Inspection Reports for Douglasville Nursing and Rehabilitation Center
4028 HWY 5, DOUGLASVILLE, GA, 30135
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 28, 2025, found the facility in compliance with Medicare regulations and no deficiencies were cited. Earlier inspections showed a pattern of deficiencies primarily related to medication management, resident care, infection control, and environmental safety, including a substantiated complaint in March 2025 involving missed seizure medication for a resident. Complaint investigations have been mostly unsubstantiated, though some substantiated complaints involved medication documentation and care plan issues without resulting in enforcement actions or fines. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements recently, correcting prior deficiencies noted in earlier surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
12.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
205 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 205
Deficiencies: 0
Date: May 28, 2025
Visit Reason
A Federal Comparative Complaint Survey was conducted by the Centers for Medicare & Medicaid Services on May 27-28, 2025.
Complaint Details
Complaint Intake Number GA00254592 was unsubstantiated.
Findings
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.
Inspection Report
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
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.
Findings
All citations from the 3/12/2025 recertification survey have been corrected as confirmed by the desk review.
Report Facts
Previous survey date: Mar 12, 2025
Inspection Report
Abbreviated Survey
Census: 209
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00254592.
Complaint Details
Complaint Intake Number GA00254592 was investigated and found unsubstantiated.
Findings
The complaint was found unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 220
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00254431 and GA00254347.
Complaint Details
Complaint GA00254431 was unsubstantiated. Complaint GA00254347 was substantiated.
Findings
Complaint GA00254431 was unsubstantiated, and complaint GA00254347 was substantiated. No deficiencies were cited related to either complaint.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to include seizure medication in the care plan for one resident, leading to a gap in medication administration.
Report Facts
Sampled residents: 9
Days without medication: 4
Days without medication: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding resident R1 being without seizure medication for about four days | |
| Nurse Practitioner (NP) AA | Interviewed and revealed that carbamazepine had not been given for seven days to resident R1 |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Date: Mar 12, 2025
Visit Reason
An Abbreviated Survey was conducted to investigate Complaint Number GA00253939, initiated on February 25, 2025, and concluded on March 12, 2025.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to include seizure medication in the care plan for one of nine sampled residents (R1), risking that R1 might not receive treatment according to needs.
Facility failed to transfer a medication order and failed to give the medication as ordered for one resident (R1), causing R1 not to receive ordered seizure medication.
Report Facts
Census: 81
Days medication not given: 7
Medication dosage: 10
Lab test result: 4.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Nurse Practitioner | Interviewed regarding medication omission and resident condition. |
| NN | Licensed Practical Nurse | Employee who removed medication from MAR by mistake, discussed in employee counseling. |
| BB | Unit Manager | Interviewed about medication omission and communication with complainant. |
Inspection Report
Re-Inspection
Census: 227
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 10, 2024, complaint survey.
Complaint Details
This was a follow-up to a complaint survey conducted on October 10, 2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the October 10, 2024, complaint survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 226
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00252622.
Complaint Details
Complaint Intake Number GA00252622 was substantiated with no regulatory violations cited.
Findings
The complaint was substantiated with no regulatory violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 10, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to provide services with reasonable accommodation of needs for one resident related to scheduled appointments due to transportation wheelchair issues.
Failed to provide toileting assistance and assessment and treatment of a bleeding right leg to one resident.
Failed to ensure that an allegation of sexual abuse was thoroughly investigated to rule out abuse for two residents.
Failed to ensure the resident environment remained free of accident hazards related to mechanical lift use and supervision for one resident.
Report Facts
Sampled residents: 28
Sampled residents: 3
Sampled residents: 4
BIMS score: 15
BIMS score: 15
BIMS score: 99
BIMS score: 15
Date of incident: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Named in toileting assistance and bleeding leg deficiency; denied allegations of abuse. |
| CNA HH | Certified Nursing Assistant | Named in toileting assistance deficiency; responsible for bedside commode cleaning. |
| Director of Nursing Services | Director of Nursing | Interviewed regarding facility policies and deficiencies. |
| Executive Director | Executive Director | Interviewed and involved in suspension of LPN EE pending investigation. |
| Vice President of Operations | Vice President of Operations | Interviewed regarding reporting of abuse allegations. |
| Social Worker | Social Worker | Interviewed regarding sexual abuse investigation. |
| LPN MM | Licensed Practical Nurse | Interviewed about resident aggression awareness. |
| LPN II | Licensed Practical Nurse | Interviewed about resident aggression awareness. |
| CNA JJ | Certified Nursing Assistant | Named in mechanical lift incident involving resident R16. |
| LPN PP | Licensed Practical Nurse | Named in mechanical lift incident involving resident R16. |
| LPN RR | Licensed Practical Nurse | Interviewed regarding mechanical lift incident involving resident R16. |
| Director of Rehab | Director of Rehabilitation | Interviewed regarding mechanical lift use and safety. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 10, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to provide services with reasonable accommodation of needs for one resident related to scheduled appointments due to transportation wheelchair issues.
Failed to provide toileting assistance and assessment and treatment of a bleeding right leg to one resident, including failure to clean bedside commode and respond to call lights.
Failed to ensure that an allegation of sexual abuse was thoroughly investigated to rule out abuse for two residents.
Failed to ensure resident environment remained free of accident hazards related to mechanical lift use, including transferring a resident alone with the lift causing injury.
Report Facts
Complaint Intake Numbers: 20
Sampled residents: 28
Residents involved in deficiencies: 4
BIMS score: 15
BIMS score: 99
Date of incident: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Transportation Staff | Newly assigned transportation staff involved in missed appointment due to wheelchair issue |
| DD | Licensed Practical Nurse (LPN) | Observed unclean bedside commode and involved in care of resident R7 |
| HH | Certified Nursing Assistant (CNA) | Assigned to clean bedside commode and assist resident R7 with toileting |
| AA | Licensed Practical Nurse (LPN) | Observed bedside commode condition for resident R7 |
| APRN | Advanced Registered Nurse Practitioner | Notified of resident R7's bleeding leg and abuse allegation |
| Executive Director | Informed of abuse allegation and suspended LPN EE pending investigation | |
| VP Operations | Vice President of Operations | Spoke to APRN and reported abuse allegation to State |
| DON | Director of Nursing | Provided facility investigations, interviewed regarding sexual abuse allegations and mechanical lift practices |
| JJ | Certified Nursing Assistant (CNA) | Involved in resident R16 transfer incident causing injury |
| PP | Licensed Practical Nurse (LPN) | On standby during resident R16 transfer incident |
| RR | Licensed Practical Nurse (LPN) | Provided clarification on standby role during resident R16 transfer |
| DOR | Director of Rehab | Explained mechanical lift safety requirements |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 21, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Follow-Up
Census: 150
Deficiencies: 1
Date: Apr 1, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
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.
Deficiencies (1)
Fire alarm breaker did not have a lock to prevent accidental cut-off.
Report Facts
Residents at risk: 150
Staff at risk: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
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.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 206
Deficiencies: 0
Date: Mar 26, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on February 8, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 141
Capacity: 141
Deficiencies: 3
Date: Feb 8, 2024
Visit Reason
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.
Findings
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.
Deficiencies (3)
Failure to maintain dignity by not providing urinary catheter dignity bags for two residents, resulting in visible catheter bags.
Failure to develop and implement care plans for psychotropic medication and hospice/O2 care for two residents.
Failure to maintain a clean, comfortable, homelike environment due to dirty PTAC filters, broken slats, loose call light panels, and oversized ceiling light fixtures covering return air vents in six resident rooms.
Report Facts
Number of residents sampled: 45
Number of occupied resident rooms: 141
Number of rooms with environmental deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Confirmed that resident R654 should have a dignity bag to cover his indwelling urinary catheter bag to protect privacy |
| Unit Manager | Stated respect includes ensuring indwelling urinary catheter bags are properly covered with dignity bags | |
| Maintenance Director | Confirmed observations of environmental deficiencies and described corrective actions planned | |
| MDS Coordinator | Acknowledged no care plans were developed for psychotropic medication for R82 and hospice/O2 care for R126 | |
| MDS Director | Acknowledged no care plans were developed for psychotropic medication for R82 and hospice/O2 care for R126 |
Inspection Report
Complaint Investigation
Census: 202
Deficiencies: 4
Date: Feb 8, 2024
Visit Reason
A standard survey was conducted from February 6 through February 8, 2024, including investigation of four complaint intake numbers which were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00239881, GA00240064, GA00240059, and GA00241610 were investigated and found unsubstantiated.
Findings
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.
Deficiencies (4)
Failure to maintain dignity by ensuring urinary catheter dignity bags were provided for two of 45 sampled residents.
Failure to maintain a clean, comfortable, homelike environment evidenced by dirty PTAC filters, broken slats, loose call light panels, and oversized ceiling light fixtures covering return air vents in six of 141 occupied resident rooms.
Failure to develop and implement a care plan for two of 45 residents, specifically for psychotropic medication and hospice care/oxygen use.
Failure to deliver oxygen per physician orders for seven of 36 sampled residents, including incorrect flow rates, lack of humidification when required, and failure to maintain clean oxygen concentrators.
Report Facts
Resident census: 202
Sampled residents for catheter dignity bag deficiency: 45
Occupied resident rooms inspected for environment issues: 141
Sampled residents for oxygen therapy deficiency: 36
Oxygen flow rate deviations: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Confirmed catheter dignity bag deficiency and oxygen therapy issues |
| BB | Licensed Practical Nurse (LPN) | Verified oxygen flow rate discrepancy for resident R37 |
| AA | Licensed Practical Nurse (LPN) | Confirmed oxygen concentrator flow rate for resident R9 |
| HH | Licensed Practical Nurse (LPN) | Verified oxygen flowmeter setting for resident R647 |
Inspection Report
Life Safety
Census: 202
Capacity: 246
Deficiencies: 14
Date: Feb 6, 2024
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 Edition.
Findings
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.
Deficiencies (14)
Failed to repair drywall involving smoke wall at pulmonary building supply room.
Failed to maintain clear corridor for emergency egress; corridor partially blocked with chairs, wheelchairs, and portable bed.
Failed to protect hazardous areas in ground floor supply room and pulmonary building storage room; missing self-closing devices and openings allowing smoke passage.
Failed to properly maintain cooking facility fire prevention systems; Type K extinguisher improperly used, inspection tag expired, grease filters not fitting properly, missing cleaning records.
Failed to properly maintain fire alarm system; trouble alarm activated and breaker lacked lock to prevent accidental cut-off.
Failed to properly maintain sprinkler system; yellow tag due to 2 bad sprinkler heads not replaced, missing connection cap on FDC.
Failed to fill penetrations in fire barrier allowing potential smoke migration.
Failed to properly maintain smoke barrier doors; doors near room 328 and entrance to suites failed to close properly.
Failed to properly follow smoking regulations; cigarette butts mixed with regular trash and scattered in smoking area.
Failed to provide curtains/draperies with fire retardant tags indicating compliance with NFPA 701.
Failed to provide proper size containers for soiled linen and trash; numerous receptacles exceeded 32 gallon limit.
Construction repair in janitor closet of Pulmonary Building with drywall and ceiling tiles removed; means of egress not inspected daily.
Failed to properly maintain emergency generator; warning lights indicated low coolant.
Failed to properly store oxygen cylinders; cylinders stored indoors without signage indicating full or empty, and outside cylinders unsecured.
Report Facts
Census: 202
Total Capacity: 246
Residents at risk: 20
Employees at risk: 5
Residents at risk: 25
Staff at risk: 5
Residents at risk: 50
Staff at risk: 20
Residents at risk: 150
Staff at risk: 30
Residents at risk: 30
Staff at risk: 10
Residents at risk: 100
Staff at risk: 20
Residents at risk: 20
Staff at risk: 2
Residents at risk: 30
Staff at risk: 5
Residents at risk: 10
Staff at risk: 3
Residents at risk: 30
Staff at risk: 5
Residents at risk: 10
Staff at risk: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple deficiencies during facility tour on 2/6/2024 |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center following an inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 206
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the abbreviated/partial extended survey concluded on October 13, 2023.
Findings
All deficiencies cited in the prior abbreviated/partial extended survey were found to be corrected during this revisit survey.
Report Facts
Census: 206
Inspection Report
Annual Inspection
Census: 199
Deficiencies: 6
Date: Oct 3, 2023
Visit Reason
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.
Findings
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.
Deficiencies (6)
Failed to provide residents with a grievance process that provided solutions for grievances filed for three residents.
Failed to ensure timely administration of medications for two residents and secure medication carts.
Failed to follow infection control procedures on multiple units including lack of PPE, improper signage, unlocked soiled utility rooms, and improper biohazard waste handling.
Failed to implement care plans for ADL assistance, including scheduled showers/baths, incontinence care, nail care, and bowel management for multiple residents.
Failed to provide a comfortable and homelike atmosphere due to inadequate supply of linens, dirty rooms, pest infestations, soiled privacy curtains, and urine odors.
Failed to ensure opened food items were securely wrapped, labeled, and dated; failed to discard expired food; failed to store food properly; and failed to maintain sanitary kitchen equipment.
Report Facts
Sample residents: 56
Falls: 229
Residents with major injury falls: 18
Census: 199
Medication administration delay: 6.5
Medication administration delay: 3
Linen counts: 14
Linen counts: 9
Linen counts: 7
Linen counts: 4
Linen counts: 5
Linen counts: 16
Linen counts: 10
Linen counts: 1
Linen counts: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DDD | Director of Social Services | Discussed grievance process and follow-up responsibilities |
| ZZ | Social Worker | Handled grievances and follow-up, instructed not to provide grievance copies |
| EEE | Unit Manager | Involved in grievance follow-up |
| GGG | Former Administrator | Spoke with family about missing glasses grievance |
| UUU | Licensed Practical Nurse | Administered medications late, failed to sign out fentanyl patch |
| JJJJJ | Director of Nursing | Confirmed medication administration issues and expectations |
| PPP | Physician | Stated orders should be carried out as prescribed |
| LLLLL | Licensed Practical Nurse | Reported medication availability issues with agency staff |
| FF | Respiratory Therapist | Confirmed medication cart was unlocked and contained prescription medication |
| JJ | Licensed Practical Nurse | Confirmed medication cart should be locked |
| GG | Infection Preventionist | Responsible for infection control signage and PPE supplies |
| HH | Licensed Practical Nurse | Confirmed infection control signage and PPE issues |
| BBB | Housekeeper Supervisor | Confirmed soiled utility rooms should be locked |
| MMM | Certified Nursing Assistant | Described linen laundering process and challenges |
| MM | Dining Services Supervisor | Discussed kitchen sanitation and equipment issues |
Inspection Report
Abbreviated Survey
Census: 199
Deficiencies: 13
Date: Oct 3, 2023
Visit Reason
An abbreviated/partial extended survey investigating multiple complaints was conducted to assess compliance with Medicare/Medicaid regulations.
Complaint Details
The survey was initiated based on multiple complaints alleging issues with care, environment, and infection control.
Findings
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.
Deficiencies (13)
Failure to provide adequate supply of linens, dirty rooms, used pest traps, trash on floors, soiled privacy curtains, and urine odors on multiple units.
Failure to provide residents with a grievance process that provided solutions for grievances filed.
Failure to fully investigate an allegation of sexual abuse for one resident.
Failure to implement care plans for two residents resulting in actual harm including a fracture from a fall.
Failure to provide scheduled showers/baths, incontinence care, and nail care to seven residents.
Failure to ensure residents were free from accidents related to fall risk and neuro checks, and failure to store chemicals safely.
Failure to provide safe and sanitary tracheostomy care for three residents.
Failure to administer medications timely for two residents.
Failure to ensure medication carts were secured and inaccessible to residents.
Failure to ensure opened food items were securely wrapped, labeled, and dated; failure to discard expired food; failure to store food properly; and failure to maintain sanitary kitchen equipment.
Failure to follow infection control processes and procedures to prevent spread of infections and contamination on multiple units.
Failure to maintain a safe, functional, sanitary, and comfortable environment on multiple units including dirty floors, soiled privacy curtains, missing closet doors, malodorous rooms, pest infestations, broken equipment, and unclean shower rooms.
Failure to maintain an effective pest control program with presence of gnats, flies, and roaches in resident rooms and common areas.
Report Facts
Resident Census: 199
Falls: 229
Falls with major injuries: 18
Medication administration times missed: 10
Days without bowel movement: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA RRR | Certified Nursing Assistant | Named in fall incident causing fracture to resident R19 |
| Director of Nursing JJJJJ | Director of Nursing | Provided statements on medication administration and infection control |
| RT MMMMM | Respiratory Therapist | Observed performing tracheostomy care with improper sterile technique |
| LPN DD | Licensed Practical Nurse | Involved in tracheostomy speaking valve incident with resident R15 |
| Infection Preventionist GG | Infection Preventionist | Provided statements on infection control signage and procedures |
| Maintenance and Housekeeping Supervisor HHH | Supervisor | Provided statements on pest control and facility cleanliness |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
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.
Deficiencies (1)
Guard Rails in the Stairways failed to meet Life Safety Code requirements; openings between the rails exceed the allowable 4-inch sphere.
Report Facts
Residents and staff at risk: 100
Allowable opening size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings related to stairway guard rails during the survey. |
Inspection Report
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
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.
Findings
The report contains initial comments but does not provide specific details about deficiencies or findings.
Inspection Report
Re-Inspection
Census: 213
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on 7/28/22.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 220
Capacity: 246
Deficiencies: 2
Date: Aug 25, 2022
Visit Reason
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.
Findings
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.
Deficiencies (2)
Emergency Preparedness Plan was not available for review during the inspection.
Guard rails in the stairways had openings exceeding the allowable 4-inch sphere, failing to meet Life Safety Code requirements.
Report Facts
Census: 220
Total Capacity: 246
Inspection Date: Aug 25, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to Emergency Preparedness Plan and stairway guard rails |
Inspection Report
Renewal
Deficiencies: 3
Date: Jul 28, 2022
Visit Reason
A Licensure Survey was conducted from July 25, 2022 through July 28, 2022 to assess compliance with licensure requirements and identify any deficiencies.
Findings
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.
Deficiencies (3)
Failure to notify the physician/nurse practitioner timely of culture and sensitivity results for a urinary tract infection requiring treatment for one resident.
Facility failed to provide a clean and sanitary environment on one nursing unit with food, trash, dirt, and debris on floors and bedside tables not cleaned for multiple days.
Facility failed to ensure the kitchen was maintained in a sanitary manner; clean serving pans were stacked wet.
Report Facts
Number of sampled residents: 35
Dates of survey: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Interviewed regarding laboratory result notification process |
| Nurse Practitioner | NP | Interviewed regarding notification and antibiotic order for UTI |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for notification of lab results |
| Housekeeper 2 | Housekeeper | Interviewed about cleaning practices on Magnolia Terrace unit |
| Unit Manager 1 | Unit Manager | Interviewed about CNA responsibilities for cleaning bedside tables |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning priorities and staffing |
| CNA 2 | Certified Nursing Assistant | Interviewed about wiping bedside tables after meals |
| CNA 3 | Certified Nursing Assistant | Interviewed about bedside table cleaning on Room 232 |
| Dietary Aide 1 | Dietary Aide | Interviewed about dishwashing and stacking clean pans |
| Dietary Manager | Dietary Manager | Interviewed about dishwashing and stacking clean pans |
Inspection Report
Annual Inspection
Census: 211
Deficiencies: 6
Date: Jul 28, 2022
Visit Reason
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.
Complaint Details
The inspection included investigation of complaint intake numbers GA00224305, GA00223769, GA00222909, GA00221131, GA00219242, GA00224187, GA00223229, GA00220365, GA00220374, GA00220232 in conjunction with the standard survey.
Findings
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.
Deficiencies (6)
Failure to notify physician timely of culture and sensitivity results for a urinary tract infection, resulting in delayed antibiotic treatment for one resident.
Failure to maintain a clean and sanitary environment on one nursing unit with food, trash, and debris found on floors and bedside tables over multiple days.
Failure to ensure accuracy of Minimum Data Set assessments for two residents, including incorrect catheter status and failure to interview resident for preferences.
Failure to maintain appropriate infection control for respiratory equipment, including use of oxygen nasal cannula tubing dated over 2 months old for three residents.
Failure to ensure kitchen food service safety; clean serving pans were stacked wet.
Failure to maintain safe, functional, sanitary, and comfortable environment; multiple resident bathrooms had discolored floor and ceiling tiles, exposed rusty toilet bowl screws, and other maintenance issues.
Report Facts
Resident census: 211
Sampled residents: 35
Oxygen nasal cannula tubing date: May 25, 2022
Length of exposed toilet screws: 2
Inspection Report
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
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.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 215
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 11/18/2021 Complaint Survey.
Findings
All deficiencies cited as a result of the 11/18/2021 Complaint Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 0
Date: Nov 18, 2021
Visit Reason
The inspection was conducted as a Licensure Survey from 11/16/2021 through 11/18/2021 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey conducted from 11/16/2021 through 11/18/2021.
Inspection Report
Complaint Investigation
Census: 207
Deficiencies: 1
Date: Nov 18, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide quality care by not administering pain and anxiety medications to resident R#2 as ordered.
Report Facts
Resident census: 207
Medication quantities: 14
Medication quantities: 22
Medication quantities: 300
Medication quantities: 10
Medication quantities: 30
Medication quantities: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Documented awaiting resident's medications on 8/20/2021 |
| LPN II | Licensed Practical Nurse | Reported to Director of Nursing that Hospice agency could not provide medications on weekend |
| CNA FF | Certified Nursing Assistant | Completed resident's inventory sheet and reported resident refusal to inventory belongings |
| SW EE | Social Worker | Notified nursing supervisor and CNA about medications in resident's bag |
| LPN CC | Licensed Practical Nurse | Described admission and medication handling process |
| LPN JJ | Licensed Practical Nurse | Described medication ordering and inventory process |
| Director of Nursing Services | Director of Nursing | Provided expectations on inventory and documentation procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Douglasville Nursing and Rehabilitation Center following a regulatory inspection.
Findings
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 14, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey of 5/25/21.
Complaint Details
The revisit was related to a complaint survey conducted on 5/25/21; the deficiency was corrected by the revisit date.
Findings
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.
Report Facts
Survey dates: May 25, 2021
Survey dates: Jul 14, 2021
Compliance date: Jul 7, 2021
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 25, 2021
Visit Reason
The inspection was conducted as a complaint survey to investigate alleged deficiencies at the facility.
Complaint Details
No licensure deficiencies were identified during the complaint survey.
Findings
No licensure deficiencies were identified during the complaint survey of 5/25/2021.
Inspection Report
Abbreviated Survey
Census: 203
Deficiencies: 1
Date: May 25, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (GA00214405, GA00214324, GA00213192, GA00212572).
Complaint Details
Complaint GA00214405 was substantiated with deficiencies. Complaints GA00214324, GA00213192, and GA00212572 were unsubstantiated with no deficiencies.
Findings
Complaint GA00214405 was substantiated with deficiencies related to inaccurate medication documentation for one resident. Other complaints were unsubstantiated with no deficiencies.
Deficiencies (1)
Failure to ensure two nurses accurately documented medications given for one resident, including missing signatures and incorrect recording of insulin dosage.
Report Facts
Facility census: 203
Medication administration dates missing signatures: 2
Blood glucose reading: 400
Insulin units given: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse | Interviewed regarding medication administration and documentation errors |
| NN | Licensed Practical Nurse | Interviewed and revealed she forgot to sign out medications for resident on 03/10/2021 and 03/11/2021 |
| Director of Nursing | Interviewed regarding resident's blood glucose and medication documentation |
Inspection Report
Abbreviated Survey
Census: 200
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
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.
Complaint Details
Complaint #GA00212281 was substantiated with no regulatory violations.
Findings
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.
Inspection Report
Complaint Investigation
Census: 218
Deficiencies: 0
Date: Jan 27, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 1/27/2021 through 1/28/2021, including investigation of Complaint Intake Number GA00210289.
Complaint Details
Complaint Intake Number GA00210289 was investigated and found to be unsubstantiated with no deficiencies.
Findings
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.
Report Facts
Total census: 218
Inspection Report
Re-Inspection
Census: 218
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the December 7, 2020 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on December 7, 2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the December 7, 2020 Complaint Survey were found to be corrected.
Report Facts
Total census: 218
Inspection Report
Complaint Investigation
Census: 211
Deficiencies: 2
Date: Dec 3, 2020
Visit Reason
An Abbreviated/Partial Extended Survey and Emergency Preparedness survey were conducted in conjunction with multiple complaint investigations, including substantiated and unsubstantiated complaints.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to document pain assessments for each dose of Oxycodone-Acetaminophen as needed for one resident after medication decrease.
Failure to maintain safe, functional, sanitary, and comfortable environment in shower rooms including broken heaters, dirty floors and equipment, broken tiles, and unsecured doors.
Report Facts
Total census: 211
Pain level: 8
Pain medication doses: 2
Pain medication doses: 6
Medication tablets dispensed: 180
Medication tablets remaining: 68
Temperature: 66.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Medication nurse who administered pain medication and interviewed regarding pain management for Resident #9 |
| DON | Director of Nursing | Interviewed about pain documentation and in-service conducted |
| Administrator | Facility Administrator | Interviewed about pharmacy labels and facility spa conditions |
| NP | Nurse Practitioner | Interviewed regarding Resident #9's pain medication and behavior |
| Medical Director | Medical Director | Interviewed regarding Resident #9's pain complaints and medication |
| LPN HH | Unit Manager Licensed Practical Nurse | Accompanied surveyor during spa/shower room observations on first floor |
| LPN AA | Licensed Practical Nurse | Interviewed about shower area conditions on her hall |
| Infection Control Nurse | Infection Control Nurse | Interviewed about responsibility for inspecting facility spas |
| Assistant Executive Director | Assistant Executive Director | Measured temperature in spa room and confirmed heater was out of order |
Inspection Report
Routine
Census: 193
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Census: 186
Deficiencies: 0
Date: Jun 26, 2020
Visit Reason
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.
Complaint Details
Complaints #GA00204282, GA00206010, 204644, 203786, and 203497 were investigated and found unsubstantiated with no deficiencies cited.
Findings
The complaint investigations were unsubstantiated with no regulatory violations cited. The COVID-19 focused infection control survey also found no regulatory violations.
Report Facts
Total census: 186
Inspection Report
Routine
Census: 186
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
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).
Findings
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.
Report Facts
Census: 186
Inspection Report
Abbreviated Survey
Census: 213
Deficiencies: 0
Date: Jan 6, 2020
Visit Reason
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 Details
Complaint GA00201804 was unsubstantiated. Complaint GA00201271 was substantiated with no citation issued.
Findings
Complaint GA00201804 was unsubstantiated. Complaint GA00201271 was substantiated with no citation issued.
Report Facts
Resident census: 213
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
A complaint survey was conducted to investigate complaints #GA00201545 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00201545 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Census: 221
Deficiencies: 0
Date: Sep 16, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey investigated complaints GA00199113, GA00199137, GA00198824, GA00199254, GA00199262, and GA00199395.
Findings
Based on the findings of the survey, no deficiencies were cited at the facility.
Report Facts
Resident Census: 221
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 30, 2019
Visit Reason
A revisit survey to the complaint survey of 5/23/19 was conducted to verify correction of previous deficiencies.
Complaint Details
This was a follow-up to a complaint survey conducted on 5/23/19.
Findings
The revisit survey revealed that all deficiencies were corrected and the facility was found in substantial compliance as of 7/7/19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 8, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00197319 from 7/2/2019 to 7/8/2019.
Complaint Details
The complaint was substantiated without deficiencies.
Findings
The complaint was substantiated but no deficiencies were identified during the survey.
Inspection Report
Re-Inspection
Census: 220
Deficiencies: 0
Date: Mar 6, 2019
Visit Reason
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.
Findings
All deficiencies cited in the December 20, 2018 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2019
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 survey tags have been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 13, 2019
Visit Reason
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.
Complaint Details
The survey was conducted in response to complaints GA00194220 and GA00194658; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 5, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
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.
Deficiencies (1)
Downstairs Mechanical room door would not close to latch and did not have a door closer attached to this rated door.
Report Facts
Staff and residents at risk: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding mechanical room door during follow-up survey |
Inspection Report
Routine
Census: 220
Deficiencies: 10
Date: Jan 11, 2019
Visit Reason
A standard survey was conducted from 12/16/18 through 12/20/18, including investigation of complaint intake numbers GA00193058 and GA00193375.
Complaint Details
Complaint Intake Numbers GA00193058 and GA00193375 were investigated during the standard survey.
Findings
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.
Deficiencies (10)
Failed to provide quarterly resident trust fund account statements for three residents.
Failed to follow care plan for diabetic ulcer treatment; dressing not changed as ordered.
Failed to update care plan to reflect change from Foley catheter to suprapubic catheter for one resident.
Failed to maintain safe water temperatures in resident rooms; temperatures up to 146°F observed.
Failed to remove Foley catheter when clinically warranted for one resident.
Failed to change disposable oxygen equipment weekly for one resident.
Failed to monitor behaviors for two residents receiving psychotropic medications; incomplete behavior documentation.
Failed to discard expired food items and sanitize thermometer between food temperature checks.
Failed to record medication administration in both electronic MAR and departmental notes for one resident.
Failed to provide evidence of infection control surveillance data for May 2018, failed to analyze April 2018 data, failed to conduct annual IPCP review, failed to don appropriate PPE, and failed to perform hand hygiene during medication administration.
Report Facts
Resident census: 220
Expired food items: 4
Water temperatures: 146
Behavior documentation: 5
Behavior documentation: 21
Behavior documentation: 4
Behavior documentation: 3
Behavior documentation: 5
Behavior documentation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Unit Manager | Named in diabetic ulcer dressing change deficiency and Foley catheter removal deficiency |
| MM | Licensed Practical Nurse | Named in diabetic ulcer dressing change deficiency |
| AA | Licensed Practical Nurse | Named in care plan update deficiency |
| YY | Respiratory Therapist | Named in oxygen equipment change deficiency |
| OO | Registered Nurse | Named in psychotropic medication monitoring deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including psychotropic medication monitoring and infection control |
| TT | Certified Nursing Assistant | Named in infection control PPE deficiency |
| GG | Certified Nursing Assistant | Named in infection control PPE deficiency |
| UU | Licensed Practical Nurse | Named in infection control PPE deficiency |
| NN | Cook | Named in food safety thermometer sanitation deficiency |
| DM | Dietary Manager | Named in food safety expired food and thermometer sanitation deficiency |
Inspection Report
Routine
Census: 220
Deficiencies: 5
Date: Jan 11, 2019
Visit Reason
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.
Findings
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.
Deficiencies (5)
Failure to monitor behaviors for two residents receiving psychotropic medications as per facility policy.
Failure to provide evidence of infection control surveillance data collection and analysis, failure to don appropriate PPE, and failure to follow hand hygiene protocols.
Failure to follow care plan for diabetic ulcer treatment, failure to update care plan for catheter change, and failure to remove Foley catheter when clinically warranted.
Failure to ensure medications were recorded both in the electronic MAR and departmental notes.
Failure to maintain safe hot water temperatures in resident rooms, with temperatures exceeding safe limits up to 146 degrees Fahrenheit.
Report Facts
Facility census: 220
Sample size: 87
Hot water temperature: 146
Hot water temperature: 80
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | Registered Nurse | Interviewed regarding resident behavior monitoring and documentation |
| CNA PP | Certified Nursing Assistant | Interviewed regarding resident behaviors |
| DON | Director of Nursing | Interviewed regarding behavior monitoring, infection control, and medication administration policies |
| LPN KK | Licensed Practical Nurse | Interviewed regarding wound care dressing dates |
| Unit Manager FF | Unit Manager | Interviewed regarding wound care and catheter removal orders |
| LPN MM | Licensed Practical Nurse | Interviewed regarding wound care dressing changes |
| LPN AA | Licensed Practical Nurse | Interviewed regarding care plan updates for catheter change |
| CNA TT | Certified Nursing Assistant | Observed and interviewed regarding failure to use PPE |
| CNA GG | Certified Nursing Assistant | Interviewed regarding failure to use PPE |
| LPN UU | Licensed Practical Nurse | Observed during medication pass with improper hand hygiene |
| LPN VV | Licensed Practical Nurse | Observed during medication pass with improper hand hygiene |
| Maintenance Assistant XX | Maintenance Assistant | Conducted water temperature measurements |
| Maintenance Director | Maintenance Director | Interviewed regarding water temperature monitoring and adjustments |
| Administrator | Facility Administrator | Interviewed regarding water temperature issues and corrective actions |
Inspection Report
Life Safety
Census: 216
Capacity: 246
Deficiencies: 7
Date: Dec 18, 2018
Visit Reason
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.
Findings
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.
Deficiencies (7)
Downstairs Mechanical room door would not close to latch and did not have a door closer attached.
Exit signage at the main entrance/exit near the lobby/nurses station was inoperable and an adjacent sign was flashing as if about to fail.
Fire alarm remote panel near nurses station showed Trouble & Supervisory warning lights with no details available.
Loaded and corroded sprinklers identified in entrance lobby, kitchen, and staff development center; sprinkler data not on data plate in riser room.
Hallway/corridor door to Resident room #236 would not close to latch to resist passage of smoke.
Large 2"x2" penetration not resealed in smoke/fire wall above doors near business office.
Several Multi-Outlet Power Sources (MOPS) discovered throughout facility posing electrical shock risk.
Report Facts
Staff & residents at risk: 15
Residents at risk: 90
Residents at risk: 216
Licensed beds: 246
Staff & residents at risk: 50
Staff & residents at risk: 35
Staff & residents at risk: 64
Staff & residents at risk: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 25, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 10/22/18 through 10/25/18 to investigate multiple complaints identified by their codes.
Complaint Details
Complaint GA00191398 was substantiated with no deficiencies. Other complaints investigated were not substantiated.
Findings
Complaint GA00191398 was substantiated with no deficiencies. Complaints GA00191536, GA00190966, GA00190996, GA00191076, GA00191234, and GA00191591 were not substantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2018
Visit Reason
A complaint survey was conducted on 7/31/2018 - 8/1/2018 to investigate complaints #GA00190075 and GA00189963.
Complaint Details
Complaints #GA00190075 and GA00189963 were investigated and found to be without deficiencies.
Findings
The survey determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2018
Visit Reason
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.
Complaint Details
The survey was conducted in response to two complaints, and no deficiencies were found, indicating compliance.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 29, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 2/15/18.
Findings
All deficiencies cited as a result of the Recertification survey of 2/15/18 were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 26, 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 survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 26, 2018
Visit Reason
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.
Complaint Details
Complaint investigation related to complaint GA 00185703; no deficiencies were found.
Findings
No deficiency was cited during the complaint survey.
Inspection Report
Life Safety
Census: 226
Capacity: 246
Deficiencies: 6
Date: Feb 12, 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 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.
Deficiencies (6)
Smoke spread control door was propped open with containers, compromising smoke containment.
Failure to maintain regular smoke sensitivity tests and records for the fire alarm system.
Fire sprinkler in laundry was found loaded, potentially delaying activation.
Door to resident room #233 would not close to latch properly, risking smoke spread.
Fire and smoke wall penetrations found above drop ceilings near nurses stations, compromising smoke barriers.
Smoke barrier doors near D.O.N. office did not close properly during fire alarm activation.
Report Facts
Census: 226
Total Capacity: 246
Staff and residents at risk: 60
Staff at risk: 30
Staff at risk: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 25, 2017
Visit Reason
An unannounced survey was conducted to investigate complaint #GA00181984.
Complaint Details
Complaint #GA00181984 was investigated and substantiated without deficiencies.
Findings
The complaint was substantiated without any deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 7, 2017
Visit Reason
A complaint was conducted at Douglasville Nursing and Rehabilitation Center from October 4, 2017 through October 6, 2017.
Complaint Details
The complaint investigation found the facility to be in substantial compliance with no citations.
Findings
The complaint survey revealed that the facility was in substantial compliance and no citations were issued.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 11, 2017
Visit Reason
A follow-up visit was conducted to the recertification survey to verify that all previously identified deficiencies had been corrected.
Findings
All deficiencies identified in the prior recertification survey had been corrected at the time of this follow-up inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 3, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 13, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176037 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00176037 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey at Douglasville Health and Rehab.
Inspection Report
Life Safety
Census: 229
Capacity: 246
Deficiencies: 7
Date: May 16, 2017
Visit Reason
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.
Findings
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.
Deficiencies (7)
Fire alarm system failed to keep the fire alarm system in peak condition; horn/strobe alarm unit in lower Dining area not engaging and smoke detector in room #316 unresponsive.
Fire sprinkler system deficiencies including loaded sprinkler heads, missing sprinkler escutcheon plates, and failure to maintain 5-year inspection standards.
Portable fire extinguisher found on the floor in the Kitchen, not in readiness position.
Resident corridor doors failed to latch properly at rooms #28 and #236, compromising smoke passage resistance.
Penetrations through fire or smoke rated wall assemblies above doors near rooms #21, #330, and #40 were not sealed to limit smoke passage.
Electrical safety deficiencies including a voided circuit in the Kitchen electrical panel box and unsecured multi-outlet power strips on the floor in office areas.
Unapproved portable space heater found under receptionist's desk without labeling or documentation verifying safe temperature limits.
Report Facts
Residents at risk due to fire alarm deficiency: 80
Residents at risk due to sprinkler system deficiency: 229
Residents at risk due to fire extinguisher deficiency: 35
Residents at risk due to corridor door deficiency: 80
Residents at risk due to smoke barrier deficiency: 120
Residents at risk due to electrical deficiencies: 60
Staff at risk due to electrical deficiencies: 8
Residents at risk due to portable space heater: 10
Staff at risk due to portable space heater: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 24, 2017
Visit Reason
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.
Complaint Details
The survey was conducted to investigate two complaints identified as #GA00172872 and #GA00172885. No deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00171304 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00171304 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 3/2/17 through 3/3/17.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
A revisit complaint survey was conducted from March 2, 2017 through March 3, 2017 to determine if previously cited deficiencies were corrected.
Complaint Details
This was a revisit complaint survey to verify correction of prior deficiencies.
Findings
All previously cited tags had been corrected and the facility was found to be in substantial compliance as of March 3, 2017.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 3, 2017
Visit Reason
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.
Complaint Details
The visit included a complaint survey component, but no further details on substantiation were provided.
Findings
All previously cited tags had been corrected. The facility is in substantial compliance as of February 7, 2017.
Inspection Report
Complaint Investigation
Census: 222
Deficiencies: 3
Date: Jan 24, 2017
Visit Reason
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.
Complaint Details
Complaint number GA00169864 was substantiated with Federal deficiencies related to medication errors and quality assurance failures.
Findings
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.
Deficiencies (3)
Failure to clarify the dosage order for Metoprolol resulting in administration of incorrect dose for resident #57.
Failure to administer Depakote as ordered and failure to transcribe the order on the MAR for resident #53, resulting in missed doses and hospitalization.
Failure to maintain an effective Quality Assurance program to analyze and correct medication errors including transcription errors.
Report Facts
Facility census: 222
Sample size: 43
Missed doses of Depakote: 10
Days Metoprolol 25mg administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Administered incorrect Metoprolol dose and failed to clarify physician order for resident #57 |
| LPN BB | Licensed Practical Nurse | Acknowledged responsibility for checking medications and clarifying orders |
| LPN EE | Licensed Practical Nurse | Failed to transcribe Depakote order on MAR for resident #53 and notified pharmacy of medication delay |
| LPN GG | Licensed Practical Nurse | Verified missing transcription of Depakote order on MAR for resident #53 |
| Director of Nurses (DON) | Director of Nursing | Acknowledged failures in medication verification and QA processes |
| Administrator | Facility Administrator | Reported lack of specific training on medication transcription and clarification |
| Medical Director | Facility Medical Director | Reported transcription concerns were not routinely discussed during QA meetings |
Inspection Report
Complaint Investigation
Census: 222
Deficiencies: 2
Date: Jan 24, 2017
Visit Reason
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.
Complaint Details
The deficiencies resulted from investigation of complaint GA00169864.
Findings
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.
Deficiencies (2)
Failed to clarify an order for the dosage of Metoprolol for Resident #57, resulting in administration of incorrect dosage for five days.
Failed to transcribe an order for Depakote to the Medication Administration Record and obtain the medication timely for Resident #53, resulting in missed doses.
Report Facts
Facility census: 222
Sample size: 17
Missed doses: 10
Missed doses: 5
Metoprolol doses administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Administered incorrect Metoprolol dose and failed to clarify the order | |
| Licensed Practical Nurse (LPN) EE | Observed medication pass and verified missed Depakote doses | |
| Director of Nurses (DON) | Acknowledged failure to clarify medication orders and verify medications on admission | |
| Licensed Practical Nurse (LPN) BB | Acknowledged responsibility for checking medications on admission | |
| Licensed Practical Nurse (LPN) GG | Missed transcribing Depakote order on MAR after hospital readmission | |
| Licensed Practical Nurse (LPN) Unit Manager FF | Stated nurse should call pharmacy and physician if ordered medication is not available |
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