Inspection Reports for Douglasville Nursing and Rehabilitation Center

A Federal Comparative Complaint Survey was conducted by the Centers for Medicare & Medicaid Services on May 27-28, 2025.

The facility was found in compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities. The complaint intake number GA00254592 was unsubstantiated.

Complaint Intake Number GA00254592 was unsubstantiated.

The document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide specific findings or deficiencies.

A desk review was conducted in lieu of an on-site revisit for Douglasville Nursing and Rehabilitation on 4/29/2025 to verify correction of citations from the 3/12/2025 recertification survey.

All citations from the 3/12/2025 recertification survey have been corrected as confirmed by the desk review.

An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00254592.

The complaint was found unsubstantiated and no deficiencies were cited during the survey.

Complaint Intake Number GA00254592 was investigated and found unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00254431 and GA00254347.

Complaint GA00254431 was unsubstantiated, and complaint GA00254347 was substantiated. No deficiencies were cited related to either complaint.

Complaint GA00254431 was unsubstantiated. Complaint GA00254347 was substantiated.

A State Licensure survey was conducted at Douglasville Nursing and Rehabilitation Center from February 25, 2025, through March 12, 2025, to assess compliance with state health regulations.

The survey revealed a deficiency where the facility failed to include seizure medication in the care plan for one of nine sampled residents, resulting in the resident not receiving seizure medication for about four to seven days.

An Abbreviated Survey was conducted to investigate Complaint Number GA00253939, initiated on February 25, 2025, and concluded on March 12, 2025.

The complaint was substantiated with deficiencies cited related to failure to include seizure medication in the care plan and failure to administer ordered seizure medication to one resident (R1). The resident was without seizure medication for about seven days, which posed a risk to her health.

The complaint was substantiated. The investigation found that resident R1 did not receive seizure medication carbamazepine for seven days due to a medication order transfer failure and medication administration error. Interviews with staff, the administrator, nurse practitioner, unit manager, and complainant confirmed the medication omission and its impact.

A revisit survey was conducted to verify correction of deficiencies cited during the October 10, 2024, complaint survey.

All deficiencies cited as a result of the October 10, 2024, complaint survey were found to be corrected.

This was a follow-up to a complaint survey conducted on October 10, 2024; all cited deficiencies were corrected.

An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00252622.

The complaint was substantiated with no regulatory violations cited.

Complaint Intake Number GA00252622 was substantiated with no regulatory violations cited.

An Abbreviated/Partial Extended Survey was conducted from October 8 to October 10, 2024, investigating multiple complaint intake numbers related to Douglasville Nursing and Rehabilitation Center.

The facility was found deficient in multiple areas including failure to provide reasonable accommodation for scheduled appointments, inadequate toileting assistance and treatment of a bleeding leg, failure to thoroughly investigate sexual abuse allegations, and failure to ensure resident environment safety related to mechanical lift use.

The survey was conducted investigating multiple complaint intake numbers. Several complaints were substantiated with deficiencies related to resident care, abuse prevention, and safety. Some complaints were unsubstantiated.

An Abbreviated/Partial Extended Survey was conducted from October 8 to October 10, 2024, investigating multiple complaint intake numbers related to Douglasville Nursing and Rehabilitation Center.

The facility was found deficient in multiple areas including failure to provide reasonable accommodation for scheduled appointments, failure to provide toileting assistance and treatment for a bleeding leg, failure to thoroughly investigate allegations of sexual abuse, and failure to ensure resident environment safety related to mechanical lift use.

The survey was conducted in response to multiple complaint intake numbers. Several complaints were substantiated with deficiencies related to resident care, abuse prevention, and safety. Some complaints were unsubstantiated.

A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

A follow-up survey was conducted to verify correction of previously cited deficiencies.

The facility failed to properly maintain the fire alarm system, specifically the fire alarm breaker did not have a lock to prevent accidental cut-off, placing 150 residents and 30 staff at risk in the event of fire.

This document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center following a survey completed on March 26, 2024.

The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.

A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on February 8, 2024.

All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.

A State Licensure survey was conducted at Douglasville Nursing and Rehabilitation Center from February 6, 2024 through February 8, 2024 to assess compliance with state health regulations and identify any deficiencies.

The survey revealed multiple deficiencies including failure to maintain resident dignity by not providing dignity bags for urinary catheter drainage bags for two residents, failure to develop and implement care plans for psychotropic medication and hospice/O2 care for two residents, and environmental sanitation issues such as dirty PTAC filters, broken slats, loose call light panels, and improperly covered air vents in six resident rooms.

A standard survey was conducted from February 6 through February 8, 2024, including investigation of four complaint intake numbers which were unsubstantiated.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain resident dignity regarding urinary catheter dignity bags, failure to maintain a clean and homelike environment, failure to develop and implement comprehensive care plans for certain residents, and failure to properly deliver oxygen therapy per physician orders for multiple residents.

Complaint Intake Numbers GA00239881, GA00240064, GA00240059, and GA00241610 were investigated and found unsubstantiated.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 Edition.

The facility was found not in substantial compliance with life safety requirements, including issues with smoke barriers, means of egress obstructions, fire alarm and sprinkler system maintenance, cooking facility fire prevention, smoking regulations, and storage of hazardous materials such as oxygen cylinders.

This document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center following an inspection.

The report contains initial comments but does not specify any detailed deficiencies or findings.

A revisit survey was conducted to verify correction of deficiencies cited in the abbreviated/partial extended survey concluded on October 13, 2023.

All deficiencies cited in the prior abbreviated/partial extended survey were found to be corrected during this revisit survey.

A Licensure Survey was initiated on 9/11/2023 and concluded on 10/3/2023 to assess compliance with state regulations and standards for Douglasville Nursing and Rehabilitation Center.

The survey identified multiple deficiencies including failure to provide an adequate grievance process, medication administration issues including late and unsecured medications, infection control lapses, failure to implement care plans especially related to ADL care and bowel management, environmental sanitation problems including insufficient linens and dirty rooms, and kitchen sanitation violations.

An abbreviated/partial extended survey investigating multiple complaints was conducted to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with multiple deficiencies including failure to provide a comfortable and homelike environment, inadequate grievance process, failure to investigate abuse allegations, failure to implement care plans, failure to provide ADL care, failure to prevent accidents, medication administration issues, unsafe medication storage, food safety violations, infection control lapses, and pest control problems.

The survey was initiated based on multiple complaints alleging issues with care, environment, and infection control.

A Follow-Up Survey was conducted to verify correction of previously cited survey tags.

All previously cited survey tags were corrected except for a deficiency related to guard rails in the stairways not meeting Life Safety Code requirements, which could place 100 residents and staff at risk during evacuation.

The document is a statement of deficiencies and plan of correction for Douglasville Nursing and Rehabilitation Center following a survey completed on 09/20/2022.

The report contains initial comments but does not provide specific details about deficiencies or findings.

A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on 7/28/22.

All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.

The inspection was conducted to review the facility's Emergency Preparedness Program and to perform a Life Safety Code Survey to assess compliance with federal and state regulations.

The facility's Emergency Preparedness Program was found not in substantial compliance due to the Emergency Preparedness Plan not being available for review. Additionally, the Life Safety Code Survey identified that guard rails in the stairways did not meet Life Safety Code requirements, posing a risk to residents and staff during evacuation.

A Licensure Survey was conducted from July 25, 2022 through July 28, 2022 to assess compliance with licensure requirements and identify any deficiencies.

The survey identified multiple deficiencies including a delay in notifying the physician of a urinary tract infection culture and sensitivity results, unsanitary conditions on one nursing unit with food and debris on floors and bedside tables, and improper kitchen sanitation with wet stacked serving pans.

A standard annual survey was conducted from July 25 through July 28, 2022, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Douglasville Nursing and Rehabilitation Center.

The facility was found not in substantial compliance with multiple regulatory requirements including timely physician notification of lab results, maintaining a clean and sanitary environment, accuracy of resident assessments, respiratory care infection control, food safety, and maintenance of a safe and comfortable environment.

The inspection included investigation of complaint intake numbers GA00224305, GA00223769, GA00222909, GA00221131, GA00219242, GA00224187, GA00223229, GA00220365, GA00220374, GA00220232 in conjunction with the standard survey.

The document is a statement of deficiencies and plan of correction for Douglasville Nursing and Rehabilitation Center following a survey completed on January 21, 2022.

The report contains initial comments but does not provide detailed findings or deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited during the 11/18/2021 Complaint Survey.

All deficiencies cited as a result of the 11/18/2021 Complaint Survey were found to be corrected.

The inspection was conducted as a Licensure Survey from 11/16/2021 through 11/18/2021 to assess compliance for facility licensure renewal.

No deficiencies were identified during the licensure survey conducted from 11/16/2021 through 11/18/2021.

A COVID-19 Focused Infection Control Survey in conjunction with a Complaint Survey was conducted from November 16 through November 18, 2021, investigating multiple complaint intake numbers, including substantiated and unsubstantiated complaints.

The facility was found in compliance with infection control regulations; however, one substantiated complaint cited deficiencies related to failure to administer pain and anxiety medications to a hospice respite resident (R#2). The resident did not receive ordered medications for two days due to medication handling and inventory issues.

Complaint Intake Numbers GA00215640, GA00218200, GA00218229, GA00216768, GA00218008, GA00218682 were unsubstantiated without deficiencies. GA00216360 and GA00216276 were substantiated without deficiency. GA00217016 was substantiated with deficiencies cited related to medication administration failures for resident R#2.

This document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center following a regulatory inspection.

The report contains initial comments and a summary statement of deficiencies identified during the inspection. Specific deficiencies and severity levels are not detailed in the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey of 5/25/21.

The deficiency cited during the complaint survey was found corrected at the time of the revisit. The facility was found in Substantial Compliance as of 7/7/21.

The revisit was related to a complaint survey conducted on 5/25/21; the deficiency was corrected by the revisit date.

The inspection was conducted as a complaint survey to investigate alleged deficiencies at the facility.

No licensure deficiencies were identified during the complaint survey of 5/25/2021.

No licensure deficiencies were identified during the complaint survey.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (GA00214405, GA00214324, GA00213192, GA00212572).

Complaint GA00214405 was substantiated with deficiencies related to inaccurate medication documentation for one resident. Other complaints were unsubstantiated with no deficiencies.

Complaint GA00214405 was substantiated with deficiencies. Complaints GA00214324, GA00213192, and GA00212572 were unsubstantiated with no deficiencies.

A COVID-19 Focused Infection Control Survey and an Abbreviated/Partial Extended Survey investigating complaint #GA00212281 were conducted from February 22 to February 23, 2021.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The complaint #GA00212281 was substantiated but with no regulatory violations.

Complaint #GA00212281 was substantiated with no regulatory violations.

A COVID-19 Focused Infection Control Survey was conducted from 1/27/2021 through 1/28/2021, including investigation of Complaint Intake Number GA00210289.

The complaint was unsubstantiated with no deficiencies found. 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.

Complaint Intake Number GA00210289 was investigated and found to be unsubstantiated with no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited during the December 7, 2020 Complaint Survey.

All deficiencies cited as a result of the December 7, 2020 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on December 7, 2020; all cited deficiencies were corrected.

An Abbreviated/Partial Extended Survey and Emergency Preparedness survey were conducted in conjunction with multiple complaint investigations, including substantiated and unsubstantiated complaints.

The facility was found noncompliant with pain management requirements for one resident due to failure to document pain assessments after decreasing pain medication. Additionally, the facility failed to maintain cleanliness, sanitary conditions, and proper repairs in three of four shower rooms, including broken heaters, dirty surfaces, broken tiles, and unsecured doors.

Multiple complaint intake numbers were investigated. Complaint Intake Number GA00203706 was substantiated with deficiency related to pain management. Other complaint intake numbers were unsubstantiated without deficiencies.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices for COVID-19 preparedness and infection control.

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.

The visit was conducted to investigate multiple complaints and to complete a focused survey on infection prevention and control practices related to COVID-19 and other communicable diseases.

The complaint investigations were unsubstantiated with no regulatory violations cited. The COVID-19 focused infection control survey also found no regulatory violations.

Complaints #GA00204282, GA00206010, 204644, 203786, and 203497 were investigated and found unsubstantiated with no deficiencies cited.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00201804 and GA00201271 and to determine compliance with Federal and State Long Term Care Requirements.

Complaint GA00201804 was unsubstantiated. Complaint GA00201271 was substantiated with no citation issued.

Complaint GA00201804 was unsubstantiated. Complaint GA00201271 was substantiated with no citation issued.

A complaint survey was conducted to investigate complaints #GA00201545 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00201545 was investigated and found to have no deficiencies.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and determine compliance with Federal and State Long Term Care Requirements.

Based on the findings of the survey, no deficiencies were cited at the facility.

The survey investigated complaints GA00199113, GA00199137, GA00198824, GA00199254, GA00199262, and GA00199395.

A revisit survey to the complaint survey of 5/23/19 was conducted to verify correction of previous deficiencies.

The revisit survey revealed that all deficiencies were corrected and the facility was found in substantial compliance as of 7/7/19.

This was a follow-up to a complaint survey conducted on 5/23/19.

An abbreviated survey was conducted to investigate complaint GA00197319 from 7/2/2019 to 7/8/2019.

The complaint was substantiated but no deficiencies were identified during the survey.

The complaint was substantiated without deficiencies.

A revisit survey was conducted from March 4, 2019 through March 6, 2019 to verify correction of deficiencies cited in the December 20, 2018 Standard Survey.

All deficiencies cited in the December 20, 2018 Standard Survey were found to be corrected during this revisit survey.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

A complaint survey was conducted to investigate complaints GA00194220 and GA00194658 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

The survey was conducted in response to complaints GA00194220 and GA00194658; no deficiencies were found.

A Follow-Up Survey was conducted to verify correction of previously cited survey tags.

The facility failed to ensure safety in mechanical and laundry areas as the downstairs mechanical room door would not close to latch and lacked a door closer, potentially placing 15 staff and residents at risk in the event of fire or explosion.

A standard survey was conducted from 12/16/18 through 12/20/18, including investigation of complaint intake numbers GA00193058 and GA00193375.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide quarterly resident trust fund statements, failure to follow care plans for diabetic ulcer treatment, failure to update care plans for catheter changes, unsafe water temperatures in resident rooms, failure to remove Foley catheter when clinically warranted, failure to timely change disposable oxygen equipment, failure to monitor behaviors for residents on psychotropic medications, failure to discard expired food and sanitize thermometer between food temperature checks, failure to record medications properly, and multiple infection control deficiencies including lack of annual review, incomplete surveillance data, and improper use of PPE.

Complaint Intake Numbers GA00193058 and GA00193375 were investigated during the standard survey.

The inspection was a routine survey to assess compliance with state and federal regulations related to pharmacy management, infection control, nursing care, medical records, and physical plant standards.

The facility was found deficient in multiple areas including failure to monitor behaviors for residents on psychotropic medications, inconsistent infection control practices, failure to follow care plans for wound and catheter care, incomplete medication documentation, and unsafe hot water temperatures in resident rooms.

The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.

The facility was found not in substantial compliance with life safety requirements, including issues with self-closing doors, exit signage, fire alarm system maintenance, sprinkler system deficiencies, corridor door latching, smoke barrier penetrations, and electrical safety concerns.

An Abbreviated/Partial Extended Survey was conducted from 10/22/18 through 10/25/18 to investigate multiple complaints identified by their codes.

Complaint GA00191398 was substantiated with no deficiencies. Complaints GA00191536, GA00190966, GA00190996, GA00191076, GA00191234, and GA00191591 were not substantiated and no deficiencies were cited.

Complaint GA00191398 was substantiated with no deficiencies. Other complaints investigated were not substantiated.

A complaint survey was conducted on 7/31/2018 - 8/1/2018 to investigate complaints #GA00190075 and GA00189963.

The survey determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.

Complaints #GA00190075 and GA00189963 were investigated and found to be without deficiencies.

A complaint survey was conducted to investigate complaints #GA00189189473 and GA00189333 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

The survey was conducted in response to two complaints, and no deficiencies were found, indicating compliance.

A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 2/15/18.

All deficiencies cited as a result of the Recertification survey of 2/15/18 were found to be corrected.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected.

A complaint survey was conducted to investigate complaints (GA 00185703) by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiency was cited during the complaint survey.

Complaint investigation related to complaint GA 00185703; no deficiencies were found.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.

The facility was found not in substantial compliance with life safety requirements, including issues with smoke spread control doors, fire alarm system testing and maintenance, sprinkler system readiness, corridor door latching, smoke barrier penetrations, and smoke control devices failing to operate properly during fire alarm activation.

An unannounced survey was conducted to investigate complaint #GA00181984.

The complaint was substantiated without any deficiencies found.

Complaint #GA00181984 was investigated and substantiated without deficiencies.

A complaint was conducted at Douglasville Nursing and Rehabilitation Center from October 4, 2017 through October 6, 2017.

The complaint survey revealed that the facility was in substantial compliance and no citations were issued.

The complaint investigation found the facility to be in substantial compliance with no citations.

A follow-up visit was conducted to the recertification survey to verify that all previously identified deficiencies had been corrected.

All deficiencies identified in the prior recertification survey had been corrected at the time of this follow-up inspection.

A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

The inspection was conducted to investigate complaint #GA00176037 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Douglasville Health and Rehab.

Complaint #GA00176037 was investigated and found to have no deficiencies cited.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found not in substantial compliance with fire safety requirements, including deficiencies in fire alarm control functions, sprinkler system maintenance, portable fire extinguishers readiness, corridor door latching, smoke barrier integrity, electrical safety, and the presence of unapproved portable space heaters.

An unannounced Complaint Survey was conducted from 3/22/17 through 3/29/17 to investigate complaint #GA00172872 and facility reported complaint #GA00172885 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

The survey was conducted to investigate two complaints identified as #GA00172872 and #GA00172885. No deficiencies were found.

The inspection was conducted to investigate complaints #GA00171304 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.

No deficiencies were cited during the complaint survey conducted from 3/2/17 through 3/3/17.

Complaint #GA00171304 was investigated and found to have no deficiencies.

A revisit complaint survey was conducted from March 2, 2017 through March 3, 2017 to determine if previously cited deficiencies were corrected.

All previously cited tags had been corrected and the facility was found to be in substantial compliance as of March 3, 2017.

This was a revisit complaint survey to verify correction of prior deficiencies.

A Revisit Survey and complaint survey was conducted on March 2, 2017 through March 3, 2017 to determine if deficiencies cited during a revisit survey that was conducted on January 24, 2017 were corrected.

All previously cited tags had been corrected. The facility is in substantial compliance as of February 7, 2017.

The visit included a complaint survey component, but no further details on substantiation were provided.

A health revisit survey to an abbreviated and partial extended survey was conducted from 1/17/17 through 1/24/17, in conjunction with an abbreviated survey to investigate multiple complaints, including complaint number GA00169864 which was substantiated with Federal deficiencies.

The facility failed to provide safe and effective nursing care by not clarifying a medication dosage order for Metoprolol for one resident and failing to administer Depakote as ordered for another resident, including failure to transcribe the order on the Medication Administration Record (MAR). These deficiencies resulted in medication errors and missed doses. The facility's Quality Assurance program was also found ineffective in addressing these medication errors and transcription issues.

Complaint number GA00169864 was substantiated with Federal deficiencies related to medication errors and quality assurance failures.

An abbreviated survey was conducted from 1/17/17 through 1/24/17 to investigate multiple complaints (GA00167697, GA00168068, GA00169588, GA00169864, and GA00170608) in conjunction with a health revisit survey.

The facility was found not in substantial compliance with Medicare/Medicaid regulations related to nursing care deficiencies. Specifically, the facility failed to clarify a medication dosage order for Metoprolol for one resident and failed to transcribe and timely obtain Depakote for another resident, resulting in missed doses.

The deficiencies resulted from investigation of complaint GA00169864.