Inspection Reports for Eagle Health & Rehabilitation
405 S COLLEGE ST, STATESBORO, GA, 30458
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 10, 2025, found no deficiencies, with all previously cited issues corrected during follow-up and revisit surveys. Earlier inspections showed a pattern of deficiencies primarily related to resident care, including diet consistency and protection from abuse, as well as fire safety and food sanitation concerns. A substantiated complaint investigation in April 2025 identified failures to protect residents from sexual abuse and to report allegations timely, but these issues were corrected by subsequent revisits. Most complaints were unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent surveys confirming correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
39 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 10, 2025
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 of the follow-up survey date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 10, 2025
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 of the follow-up survey conducted on June 10, 2025.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a facility inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted on May 10, 2025, to verify correction of deficiencies cited during the April 6, 2025, complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 6, 2025, with all cited deficiencies corrected by the revisit.
Findings
All deficiencies cited as a result of the April 6, 2025, complaint survey were found to be corrected.
Report Facts
Census: 39
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted on May 10, 2025, to verify correction of deficiencies cited during the April 6, 2025, complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 6, 2025; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 6, 2025, complaint survey were found to be corrected.
Report Facts
Census: 39
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 25, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during the revisit survey.
Report Facts
Deficiencies cited: 0
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 10, 2025
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 of the follow-up survey date.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 10, 2025
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 of the follow-up survey date.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the visible content.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the visible content.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details of deficiencies or findings.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 6, 2025 complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 6, 2025. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 6, 2025 complaint survey were found to be corrected.
Report Facts
Census: 39
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted on May 10, 2025, to verify correction of deficiencies cited during the April 6, 2025, complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 6, 2025, with all cited deficiencies corrected by the revisit.
Findings
All deficiencies cited as a result of the April 6, 2025, complaint survey were found to be corrected.
Report Facts
Census: 39
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 25, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 10, 2025
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 of the follow-up survey date.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Eagle Health & Rehabilitation following a survey completed on June 10, 2025.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the visible content.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 25, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 25, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: May 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 25, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: May 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 6, 2025, complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 6, 2025. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 6, 2025, complaint survey were found to be corrected.
Inspection Report
Life Safety
Census: 40
Capacity: 99
Deficiencies: 4
Date: Apr 30, 2025
Visit Reason
The 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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, with deficiencies including non-functioning emergency lights, ceiling penetrations allowing smoke migration, sprinkler heads obstructed by storage, and unsealed fire wall penetrations.
Deficiencies (4)
Emergency light in the kitchen area was not working when tested.
Sprinkler head was dropped and cover plate allowed smoke migration.
Storage boxes were stored too high within 18 inches of sprinkler heads in the front hallway medical records storage.
Fire wall in the front hallway had cables coming through with no approved fire caulking sealing the hole.
Report Facts
Smoke compartments affected: 1
Certified beds: 99
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the tour and at time of discovery. |
Inspection Report
Routine
Census: 41
Deficiencies: 2
Date: Apr 25, 2025
Visit Reason
A standard survey was conducted by Ascellon Corporation on behalf of the Georgia Department of Community Health at Eagle Health & Rehabilitation Center from April 22, 2025, through April 25, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to deficiencies including failure to ensure pureed diets met prescribed consistency for residents requiring mechanically altered diets, and failure to provide proper positioning and responsibility for plate guards used as adaptive equipment for a resident.
Deficiencies (2)
Facility failed to ensure pureed diet consistency met individual resident needs for two residents requiring pureed diets; food was not smooth and contained lumps, stringy meat, and skins.
Facility failed to provide special eating equipment and utensils properly, specifically failed to identify correct position and responsible party for plate guard placement for one resident.
Report Facts
Census: 41
Dates of meal menu review: Lunch menu reviewed for 4/22/2025 through 4/24/2025
Resident admission dates: R4 admitted 3/28/2022; R20 admitted 5/24/2024; R6 admitted 6/16/2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Certified Medication Aide (CMA) | Fed resident R4 and described food consistency issues |
| AA | Registered Nurse, MDS Coordinator | Assisted resident R4 and provided observations on pureed diet |
| BB | Certified Nurse Aide (CNA) | Assisted resident R20 and R6, described plate guard use and diet consistency |
| EE | Registered Dietitian (RD) | Discussed IDDSI standards and pureed diet consistency |
| FF | Dietary Manager (DM) | Discussed preparation of pureed food and consistency issues |
| CC | Director of Rehabilitation/Physical Therapist Assistant (DOR/PTA) | Discussed plate guard use, positioning, and responsibility |
| DD | Director of Nursing (DON) | Discussed responsibility and documentation of plate guard use |
| GG | Nursing Home Administrator (NHA) | Provided plan of care documentation and discussed policy absence |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 25, 2025
Visit Reason
A State Licensure survey was conducted by Ascellon Corporation on behalf of the Georgia Department of Community Health at Eagle Health & Rehabilitation Center from April 22, 2025, through April 25, 2025, to assess compliance with state health regulations.
Findings
The facility failed to ensure that two residents requiring a pureed diet received food prepared with the appropriate consistency. Observations and interviews revealed that the pureed food served was not smooth and contained lumps, stringy meat, and vegetable skins, which did not meet the International Dysphagia Diet Standardization Initiative (IDDSI) Level 4 Pureed diet standards.
Deficiencies (1)
The facility failed to ensure that the consistency of the pureed diet was appropriate to meet the needs of two residents requiring a pureed diet, with food containing lumps, stringy meat, and vegetable skins.
Report Facts
Residents requiring pureed diet: 6
Dates of survey: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Certified Medication Aide (CMA) | Fed resident R4 and described the food consistency issues during observation and interview. |
| AA | Registered Nurse, MDS Coordinator (RN/MDS) | Assisted resident R4 and commented on the food consistency during observation and interview. |
| BB | Certified Nursing Assistant (CNA) | Assisted resident R20 and described food consistency issues during observation and interview. |
| EE | Registered Dietitian (RD) | Discussed adherence to IDDSI standards and spoon test; did not provide a copy of the policy when requested. |
| AA | Registered Nurse, MDS Coordinator (RN/MDS) | Reported on dining room nursing coverage and food consistency observations. |
| GG | Nursing Home Administrator (NHA) | Stated the facility did not have a policy for mechanically altered food and relied on IDDSI standards. |
| FF | Dietary Manager (DM) | Acknowledged initial food consistency issues and importance of proper food texture for resident safety. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 6, 2025
Visit Reason
A complaint survey was conducted at Eagle Health & Rehabilitation from April 3, 2025 through April 6, 2025, investigating multiple complaint intake numbers related to allegations of sexual abuse and inappropriate sexual behaviors by a resident toward other residents.
Complaint Details
The complaint investigation involved three complaint intake numbers (GA000246359, GA000253512, GA000253880). Two were substantiated with deficiencies related to sexual abuse and failure to report. The investigation included multiple resident interviews, staff interviews, and review of facility policies and records. The facility was found noncompliant with 42 CFR Part 483, Subpart B.
Findings
The facility failed to protect residents from sexual abuse by another resident and failed to report allegations of sexual abuse to the state survey agency within the required two-hour timeframe. Deficiencies included failure to develop or implement interventions to protect residents, failure to administer prescribed medication consistently, and failure to timely report abuse allegations.
Deficiencies (2)
Facility failed to protect residents' right to be free from sexual abuse by another resident, including failure to develop or implement interventions to address inappropriate sexual behaviors.
Facility failed to ensure allegations of sexual abuse were reported to the state survey agency no later than two hours after the allegations were made.
Report Facts
Complaint Intake Numbers Investigated: 3
Behavior episodes documented: 8
Medication dosage: 5
Medication dosage: 150
Incident report dates: 3
Timeframe for reporting abuse: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Documented observation of resident masturbating and notified Administrator |
| SC 5 | Scheduling Coordinator | Witnessed inappropriate sexual behavior and reported to charge nurse |
| LPN 13 | Licensed Practical Nurse | Interviewed resident regarding abuse allegation and documented statement |
| LPN 14 | Licensed Practical Nurse | Observed inappropriate touching and reported to DON and physician |
| Administrator | Facility Administrator | Received reports of incidents, responsible for reporting to state survey agency |
| DON | Director of Nursing | Received reports of incidents and coordinated investigation and interventions |
| HNSNS | Healthcare Navigator for Skilled Nursing Services | Reported resident distress and abuse allegations to nursing staff and Administrator |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 6, 2025
Visit Reason
A State Licensure survey was conducted at Eagle Health & Rehabilitation from April 3, 2025, through April 6, 2025, to assess compliance with state health regulations.
Findings
The survey revealed no State Health deficiencies were cited during the inspection period.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 7, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00234954 and #GA00235069.
Complaint Details
The survey was complaint-related, investigating two complaints which were unsubstantiated with no deficiencies cited.
Findings
The complaints were found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 5, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Eagle Health & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 0
Date: Apr 26, 2023
Visit Reason
A revisit survey was conducted on April 25-26, 2023 to verify correction of deficiencies cited during the March 1, 2023 Recertification survey conducted in conjunction with a Complaint Survey.
Complaint Details
The revisit survey was conducted following a Complaint Survey; deficiencies from that survey were corrected.
Findings
All deficiencies cited in the March 1, 2023 Recertification and Complaint Survey were found to be corrected during this revisit survey.
Report Facts
Census: 37
Inspection Report
Life Safety
Census: 38
Capacity: 99
Deficiencies: 1
Date: Mar 2, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to properly maintain the sprinkler system, including sprinkler pipes supporting items in the attic and sprinkler heads being corroded or painted, affecting one smoke compartment.
Deficiencies (1)
Sprinkler pipes are supporting items in attic; sprinkler heads are corroded or painted.
Report Facts
Census: 38
Total Capacity: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of sprinkler system deficiencies during facility tour |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Mar 1, 2023
Visit Reason
A State Licensure survey was conducted at Eagle Health and Rehabilitation from February 27, 2023 through March 1, 2023 to assess compliance with state health regulations.
Findings
The facility was found deficient in providing adequate nursing care related to activities of daily living, specifically failure to maintain grooming for one resident and failure to apply barrier cream after incontinence episodes for two residents. Additionally, the facility failed to document meal temperatures consistently and failed to remove dented cans from dry storage, posing potential food safety risks.
Deficiencies (3)
Failure to ensure activities of daily living care were provided to maintain good grooming related to facial hair for 1 of 3 residents reviewed.
Failure to follow residents' individualized care plans directing staff to apply barrier cream after incontinence episodes for 2 of 3 residents.
Failure to store and prepare food in accordance with professional standards, including failure to document meal temperatures and failure to remove dented cans from dry storage.
Report Facts
Deficiency count: 3
Residents reviewed for ADL care: 3
Residents with grooming deficiency: 1
Residents with barrier cream deficiency: 2
Residents receiving meals: 37
Total residents: 39
Days with missing or incomplete meal temperature documentation: 40
Dented cans observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding shaving and barrier cream application deficiencies |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Acknowledged shaving residents and reported refusals without documentation |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Responsible for shaving residents and observed resident needing shave |
| Director of Nursing | Director of Nursing | Provided expectations for care refusals and barrier cream application |
| Administrator | Administrator | Provided expectations for ADL care and food safety policies |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed about meal temperature logs and food safety |
| Dietary Cook #8 | Dietary Cook | Interviewed about food temperature documentation and dented cans |
| Clinical Care Coordinator | Clinical Care Coordinator | Observed wound care and barrier cream application |
Inspection Report
Routine
Census: 39
Deficiencies: 7
Date: Mar 1, 2023
Visit Reason
A standard survey was conducted from February 27, 2023 through March 1, 2023, including investigation of Complaint Intake Number GA000227390, which was found unsubstantiated.
Complaint Details
Complaint Intake Number GA000227390 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate PASARR screenings, failure to follow individualized care plans for skin care, inadequate grooming care, improper incontinent care, failure to discontinue unnecessary medications, untimely laboratory testing, and food safety violations related to meal temperature documentation and storage of dented cans.
Deficiencies (7)
Failed to ensure Level 1 PASARRs were accurate for 2 of 3 residents, risking inadequate specialized services.
Failed to follow care plans directing application of barrier cream after incontinence episodes for 2 of 3 residents.
Failed to ensure activities of daily living care were provided to maintain good grooming related to facial hair for 1 of 3 residents.
Failed to provide proper incontinent care by not thoroughly removing urine from skin for 2 of 3 residents.
Failed to discontinue buspirone medication as ordered for 1 of 5 residents.
Failed to ensure laboratory testing was performed timely and as ordered for 1 of 5 residents.
Failed to document meal temperatures consistently and failed to remove dented cans from dry storage, risking food safety for 37 of 39 residents.
Report Facts
Resident census: 39
Days with missing meal temperature documentation: 40
Buspirone dose: 10
BIMS score: 7
BIMS score: 12
Iron level: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #2 | CNA | Acknowledged failure to apply barrier cream after incontinence care for Resident #24. |
| Certified Nursing Assistant #3 | CNA | Observed Resident #22 needing shaving and acknowledged shaving should be done daily. |
| Certified Nursing Assistant #6 | CNA and scheduler | Reported Resident #22 refused shaving but did not document refusals. |
| Licensed Practical Nurse #1 | LPN | Stated expectation for staff to follow care plans including application of barrier cream. |
| Clinical Care Coordinator | CCC | Observed failure to apply barrier cream and clean urine from Resident #31. |
| Director of Nursing | DON | Stated expectations for following care plans, discontinuing medications per physician orders, and food safety standards. |
| Pharmacy Consultant | Noted failure to discontinue buspirone and overdue laboratory tests for Resident #35. | |
| Dietary Cook #8 | Dietary Cook | Acknowledged importance of documenting meal temperatures and removing dented cans. |
| Certified Dietary Manager | CDM | Reported dented cans should be removed and meal temperatures documented. |
| Administrator | Stated expectations for compliance with physician orders, care plans, and food safety procedures. |
Inspection Report
Deficiencies: 0
Date: Oct 12, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 0
Date: Oct 12, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/18/2021 Recertification Survey.
Findings
All deficiencies cited as a result of the 8/18/2021 Recertification Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 39
Deficiencies: 0
Date: Sep 17, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey investigating complaint #GA00217459 was conducted from September 15 to September 17, 2021.
Complaint Details
Complaint #GA00217459 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Census: 39
Inspection Report
Renewal
Capacity: 33
Deficiencies: 2
Date: Aug 18, 2021
Visit Reason
A Licensure Survey was conducted from 8/15/21 through 8/18/21 to assess compliance with licensure requirements for Eagle Health & Rehabilitation.
Findings
The facility failed to maintain a clean environment in six shared resident bathrooms with dirt and grime buildup, and failed to ensure hot water temperatures did not exceed 110 degrees Fahrenheit in 16 residents' bathrooms and one shower room sink.
Deficiencies (2)
Facility failed to maintain a clean environment related to dirt buildup in six shared resident bathrooms (A14, A18, A19, A20, A30, and A34) of 33 rooms.
Facility failed to assure that hot water temperatures were less than 110 degrees Fahrenheit in 16 residents' bathrooms and one shower room sink.
Report Facts
Total licensed capacity: 33
Number of bathrooms with dirt buildup: 6
Number of bathrooms with hot water temperature issues: 16
Number of residents able to independently access hot water: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed environmental concerns and housekeeping oversight; verified no injuries from hot water temperatures | |
| Maintenance Supervisor | Conducted hot water temperature testing and environmental tour; provided temperature logs |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
Date: Aug 18, 2021
Visit Reason
A standard survey was conducted from 8/15/21 through 8/18/21, including investigation of Complaint Intake Number GA00215879, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00215879 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to ensure a resident's right to maintain personal property during a move, failure to maintain a clean environment in shared bathrooms, and failure to develop a care plan addressing behavioral needs of a resident who removes clothing.
Deficiencies (3)
Failure to ensure the right of one resident to maintain personal property during a room move.
Failure to maintain a safe, clean, comfortable, and homelike environment due to dirt buildup in six shared resident bathrooms.
Failure to develop and implement a comprehensive care plan addressing behavioral needs of one resident who removes clothing.
Report Facts
Resident census: 40
Sample size: 22
Number of shared bathrooms with dirt buildup: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding resident move and belongings. | |
| Administrator | Interviewed regarding resident belongings and environmental concerns. | |
| AA | Licensed Practical Nurse (LPN) | Interviewed about resident behavioral needs and care. |
| CC | Certified Nursing Assistant (CNA) | Interviewed about resident behavioral needs and care. |
| BB | Training Nursing Assistant (TNA) | Interviewed about resident behavioral needs and care. |
| Maintenance Supervisor | Interviewed regarding environmental concerns. |
Inspection Report
Life Safety
Census: 44
Capacity: 99
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Eagle Health & Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during an abbreviated/partial extended survey on May 4, 2021.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Date: May 4, 2021
Visit Reason
A Licensure Survey was conducted to assess compliance with physical plant standards and food safety regulations as part of the facility's licensure renewal process.
Findings
The facility failed to maintain a clean and sanitary kitchen environment, with issues including improper food storage, expired food items, dirty refrigerator vents, pest infestation (roach presence), and unclean kitchen floors and equipment. These conditions had the potential to affect 34 of 41 residents receiving an oral diet.
Deficiencies (1)
Food items were prepared in an unsanitary environment with dirt, debris, and pests present; food was improperly stored leading to contamination risks; refrigerator vents were dirty; food items were not properly labeled or dated; expired food items were not discarded.
Report Facts
Residents potentially affected: 34
Total residents: 41
Date of expired hamburger meat: Apr 22, 2021
Expiration date of hamburger meat: Apr 28, 2021
Date of open tuna package: Apr 21, 2021
Discard date of tuna package: May 1, 2021
Date of bread packages: Apr 19, 2021
Expiration date of bread packages: Apr 29, 2021
Date of open bag of French fries: Feb 8, 2021
Time of observations: 1047
Time of observations: 1048
Time of observations: 1049
Time of observations: 1052
Time of observations: 1053
Time of observations: 1055
Time of observations: 1123
Time of observations: 1127
Time of observations: 1136
Time of interview: 1203
Time of interview: 1205
Time of interview: 1207
Time of interview: 1224
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed observations of unsanitary conditions, roach infestation, and improper food storage | |
| Dietary Aide AA | Confirmed roach problem and cleaning training including mopping and fan vent cleaning | |
| Dietary Aide BB | Dietary Aide/Cook | Observed prepping food on preparation table and confirmed roach problem and cleaning training |
| Administrator | Provided expectations for kitchen cleanliness and awareness of roach problem and pest control services |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: May 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00213846, which was substantiated with deficiencies.
Complaint Details
Complaint #GA00213846 was substantiated with deficiencies related to food safety and sanitation in the kitchen.
Findings
The facility failed to ensure food was prepared, stored, and served in a sanitary environment, with issues including unsealed food items, dirty refrigerator vents, expired food not discarded, and pest infestation evidenced by roaches and debris in the kitchen area.
Deficiencies (1)
Food items were prepared in an unsanitary environment with dirt, debris, pests, and improper food storage and labeling.
Report Facts
Resident census: 41
Expired food items: 5
Expired food items: 4
Expired food items: 1
Expired food items: 1
Packages of bread: 5
Open food seasoning containers: 4
Roaches observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA AA | Dietary Aide | Observed dead and crawling roaches in kitchen; confirmed training on cleaning and food safety |
| DA BB | Dietary Aide/Cook | Observed using preparation table; confirmed training on cleaning and food safety; reported roach problem |
| Dietary Manager | Dietary Manager (DM) | Confirmed unsanitary conditions, roach infestation, and food safety violations; aware of ongoing pest control efforts |
| Administrator | Facility Administrator | Interviewed regarding kitchen cleanliness and pest control; unaware of kitchen tile conditions |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 7, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00213176.
Complaint Details
Complaint #GA00213176 was substantiated with no deficiencies cited.
Findings
The complaint #GA00213176 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209349.
Complaint Details
Complaint #GA00209349 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 21, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208833.
Complaint Details
Complaint #GA00208833 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 50
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Report Facts
Total census: 50
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
The visit was conducted as an abbreviated/partial extended survey investigating multiple complaints (GA00204429, GA00204819, GA00204769, and GA00206253) at Eagle Health and Rehabilitation.
Complaint Details
The investigation was initiated by desk review of complaints GA00204429, GA00204819, and GA00204769 conducted from 5/11/2020 through 5/14/2020. The on-site abbreviated survey conducted on 7/1/2020 to 7/2/2020 found the complaints unsubstantiated with no deficiencies.
Findings
The complaints investigated during the abbreviated survey were unsubstantiated, and no deficiencies were found. No abuse, neglect, or immediate jeopardy concerns were noted.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00201665 from February 12 to February 13, 2020.
Complaint Details
Complaint GA00201665 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Follow-Up
Census: 62
Deficiencies: 0
Date: Oct 10, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/19/19 complaint survey.
Findings
All deficiencies cited as a result of the 8/19/19 complaint survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Date: Aug 19, 2019
Visit Reason
A complaint investigation was conducted from August 5, 2019 through August 19, 2019 at Eagle Health and Rehabilitation to investigate allegations of psychological abuse by a Respiratory Therapist (RT) Manager towards a resident.
Complaint Details
The complaint investigation was substantiated for deficiencies related to psychological abuse allegations by resident #1 against RT Manager AA. The facility did not report the allegation to the State Survey Agency within two hours as required and did not suspend the employee or conduct a thorough investigation including interviews and written statements from involved parties.
Findings
The investigation found the facility failed to report an allegation of psychological abuse within two hours and did not thoroughly investigate the allegation, including failure to obtain written statements from involved staff and residents. Additionally, the facility failed to ensure adequate disposable suction catheters were available for seven tracheostomy and ventilator-dependent residents, resulting in reuse of disposable catheters.
Deficiencies (2)
Failure to report allegation of psychological abuse within two hours and failure to thoroughly investigate the allegation including obtaining written statements.
Failure to ensure adequate disposable suction catheters were available, leading to reuse of disposable catheters for ventilator-dependent residents.
Report Facts
Resident census: 72
Days delayed in reporting abuse allegation: 16
Healthcare acquired infections: 4
Healthcare acquired infections: 0
Healthcare acquired infections: 3
Healthcare acquired infections: 0
Closed suction catheters observed: 63
Disposable suction catheter kits observed: 4
Disposable suction kits in supply closet: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT Manager AA | Respiratory Therapist Manager | Named in psychological abuse allegation and failure to report and investigate abuse |
| RT Manager JJ | Respiratory Therapist Manager | New RT Manager who reported lack of disposable suction catheters and reuse of catheters |
| RN BB | Registered Nurse | Documented resident observations and was not asked to provide written statement |
| RN CC | Registered Nurse | Reported lack of disposable suction catheters and interactions with RT Manager AA |
| RT FF | Respiratory Therapist | Reported reuse of disposable suction catheters and resident complaints about RT Manager AA |
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Date: Aug 6, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the abbreviated/partial survey conducted July 12 through July 18, 2019.
Findings
All deficiencies resulting from the previous abbreviated/partial survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 2
Date: Jun 18, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from June 12, 2019 to June 18, 2019 to investigate complaints GA00195760, GA00197165, and GA00197457.
Complaint Details
The survey was conducted to investigate complaints GA00195760, GA00197165, and GA00197457.
Findings
The facility was found not to be in compliance with Federal and State Long Term Care regulations. Deficiencies included failure to timely reorder PRN pain medication for one resident and failure to provide pressure sore treatments as ordered for three residents with existing pressure sores.
Deficiencies (2)
Failure to ensure licensed/registered nursing staff reordered an 'as needed' pain medication timely prior to running out for one resident.
Failure to ensure pressure sore treatments were provided as ordered by the Physician for three residents with existing pressure sores.
Report Facts
Resident census: 74
Pressure sore measurements: 0.5
Pressure sore measurements: 5.2
Pressure sore measurements: 1.4
Pressure sore measurements: 2
Pressure sore measurements: 12.5
Pressure sore measurements: 40
Pressure sore measurements: 8.1
Pressure sore measurements: 0.2
Pressure sore measurements: 2.3
Deficiency counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | LPN/Treatment Nurse | Provided treatment to pressure sores and discussed issues with treatment nurse availability. |
| BB | Registered Nurse (RN) | Provided information about weekend treatments and documentation challenges. |
| CC | Licensed Practical Nurse (LPN) | Reported providing wound treatments frequently due to treatment nurse being pulled to medication cart. |
Inspection Report
Routine
Deficiencies: 1
Date: Jun 18, 2019
Visit Reason
The inspection was conducted to assess compliance with medical, dental, and nursing care regulations, specifically focusing on the provision of pressure sore treatments as ordered by physicians for residents.
Findings
The facility failed to ensure that pressure sore treatments were consistently provided as ordered by the physician for three residents with existing pressure sores. Multiple instances of missed or undocumented treatments were identified, and staffing shortages contributed to inconsistent care delivery.
Deficiencies (1)
Failure to provide pressure sore treatments as ordered by the physician for residents #1, #2, and #4.
Report Facts
Missed treatment dates: 3
Missed treatment dates: 3
Missed treatment dates: 2
Missed treatment dates: 1
Missed treatment dates: 3
Missed treatment dates: 4
Missed treatment dates: 2
Missed treatment dates: 3
Missed treatment dates: 8
Staffing shortages: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN)/Treatment Nurse | Provided treatments on 6/17/19 and 6/13/19; reported not providing treatments when pulled to medication cart; performed weekly pressure sore assessments. |
| BB | Registered Nurse (RN) | Worked weekends on Ventilator Unit; provided treatments on weekends; reported documentation challenges when providing treatments. |
| CC | Licensed Practical Nurse (LPN) | Provided wound treatments frequently due to treatment nurse being pulled to medication cart; stayed over shifts to provide treatments. |
| Administrator | Administrator | Acknowledged treatment nurse being pulled to medication cart; reported two LPN positions open and active recruitment; facility used agency nurses when needed. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
An unannounced complaint was investigated by State Surveyors for complaint GA00193073. The Ombudsman and complainant were contacted, and sample residents were included in the investigation.
Complaint Details
Complaint GA00193073 was substantiated but no deficient practice was cited.
Findings
The investigation included observations, staff interviews, and record review. The complaint was substantiated but no deficient practice was cited.
Inspection Report
Routine
Census: 75
Deficiencies: 0
Date: Sep 27, 2018
Visit Reason
A standard survey was conducted at Eagle Health and Rehabilitation from September 24, 2018 through September 27, 2018. In addition, Complaint GA00191537 and GA00190282 were investigated in conjunction with this standard survey.
Complaint Details
Complaints GA00191537 and GA00190282 were investigated in conjunction with the standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 43, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 77
Capacity: 99
Deficiencies: 0
Date: Sep 25, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards.
Report Facts
Stories: 1
Construction Year: 1965
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00189009 at Eagle Health and Rehabilitation.
Complaint Details
Investigation of complaint #GA00189009; no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 4, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00188377 and GA0018383 at Eagle Health and Rehabilitation.
Complaint Details
The survey was complaint-related, investigating complaints GA00188377 and GA0018383. No deficiencies were found, indicating compliance.
Findings
The facility was found to be in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities. No health deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 13, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00186263.
Complaint Details
Complaint GA00186263 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated, and no deficiencies were identified during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
A follow-up to the complaint survey conducted on December 18, 2017, to verify correction of previously identified deficiencies.
Complaint Details
The visit was a follow-up to a complaint survey; all deficiencies identified in the complaint survey were corrected.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of January 31, 2018.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 8, 2017
Visit Reason
A revisit survey was conducted on 12/8/17 for the Recertification survey of 10/5/17.
Findings
The revisit survey revealed that all previously cited deficiencies had been corrected. The facility was in substantial compliance as of 11/17/17.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 8, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint number GA00182678 at Eagle Health and Rehabilitation.
Complaint Details
Complaint number GA00182678 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 20, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Landolt | Conducted the Follow-Up Survey |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 3
Date: Oct 5, 2017
Visit Reason
The inspection was conducted as a Standard QIS Survey from October 2 through October 5, 2017, in conjunction with an abbreviated complaint survey to investigate complaint GA00180515.
Complaint Details
The visit included an abbreviated complaint survey to investigate complaint GA00180515.
Findings
The facility was found deficient in food safety practices including improper cleaning and sanitizing of the deli-food slicer and failure to enforce facial hair restraints for dietary staff. Additionally, the facility failed to maintain an effective pest control program, with observations of roaches in the kitchen and resident areas, and non-compliance with pest control recommendations.
Deficiencies (3)
Failed to ensure the deli-food slicer was properly cleaned and sanitized to remove leftover dried food particles.
Failed to follow proper food service guidelines concerning males with facial hair wearing beard guards to prevent contamination while handling food.
Failed to maintain an effective pest control program to ensure the kitchen area was free of pests and rodents.
Report Facts
Sample size: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed dried food particles on the meat slicer and discussed cleaning procedures | |
| Director of Dietary Services | Present during observation of dietary aide without facial hair restraint and stated expectations for staff to wear hair restraints | |
| Maintenance Director | Confirmed presence of roaches and described pest control services |
Inspection Report
Life Safety
Census: 80
Capacity: 99
Deficiencies: 6
Date: Oct 2, 2017
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 Code requirements, including issues with exit discharge ramp deterioration, fire alarm system installation and labeling, smoke barrier penetrations, smoke barrier door closing, electrical safety violations, and smoking area safety. These deficiencies could place residents at risk in the event of fire.
Deficiencies (6)
Exit discharge ramp bottom landing deteriorated leaving a hole in the ground.
Fire alarm panel not marked for electrical panel location and not properly locked out.
Smoke barrier penetrations in attic not properly sealed.
Smoke barrier double doors in A Hall did not close completely.
Portable power taps resting on floor and open breaker slots in electrical panel.
Smoking patio metal trash container had a combustible hard plastic liner.
Report Facts
Residents at risk: 80
Residents at risk: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Craig Landolt | Named in multiple deficiency findings | |
| Staff M | Confirmed findings during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 2, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00177942.
Complaint Details
Complaint GA00177942 was investigated and found not substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was not substantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 12, 2016
Visit Reason
A Revisit Survey was conducted on December 12, 2016 to determine if deficiencies cited during the Standard Survey conducted October 20, 2016 were corrected.
Findings
The facility was found to be in substantial compliance as of December 4, 2016.
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