinder storage.
Deficiencies (4)
Two pendent sprinkler heads were obstructed by surface mounted fluorescent light fixtures.
A sprinkler head in the Soiled Utility room was bent and damaged; another sprinkler head in the walk-in freezer lost the color or liquid in the glass bulb.
Three corridor separation doors to resident rooms (305, 500, 706) would not positively latch.
Outdoor oxygen cylinders were stored without protection from weather, lacking cover, shelter, or roof.
Report Facts
Residents at risk due to sprinkler obstruction: 12
Residents and staff at risk due to sprinkler maintenance issues: 6
Residents at risk due to corridor door latch failures: 25
Residents and staff at risk due to outdoor oxygen cylinder storage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during facility tour |
Inspection Report
Abbreviated Survey
Census: 105
Deficiencies: 0
Date: May 30, 2018
Visit Reason
An abbreviated survey was conducted at Coastal Manor on May 30, 2018 to investigate complaint GA00188942.
Complaint Details
Investigation of complaint GA00188942; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Date: May 25, 2018
Visit Reason
An abbreviated survey was conducted at Coastal Manor on May 25, 2018 to investigate complaint GA00188775.
Complaint Details
Investigation of complaint GA00188775; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Facility census: 106
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 29, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00184556 at Coastal Manor Health and Rehabilitation.
Complaint Details
Investigation of complaint GA00184556; no citations recommended indicating no substantiated deficiencies.
Findings
The facility was not found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities; however, no citations were recommended.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 6, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00178765.
Complaint Details
Complaint GA00178765 was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was not substantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 22, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 102
Deficiencies: 0
Date: Jul 27, 2017
Visit Reason
A standard survey was conducted at Coastal Manor from July 24, 2017 through July 27, 2017. In addition, complaints GA00177426 and GA00176936 were investigated in conjunction with this standard survey.
Complaint Details
Complaints GA00177426 and GA00176936 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R Part 483, Subpart B-Requirements for Long Term Care Facilities. The complaints investigated were found to be unsubstantiated.
Inspection Report
Life Safety
Census: 104
Capacity: 108
Deficiencies: 1
Date: Jul 24, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to ensure the automatic sprinkler system was inspected, tested, and properly maintained. Specifically, the 5-year internal inspection of the sprinkler system had not been completed since 04/25/2012, placing residents at risk in the event of a fire.
Deficiencies (1)
Failure to ensure the automatic sprinkler system was inspected, tested, and properly maintained, with the 5-year internal inspection overdue since 04/25/2012.
Report Facts
Census: 104
Certified beds: 108
Date of last 5-year internal sprinkler inspection: Apr 25, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system inspection |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 19, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00177390.
Complaint Details
Complaint GA00177390 was investigated during the survey.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 13, 2017
Visit Reason
The visit was an Abbreviated/Partial Extended Survey investigating complaints GA 00171782, GA 00165999, GA 00161168, and GA 00158043.
Complaint Details
The survey was complaint-related, investigating multiple complaints (GA 00171782, GA 00165999, GA 00161168, GA 00158043), with no health deficiencies found.
Findings
No health deficiencies were cited during the investigation of the complaints.
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