Inspection Reports for Cumming Nursing Center
2775 CASTLEBERRY ROAD, CUMMING, GA, 30041
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 7, 2021, found no deficiencies and determined the complaint investigated was unsubstantiated. Earlier inspections showed a pattern of compliance with infection control and licensure requirements, though prior Life Safety Code surveys identified issues with fire safety equipment, kitchen appliance placement, and oxygen tank storage. Deficiencies mainly involved fire safety system maintenance and proper signage or separation in hazardous areas. Complaint investigations were generally unsubstantiated, with no enforcement actions or fines listed in the available reports. The facility appears to have addressed previous deficiencies over time, showing improvement in compliance with regulatory standards.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
55 residents
Based on a December 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Date: Dec 7, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00213141.
Complaint Details
Complaint #GA00213141 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: 50
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and had fully implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 52
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess 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 §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Report Facts
Total census: 52
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 12, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00204040 and GA00205908.
Complaint Details
Complaints GA00204040 and GA00205908 were investigated and found unsubstantiated with no deficiencies cited.
Findings
Both complaints GA00204040 and GA00205908 were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
A desk review was conducted to verify that the approved Plan of Correction (POC) was completed.
Findings
All previous citations have been corrected as confirmed by the Fire Safety Supervisor during the desk review.
Inspection Report
Routine
Census: 53
Deficiencies: 0
Date: Jun 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 27, 2020
Visit Reason
The visit was conducted as a Licensure Survey to assess compliance with licensure requirements for the facility.
Findings
No licensure deficiencies were identified during the Licensure Survey.
Inspection Report
Routine
Census: 77
Deficiencies: 0
Date: Feb 27, 2020
Visit Reason
A standard survey was conducted at Cumming Nursing Center from February 24, 2020 through February 27, 2020. In addition, three complaint intake numbers were investigated in conjunction with this standard survey.
Complaint Details
Complaint Intake Numbers GA00196156, GA00196840, and GA00196850 were investigated and substantiated without deficiencies.
Findings
The complaint investigations were substantiated without deficiencies. The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Capacity: 87
Deficiencies: 3
Date: Feb 24, 2020
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 inadequate protection separation between deep fryer and open flame appliance, smoke detection devices installed too close to HVAC vents, and improper signage for oxygen tank storage.
Deficiencies (3)
Failed to provide adequate protection separation between the deep fryer and the appliance with an open burner-flame under the main kitchen commercial hood.
Failed to have smoke detection devices installed in the ceiling adequately separated from HVAC vents by 36 inches.
Failed to have proper signage indicating full or empty oxygen tanks in the oxygen tank storage area.
Report Facts
Certified beds: 87
Separation distance: 36
Separation distance: 406
Separation height: 203
Temperature limit: 246
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 17, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Cumming Nursing Center following a survey completed on 10/17/2018.
Findings
No specific deficiencies or findings are detailed in the provided document; the form appears to be a template or cover sheet for the plan of correction without substantive content.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 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 during the follow-up survey.
Inspection Report
Life Safety
Census: 74
Capacity: 87
Deficiencies: 2
Date: Sep 4, 2018
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 standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to have all cooking appliances under the fire suppression vent hood in the main kitchen and lack of fire alarm strobes in staff restrooms in the 100 hall and main kitchen area.
Deficiencies (2)
Facility failed to have all cooking appliances stationed under the fire suppression vent hood in the main kitchen.
Facility failed to have fire alarm strobes installed in staff restrooms located in 100 hall and the main kitchen area.
Report Facts
Residents and staff at risk: 20
Staff at risk: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 2, 2018
Visit Reason
A complaint survey was conducted on 4/2/18 to investigate complaint #GA00187181 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00187181 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 30, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 80
Deficiencies: 0
Date: Sep 7, 2017
Visit Reason
A standard survey was conducted at Cumming Nursing Center from September 5, 2017 to September 7, 2017 to assess compliance with Medicare/Medicaid regulations.
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.
Inspection Report
Life Safety
Census: 81
Capacity: 87
Deficiencies: 6
Date: Sep 6, 2017
Visit Reason
During a Life Safety Code Survey conducted on 09/06/2017, the facility was found not in substantial compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility failed to ensure proper installation and maintenance of fire alarm and sprinkler systems, emergency power generator installation and testing, proper use of power strips, and correct storage of oxygen tanks. These deficiencies could place residents and staff at risk in the event of fire or emergency.
Deficiencies (6)
Fire alarm circuit was not marked red and was not locked out to prevent being shut off in panel box.
No documentation available that internal inspection test of sprinkler system had been performed in the past 5 years.
No remote annunciator installed in a location readily observed by operational personnel outside of the emergency power generating room.
Emergency power generator was not properly maintained and tested; no annual load bank documentation or proper documentation for under load operation.
Unapproved multi-tap power strips/multi-plugs used in resident/patient treatment and non-treatment areas in multiple hallways.
Oxygen tanks were stored both empty and full without being separated and clearly marked in storage rooms.
Report Facts
Census: 81
Total Capacity: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
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