Inspection Reports for East Cobb Center for Nursing and Healing

This document is a Statement of Deficiencies and Plan of Correction for East Cobb Center for Nursing and Healing LLC following a survey completed on May 8, 2024.

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

A revisit survey was conducted to verify correction of deficiencies cited during the 3/14/2024 recertification survey.

All deficiencies cited as a result of the 3/14/2024 recertification survey were found to be corrected.

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

All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.

A State Licensure survey was conducted at East Cobb Center for Nursing and Healing from March 12, 2024, through March 14, 2024, to assess compliance with State Health regulations.

The facility failed to discard expired biologicals prior to the expiration date printed on the medication in one of two medication storage rooms and one of seven medication carts, including a vial of Tuberculin Purified Protein Derivative and a vial of Lantus insulin that were not discarded within the required timeframe.

A standard annual survey was conducted at East Cobb Center for Nursing and Healing from March 12 through March 14, 2024, to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to complete a significant change Minimum Data Set (MDS), failure to include anticoagulant use in baseline care plans, failure to maintain respiratory equipment properly, and failure to discard expired biologicals in medication storage.

The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.

The facility was found not in substantial compliance with life safety requirements, specifically regarding corridor doors that failed to resist the passage of smoke and failure to maintain emergency electrical systems, including a missed 4-hour load bank test for the generator.

The inspection report documents the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.

The facility did not report complete COVID-19 data to the NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.

The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.

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

A revisit survey was conducted on 3/23/2023 to verify correction of deficiencies cited in the 1/26/2023 Recertification Survey and to investigate Complaint Intake Number GA00231863.

All deficiencies cited in the 1/26/2023 Recertification Survey were found to be corrected. The complaint investigation for GA00231863 was found to be unsubstantiated.

Complaint Intake Number GA00231863 was investigated and found to be unsubstantiated.

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

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

A State Licensure survey was conducted at East Cobb Center for Nursing and Healing, LLC from January 24, 2023 through January 26, 2023 to assess compliance with state health regulations.

The facility failed to follow the comprehensive, person-centered care plan for one resident (R#58) related to activities. The resident did not receive individualized, person-centered activities as required, and the facility lacked documentation of one-on-one activities provided. The resident was cognitively intact but confined to bed and did not participate in activities outside her room except bingo via intercom.

A standard survey was conducted from January 24, 2023 through January 26, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found not in substantial compliance with regulations, specifically failing to provide a comprehensive, person-centered activities program for one resident (R#58) who required extensive assistance. The resident did not receive one-on-one activities as outlined in the care plan, and the facility lacked documentation of such activities being offered or refused.

The investigation included multiple complaint intake numbers (GA00224784, GA00231475, GA00225265, GA00225706, GA00228161) and found that the resident R#58 was not provided one-on-one activities as required. The resident expressed desire for more socialization and activities in her room due to inability to participate in group activities outside her room. Staff interviews confirmed lack of documentation and provision of one-on-one activities.

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

The facility was found not in substantial compliance with life safety code requirements, including issues with delayed egress doors lacking proper panic hardware and signage, outdated fire suppression hood system inspection, blocked electrical panels, resident room door failing to latch, and smoke barriers with unsealed penetrations.