Inspection Reports for East Lake Arbor
304 5th Ave, Decatur, GA 30030, United States, GA, 30030
Back to Facility Profile
Inspection Report
Deficiencies: 0
Apr 21, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report; only initial comments are noted without further elaboration.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Apr 21, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in a prior Complaint Investigation survey concluded on March 7, 2024.
Findings
All deficiencies cited in the previous Complaint Investigation survey were found to be corrected during this revisit survey.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey concluded on March 7, 2024, verifying correction of cited deficiencies.
Report Facts
Facility census: 84
Inspection Report
Routine
Deficiencies: 1
Mar 7, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to maintain an effective pest control program in five of eight resident rooms, with multiple sightings of live and dead roaches and a spider. Pest Control Technician reports and observations confirmed ongoing sanitation issues contributing to the infestation.
Severity Breakdown
State Health deficiency: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an effective pest control program in five of eight resident rooms (Rm102,103,403,407,506). | State Health deficiency |
Report Facts
Pest sightings: 207
Pest sightings: 5
Resident rooms with pest control issues: 5
Pest Control Technician Service Inspection reports: 3
Treatment effectiveness duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Housekeeper | Reported pest sightings and pest book entry process. |
| CC | Pest Control Technician | Provided details on infestation cause and treatment effectiveness. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 7, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00253873 on March 7, 2025. The investigation was initiated due to complaints regarding pest control issues within the facility.
Findings
The facility failed to maintain an effective pest control program in five of eight resident rooms, with live and dead roaches observed in multiple locations including dresser drawers, cabinets, sink counters, floors, and walls. Pest control technician reports and resident interviews confirmed ongoing infestation issues primarily due to sanitation problems.
Complaint Details
Complaint Intake Number GA00253873 was substantiated with deficiency related to pest control issues.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an effective pest control program in five of eight resident rooms (Rm102, 103, 403, 407, 506) with sightings of live and dead roaches and a spider. | SS=E |
Report Facts
Pest sightings: 207
Pest sightings: 5
BIMS score: 15
Treatment effectiveness duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Housekeeper | Reported pest sightings and entered concerns in the pest book at the nurse station. |
| CC | Pest Control Technician | Confirmed roach infestation due to sanitation issues and described treatment observations. |
| Administrator | Acknowledged infestation issue and described facility's pest control rounds and reporting. | |
| Vice President of Clinical Service | Participated in observation rounds for environmental, sanitation, and pest control sightings. |
Inspection Report
Deficiencies: 0
Feb 19, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the report; only initial comments are noted without further elaboration.
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Feb 19, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 9, 2024 Recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 86
Capacity: 97
Deficiencies: 0
Jan 14, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the requirements set forth in 42 CFR § 483.73 and the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 9, 2025
Visit Reason
The inspection was a State Licensure survey conducted from January 6, 2025 through January 9, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to secure medication carts and remove expired medications, failure to maintain infection control during wound care, inadequate accessibility of call lights for residents, failure to provide adequate activities of daily living care, and failure to provide and document restorative nursing services as ordered.
Deficiencies (6)
| Description |
|---|
| Failed to lock medication carts on 100-Hall and 200-Hall when not in use and failed to remove expired medications from 100-Hall and 500-Hall medication carts. |
| Failed to maintain infection control protocol by not practicing hand hygiene during wound care for one resident (R64). |
| Failed to ensure call lights were accessible to two residents (R51 and R38), potentially delaying assistance. |
| Failed to provide activities of daily living care including nail care and bathing for three residents (R8, R38, and R16) according to care needs. |
| Failed to provide evidence that restorative services for splinting and range of motion were consistently provided for one resident (R8). |
| Failed to complete, maintain, and make readily accessible accurate documentation of medical records for one resident (R8) reviewed for rehab and restorative nursing services. |
Report Facts
Expired medication bottles: 4
Expired medication bottles: 2
Sampled residents: 45
Residents with call light accessibility issues: 2
Residents with ADL care deficiencies: 3
Showers received by R16: 14
Restorative services documented: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Registered Nurse (RN) | Named in medication cart security and expired medication findings |
| MM | Unit Manager (UM) | Named in medication cart security, hand hygiene, and call light accessibility findings |
| HH | Wound Care Nurse (WCN) and Unit Manager (UM) | Named in wound care hand hygiene and medication cart expired medication findings |
| LL | Licensed Practical Nurse (LPN) | Named in expired medication and shower care findings |
| KK | Certified Nursing Assistant (CNA) | Named in call light accessibility findings |
| CC | Certified Nursing Assistant (CNA) | Named in call light accessibility findings |
| DD | Certified Nursing Assistant (CNA) | Named in call light accessibility findings and nail care findings |
| EE | Restorative Aide | Named in call light usage and restorative services findings |
| NN | Licensed Practical Nurse (LPN) | Named in nail care and shower care findings |
| GG | Registered Nurse (RN) | Named in nail care, shower care, and restorative services findings |
| FF | Certified Nursing Assistant (CNA) and Restorative Aide | Named in nail care, shower care, and restorative services findings |
| DON | Director of Nursing | Named in multiple findings including medication cart security, hand hygiene, call light accessibility, nail care, shower care, and restorative services |
| Administrator | Facility Administrator | Named in restorative nursing documentation challenges |
Inspection Report
Routine
Census: 86
Deficiencies: 9
Jan 9, 2025
Visit Reason
A standard survey was conducted from January 6, 2025 through January 9, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to ensure call lights were accessible, failure to honor resident rights, inaccurate coding of falls, failure to revise care plans for restorative nursing refusals, failure to provide adequate activities of daily living care, failure to provide restorative nursing services as ordered, failure to lock medication carts and remove expired medications, failure to maintain accurate restorative nursing documentation, and failure to maintain infection control during wound care.
Complaint Details
The survey included investigation of multiple complaint intake numbers: GA00248125, GA00250382, GA00248280, GA00240308, GA00245261, GA00243190, GA00245573, GA00241838, GA00247611, GA00245542, GA00248419, GA00240670, GA00240211, GA00250378, and GA00240279.
Severity Breakdown
SS= D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure call lights were accessible to residents R51 and R38, potentially causing delayed assistance and worsening medical conditions. | SS= D |
| Failure to honor resident R8's right to make a choice related to returning to bed for a nap, risking unmet care needs and diminished quality of life. | SS= D |
| Failure to accurately code a fall with major injury on the MDS for resident R14, risking additional falls and adverse effects. | SS= D |
| Failure to revise care plan addressing refusals of restorative nursing services for resident R8, including splint usage and ROM exercises. | SS= D |
| Failure to provide activities of daily living care for residents R8, R38, and R16 according to care needs, including nail care and bathing. | SS= D |
| Failure to provide evidence that restorative services for splinting and range of motion were consistently provided for resident R8. | SS= D |
| Failure to lock medication carts on 100-Hall and 200-Hall when not in use and failure to remove expired medications from 100-Hall and 500-Hall medication carts. | SS= D |
| Failure to complete, maintain, and make readily accessible accurate documentation of restorative nursing services for resident R8. | SS= D |
| Failure to maintain infection control protocol by not practicing hand hygiene during wound care for resident R64, increasing risk of infection. | SS= D |
Report Facts
Residents sampled: 45
Resident census: 86
Fall date: Aug 13, 2024
MDS BIMS scores: 5
MDS BIMS scores: 10
MDS BIMS scores: 14
MDS BIMS scores: 11
Expired medications: 4
Expired medications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Registered Nurse | Confirmed call light accessibility issues and medication cart left unlocked |
| MM | Unit Manager | Discussed call light accessibility and medication cart locking |
| DON | Director of Nursing | Provided expectations on call light accessibility, medication cart security, hand hygiene, and restorative nursing documentation |
| KK | Certified Nursing Assistant | Confirmed call light accessibility issues |
| CC | Certified Nursing Assistant | Discussed resident R38's call light usage |
| DD | Certified Nursing Assistant | Discussed resident R38's call light usage and nail care |
| EE | Restorative Aide | Discussed resident R38's call light usage |
| II | Certified Nursing Assistant | Discussed resident R8's nap request and nail care |
| GG | Registered Nurse | Discussed resident R8's nap request, restorative care, shower expectations, and hand hygiene during wound care |
| NN | Licensed Practical Nurse | Discussed nail care for resident R38 |
| LL | Licensed Practical Nurse | Discussed shower documentation and expired medications |
| FF | Certified Nursing Assistant / Restorative Aide | Discussed shower schedule and restorative nursing documentation |
| HH | Licensed Practical Nurse / Wound Care Nurse | Observed not sanitizing hands during wound care |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 20, 2024
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 data to the NHSN between 02/12/2024 and 02/18/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 1
Feb 12, 2024
Visit Reason
The inspection was conducted due to 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.
Findings
The facility did not report complete COVID-19 data to the NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Feb 6, 2024
Visit Reason
The inspection was conducted due to 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.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/29/2024 and 02/04/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 30, 2024
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/22/2024 and 01/28/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Jan 3, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies have been corrected.
Inspection Report
Deficiencies: 0
Dec 29, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report; only an initial comments section is present without further content.
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Dec 29, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 4, 2023 Standard Survey.
Findings
All deficiencies cited in the prior October 4, 2023 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 7
Oct 4, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from September 26, 2023 through October 4, 2023 to assess compliance with state and federal regulations for the healthcare facility.
Findings
The facility was found out of compliance with multiple deficiencies including failure to maintain emergency tracheostomy supplies and staff training, improper medication management, infection control breaches, inadequate care planning, environmental sanitation issues, and unsafe water temperatures. Immediate Jeopardy was identified related to tracheostomy care but was removed after corrective actions.
Severity Breakdown
Immediate Jeopardy: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide oversight and monitoring to ensure competent nursing staff trained for special care needs such as tracheostomy care and failure to maintain emergency tracheostomy supplies at bedside and crash cart. | Immediate Jeopardy |
| Failure to document intended duration of therapy for PRN antianxiety medications beyond 14 days for one resident. | — |
| Failure to maintain infection prevention and control program including hand hygiene breaches during tracheostomy care and improper handling and storage of linens. | — |
| Failure to assess and determine ability of one resident to safely self-administer medications left at bedside. | — |
| Failure to develop and implement person-centered comprehensive care plans including emergency trach supplies, CPAP use, accurate advanced directive status, and physician order for indwelling catheter. | Immediate Jeopardy |
| Failure to ensure a clean, comfortable, and homelike environment with grime buildup in resident bathrooms, dust on AC units, holes in doors, loose handrails, and damaged laundry room. | — |
| Failure to maintain safe water temperatures below 110 degrees Fahrenheit in resident rooms and shower rooms. | — |
Report Facts
Facility census: 96
Water temperature readings: 120
Date of inspection: Oct 4, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in tracheostomy care deficiency and lack of emergency supplies |
| RN CC | Registered Nurse | Interviewed regarding tracheostomy care and emergency supplies |
| DON | Director of Nursing | Named in oversight failures related to tracheostomy care and medication management |
| NP GG | Nurse Practitioner | Interviewed regarding nursing staff training on tracheostomy care |
| LPN UU | Licensed Practical Nurse | Named in lack of training on emergency tracheostomy care |
| LPN KK | Licensed Practical Nurse | Named in lack of formal training on emergency tracheostomy care |
| LPN YY | Licensed Practical Nurse | Named in medication management deficiency |
| Laundry Aide HH | Laundry Aide | Named in infection control and sanitation deficiencies in laundry |
| Administrator | Facility Administrator | Named in oversight failures and environmental sanitation deficiencies |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 12
Oct 4, 2023
Visit Reason
A standard annual survey was conducted at East Lake Arbor from September 26, 2023 through October 4, 2023 to assess compliance with Medicare/Medicaid regulations and facility licensing requirements.
Findings
The survey identified multiple deficiencies including Immediate Jeopardy related to lack of emergency tracheostomy supplies and staff training for resident #69, medication self-administration assessment failure for resident #70, environmental cleanliness issues, failure to obtain criminal background check for the Administrator, incomplete comprehensive care plans for several residents, unsafe hot water temperatures, missing physician order for urinary catheter for resident #349, improper respiratory equipment storage, failure to document duration of psychotropic medication for resident #20, medication administration errors for resident #97, inadequate administrative oversight, and infection control breaches during tracheostomy care and laundry operations.
Severity Breakdown
J: 4
F: 4
E: 1
D: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Immediate Jeopardy due to lack of emergency tracheostomy supplies and staff training for resident #69. | J |
| Failure to assess and determine ability for resident #70 to safely self-administer medications left at bedside. | D |
| Facility failed to ensure a clean, comfortable, and homelike environment with grime buildup, loose handrails, holes in doors, and laundry room disrepair. | E |
| Failure to obtain criminal background check including FBI fingerprint for the Administrator. | F |
| Failure to develop and implement comprehensive care plans for residents including emergency trach supplies, CPAP use, and accurate advanced directive coding. | J |
| Unsafe hot water temperatures above 120 degrees Fahrenheit in multiple resident rooms and shower rooms. | F |
| Failure to obtain physician order for indwelling catheter for resident #349. | D |
| Failure to ensure staff trained for emergency tracheostomy care and provide emergency trach kits for resident #69; improper storage of respiratory equipment for residents #19 and #70. | J |
| Facility administration failed to provide oversight and monitoring to ensure competent nursing staff and emergency trach supplies for resident #69. | J |
| Failure to maintain infection prevention and control program including hand hygiene during trach care and proper linen handling and laundry operations. | F |
| Failure to document intended duration of therapy for PRN antianxiety medication for resident #20 beyond 14 days. | D |
| Medication administration errors related to hospital discharge orders for resident #97 including delayed start and incorrect dosing of apixaban. | D |
Report Facts
Resident census: 96
Deficiency count: 12
Hot water temperature: 124
BIMS score: 3
BIMS score: 15
BIMS score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Provided tracheostomy care to resident #69 and involved in emergency event of trach dislodgement |
| RN CC | Registered Nurse | Provided tracheostomy care and interviewed regarding emergency supplies for resident #69 |
| DON | Director of Nursing | Responsible for oversight of nursing staff and care plans; interviewed regarding multiple deficiencies |
| Administrator | Facility Administrator | Responsible for facility oversight and compliance; interviewed regarding multiple deficiencies |
| LPN UU | Licensed Practical Nurse | Staff nurse interviewed regarding lack of training and supply issues for tracheostomy care |
| NP GG | Nurse Practitioner | Interviewed regarding expectations for nursing staff training on tracheostomy care |
| Pharmacist XX | Pharmacist | Interviewed regarding medication order entry and monitoring |
| LPN YY | Licensed Practical Nurse | Interviewed regarding medication administration and self-administration assessment |
| LPN ZZ | Licensed Practical Nurse | Interviewed regarding medication administration and PRN medication stop dates |
| Laundry Aide HH | Laundry Aide | Observed handling clean linen improperly and interviewed regarding laundry practices |
| Housekeeping/Laundry Supervisor II | Housekeeping/Laundry Supervisor | Interviewed regarding laundry infection control issues |
| Regional Director for Housekeeping | Regional Director | Interviewed regarding laundry infection control and staff re-education |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 2, 2023
Visit Reason
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.
Findings
The facility did not report complete COVID-19 data to the NHSN between 09/25/2023 and 10/01/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Life Safety
Census: 96
Capacity: 103
Deficiencies: 10
Sep 27, 2023
Visit Reason
Life Safety Code Survey 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 blocked egress corridors, failure to maintain smoke-tight hazardous areas, incomplete sprinkler coverage, lack of electronic monitoring on sprinkler system valves, doors failing to latch or seal properly, missing junction box covers, overdue elevator inspection, missing generator annunciator, and improper use of electrical power strips.
Severity Breakdown
SS= D: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Lifts, storage items, beds, etc. obstructing egress in corridors and first floor stairwell entrance. | SS= D |
| Mechanical/boiler room failed to ensure smoke-tight area due to missing ceiling tiles and unsealed penetrations. | SS= D |
| Fire sprinkler coverage missing under main entrance canopy and in main dining room ceiling. | SS= D |
| OS&Y valves on fire sprinkler system backflow preventer not electronically monitored. | SS= D |
| Patient room doors 104 and 409 failed to latch. | SS= D |
| Patient room doors 401 and 402 do not seal to prevent smoke; patient room 411 door has a hole. | SS= D |
| Electric junction box in kitchen storage room missing cover with exposed wires. | SS= D |
| Elevator inspection overdue; last inspection in 2017. | SS= D |
| No annunciator installed for generator in a location visible to operating staff. | SS= D |
| Electrical power strips improperly used; found on floor and not mounted in multiple locations including nursing stations, director of nursing office, and kitchen. | SS= D |
Report Facts
Census: 96
Total Capacity: 103
Last Elevator Inspection Year: 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed all findings during facility tour on 9/27/2023 |
Inspection Report
Deficiencies: 1
Aug 22, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/15/2022 to 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period. | F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Apr 20, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Apr 20, 2022
Visit Reason
A revisit was conducted on 4/20/2022 to verify correction of deficiencies cited during the previous revisit survey on 2/17/2022.
Findings
All deficiencies cited as a result of the revisit survey on 2/17/2022 were found to be corrected as of 3/8/2022.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 11, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00222595.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint #GA0022595 was unsubstantiated with no deficiencies.
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Feb 17, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00220378.
Findings
The complaint GA00220378 was found to be unsubstantiated after the investigation.
Complaint Details
Complaint GA00220378 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 9
Deficiencies: 1
Feb 17, 2022
Visit Reason
The revisit survey was conducted from 2/15/22 through 2/17/22 to verify correction of previously identified deficiencies related to nursing care and adherence to resident care plans.
Findings
The facility failed to follow the care plan for one resident (R#77) who was required to wear a smoking apron for safe smoking. Observation and interviews confirmed the resident smoked without wearing the apron, and staff did not verify the resident's compliance with the care plan.
Deficiencies (1)
| Description |
|---|
| Failure to follow the care plan for resident R#77 related to wearing a smoking apron for safe smoking. |
Report Facts
Residents observed smoking: 9
Residents assessed for smoking: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Supervised residents during smoking break and confirmed resident R#77 was smoking without wearing the required smoking apron. |
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 4
Feb 17, 2022
Visit Reason
A revisit survey was conducted from 2/15/2022 through 2/17/2022, including investigation of Complaint Intake Number GA00220378, which was unsubstantiated. The revisit survey aimed to verify correction of previous deficiencies related to Medicare/Medicaid compliance.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to follow the care plan for safe smoking practices for one resident (R#77), failure to ensure safe smoking supervision and use of smoking aprons, failure of administration to effectively oversee the smoking program, and failure of the Quality Assurance-Performance Improvement (QAPI) committee to implement corrective actions addressing smoking safety.
Complaint Details
Complaint Intake Number GA00220378 was investigated in conjunction with the revisit survey and was found to be unsubstantiated.
Severity Breakdown
SS= D: 2
SS= F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to follow the care plan for one resident (R#77) related to wearing a smoking apron for safe smoking. | SS= D |
| Failure to ensure safe smoking by not providing a smoking apron for one resident (R#77) and inadequate supervision during smoking breaks. | SS= D |
| Failure of facility administration to effectively oversee the resident smoking program to ensure smoking safety for one resident (R#77). | SS= F |
| Failure of the Quality Assurance-Performance Improvement (QAPI) committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to smoking safety for one resident (R#77). | SS= F |
Report Facts
Facility census: 91
Residents assessed for smoking: 9
Resident R#77 admission date: May 31, 2021
Resident R#77 BIMS score: 7
Smoking Safety Evaluation date: Dec 27, 2021
In-service education date: Feb 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant | Supervised smoking breaks, confirmed resident R#77 was smoking without required smoking apron | |
| Director of Nursing | DON | Unaware of resident R#77 smoking without apron, committed to educate Maintenance Assistant |
| Administrator | Responsible for overseeing smoking breaks, acknowledged Maintenance Assistant was new and failed to enforce smoking apron use | |
| Nurse Consultant | Spoke with Maintenance Assistant about smoking apron enforcement concerns | |
| Corporate Nurse | Stated QAPI Committee responsibility to identify and correct breakdowns in smoking safety |
Inspection Report
Renewal
Deficiencies: 2
Dec 8, 2021
Visit Reason
The inspection was a licensure survey conducted from 12/5/21 to 12/8/21 to assess compliance with nursing care and safety regulations for residents.
Findings
The facility failed to follow care plans for four residents related to weekly skin assessments and safe smoking practices. Specifically, skin assessments were not consistently documented or explained, and residents were observed smoking without required safety aprons.
Deficiencies (2)
| Description |
|---|
| Failure to follow care plan for weekly skin assessments for residents R#49 and R#53, including missing documentation and lack of progress notes explaining skin impairments. |
| Failure to ensure safe smoking practices for residents R#11 and R#77, who were observed smoking without required aprons. |
Report Facts
Sampled residents: 53
Weekly skin assessments missing: 8
Dates of skin assessment documentation: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director QQ | Maintenance Director | Supervised smoking break and interviewed regarding smoking apron compliance |
| Activities Director RR | Activities Director | Supervised smoking break |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed about wound care responsibilities and skin assessments |
| Assistant Director of Nursing | Interviewed about wound care and skin assessment responsibilities | |
| Director of Nursing | Interviewed about wound care and skin assessment responsibilities | |
| Regional Nurse Consultant | Interviewed about wound care and skin assessment responsibilities |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Dec 8, 2021
Visit Reason
A standard survey was conducted from December 5, 2021 through December 8, 2021, including investigation of multiple complaint intakes related to the facility's compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to prevent abuse of a resident by a contracted CNA, failure to follow care plans for skin assessments and safe smoking, failure to perform weekly skin assessments on residents with pressure ulcers, failure to provide smoking aprons to residents assessed as needing them, and failure to follow physician orders for tube feeding management.
Complaint Details
Complaint Intake Numbers GA00215433, GA00216093, GA00217998, and GA00218845 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure resident R#391 was free from physical abuse by a contracted CNA who hit the resident, resulting in injury and police involvement. | SS= D |
| Failure to develop and implement comprehensive care plans related to weekly skin assessments and safe smoking for residents R#49, R#53, R#11, and R#77. | SS= D |
| Failure to perform weekly skin assessments on residents R#49 and R#53 with pressure ulcers as required by physician orders and facility policy. | SS= D |
| Failure to provide smoking aprons to residents R#11 and R#77 who were assessed as needing them for safe smoking. | SS= D |
| Failure to follow physician orders for tube feeding management for resident R#53, including failure to stop tube feeding at ordered times. | SS= D |
Report Facts
Resident census: 86
Sample size: 53
Number of assessed smokers: 17
BIMS score: 6
BIMS score: 12
BIMS score: 7
Pressure ulcers: 5
Tube feeding rate: 65
Tube feeding duration: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SS | Certified Nursing Assistant | Named in physical abuse finding against resident R#391 |
| KK | Licensed Practical Nurse | Witnessed resident report of abuse and described incident |
| NN | Licensed Practical Nurse | Provided information about resident behavior and staff relations |
| AA | Licensed Practical Nurse | Wound care nurse involved in skin assessment and wound care for resident R#49 and R#53 |
| Maintenance Director | Supervised smoking breaks and acknowledged knowledge of residents needing smoking aprons | |
| RR | Activities Director | Supervised smoking breaks |
| HH | Licensed Practical Nurse | Unaware of tube feeding stop order for resident R#53 |
Inspection Report
Life Safety
Census: 88
Capacity: 93
Deficiencies: 0
Dec 7, 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 conducted on 12/07/2021.
Inspection Report
Deficiencies: 0
Jul 28, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Jul 28, 2021
Visit Reason
A revisit survey was conducted from 7/27/2021 through 7/28/2021 to verify correction of deficiencies cited in the 4/30/2021 COVID-19 Focus Infection Control and Complaint Survey.
Findings
All deficiencies cited as a result of the 4/30/2021 COVID-19 Focus Infection Control and Complaint Survey were found to be corrected.
Inspection Report
Original Licensing
Deficiencies: 2
May 11, 2021
Visit Reason
A Licensure Survey was conducted from 4/5/2021 through 4/30/2021 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to complete fall risk assessments and implement interventions to prevent falls for one resident out of 14 reviewed, and failed to offer and administer the pneumonia vaccine to five of 30 sampled residents.
Deficiencies (2)
| Description |
|---|
| Failure to complete fall risk assessments and implement interventions to prevent falls for resident #4 after multiple documented falls. |
| Failure to offer and administer the pneumonia vaccine to five of 30 sampled residents (#1, #2, #3, #6, and #7). |
Report Facts
Residents reviewed for falls: 14
Residents sampled for pneumonia vaccine: 30
Residents not offered pneumonia vaccine: 5
Fall risk evaluation score: 8
Pneumonia vaccines purchased: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding fall assessments and post-fall procedures |
| MM | Licensed Practical Nurse (LPN) | Interviewed regarding implementation of fall interventions |
| Director of Nursing | Director of Nursing (DON), Infection Control Preventionist, Registered Nurse | Interviewed regarding fall evaluations, assessments, and vaccination procedures |
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 10
May 11, 2021
Visit Reason
An Abbreviated Survey was conducted to verify the removal of Immediate Jeopardy related to COVID-19 infection control and staffing deficiencies identified during a prior extended survey.
Findings
The facility was found to have removed the Immediate Jeopardy but remained out of compliance at a lower scope and severity for issues including sufficient nursing staff, administration, governing body oversight, QAPI activities, infection prevention and control, and COVID-19 testing of residents and staff.
Severity Breakdown
Level E: 2
Level F: 6
Level D: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for falls for one resident (#4). | Level D |
| Failed to complete fall risk assessments and implement interventions to prevent falls for one resident (#4). | Level D |
| Failed to provide sufficient nursing staff to assure resident safety and meet resident needs, resulting in inadequate COVID-19 testing and monitoring. | Level F |
| Failed to provide a full-time Director of Nursing without requiring the DON to work as charge nurse when census was above 60. | Level F |
| Failed to provide adequate administrative oversight and monitoring of the Infection Control Program and staffing. | Level F |
| Failed to ensure the governing body effectively identified and corrected quality deficiencies related to infection control and staffing. | Level F |
| Failed to establish and maintain an effective infection prevention and control program, including lack of dedicated COVID-19 unit with dedicated staff, inadequate resident monitoring for COVID-19 symptoms, failure to contact local health department, improper storage of resident care items, lack of non-COVID infection surveillance, and insufficient PPE stock. | Level F |
| Failed to offer and administer pneumococcal vaccine to five residents (#1, #2, #3, #6, #7). | Level E |
| Failed to conduct COVID-19 testing of residents and staff in accordance with current standards of practice, including failure to conduct outbreak testing for 13 of 22 residents and failure to test 14 of 40 nursing staff weekly. | Level F |
| Failed to maintain an effective pest control program related to roaches observed in multiple resident rooms and facility areas. | Level E |
Report Facts
Resident census: 74
Residents tested: 76
Residents tested: 77
Staff tested: 68
Staff tested: 40
Residents reviewed for COVID testing: 22
Residents reviewed for falls: 14
Staff educated: 96
Pest control treatments: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Stated she does not update care plans after resident falls |
| LPN MM | Licensed Practical Nurse | Stated charge nurses are supposed to implement fall interventions but are not |
| DON | Director of Nursing | Interviewed regarding fall assessments, staffing, infection control, and COVID testing |
| Executive Director | Administrator | Informed of Immediate Jeopardy, involved in staffing and infection control oversight |
| Regional Executive Director Consultant KKK | Involved in oversight, QAPI, and staffing improvement efforts | |
| Regional Nurse Consultant | Involved in infection control and COVID testing oversight | |
| Medical Director | Reviewed infection control policies and QAPI |
Inspection Report
Renewal
Deficiencies: 2
Apr 30, 2021
Visit Reason
A Licensure Survey was conducted from 4/5/2021 through 4/30/2021 to assess compliance with licensure requirements for the facility.
Findings
The facility was found deficient in completing fall risk assessments and implementing interventions to prevent falls for one resident, and in offering and administering the pneumonia vaccine to five of 30 sampled residents.
Deficiencies (2)
| Description |
|---|
| Failure to complete fall risk assessments and implement interventions to prevent falls for one resident (#4) after multiple documented falls. |
| Failure to offer and administer the pneumonia vaccine to five of 30 sampled residents (#1, #2, #3, #6, and #7). |
Report Facts
Residents reviewed for falls: 14
Residents sampled for pneumonia vaccine: 30
Residents not offered pneumonia vaccine: 5
Fall risk evaluation score: 8
Fall risk evaluation high risk threshold: 10
Pneumonia vaccines purchased: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Described fall assessment and post-fall procedures | |
| Licensed Practical Nurse (LPN) MM | Reported on fall intervention implementation issues | |
| Director of Nursing (DON) | Provided information on fall evaluation and vaccination procedures |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 11
Apr 30, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with a complaint survey was conducted from 4/5/2021 through 4/30/2021 to investigate multiple complaints related to infection control and COVID-19 testing.
Findings
The facility was found not in compliance with infection control regulations, with substantiated complaints citing failures in COVID-19 outbreak testing, insufficient nursing staff, lack of dedicated COVID units and staff, inadequate resident monitoring for COVID symptoms, and ineffective infection control practices. Immediate Jeopardy was identified due to these deficiencies.
Complaint Details
Complaint #GA00211683, #GA00212691, #GA00212584, #GA00213946 and #GA00206759 were substantiated. Complaint #GA00212693 was unsubstantiated.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 1
SS=L: 6
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for falls for one resident (#4) of 14 reviewed. | SS=D |
| Failed to complete fall risk assessments and implement interventions to prevent falls for one resident (#4) of 14 reviewed. | SS=D |
| Failed to provide sufficient nursing staff to assure resident safety and needs for 19 of 22 residents, including inadequate COVID-19 testing of staff and residents. | SS=L |
| Director of Nursing worked as charge nurse administering medications when census was greater than 60 residents. | SS=F |
| Failed to provide effective oversight and monitoring of infection control program and staffing by facility administration. | SS=L |
| Failed to ensure governing body oversight and participation in quality assurance and facility management. | SS=L |
| Failed to have an effective Quality Assurance process to identify and correct deficiencies related to COVID-19 screening/testing and staffing. | SS=L |
| Failed to implement an effective infection control program including lack of dedicated COVID unit, inadequate resident monitoring for COVID symptoms, improper PPE use, and lack of communication with local health department. | SS=L |
| Failed to offer and administer pneumococcal vaccine to five of 30 sampled residents. | SS=E |
| Failed to conduct COVID-19 testing for residents and staff in accordance with current standards and county positivity rates, with incomplete testing documentation. | SS=L |
| Failed to maintain an effective pest control program with ongoing roach infestations observed in multiple resident rooms and common areas. | SS=E |
Report Facts
Facility census: 85
Nursing staff tested: 14
Residents reviewed for COVID testing: 22
Residents not tested for COVID: 13
Open nursing shifts: 1
Open nursing shifts: 2
Fall risk score: 8
COVID county positivity rate: 11.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Named in findings related to falls care plan and medication administration on 200 Hall |
| DON | Director of Nursing | Named in findings related to staffing shortages, infection control, medication administration, and COVID testing |
| Administrator | Administrator | Named in findings related to staffing shortages, infection control, medication administration, and COVID testing |
| ADON | Assistant Director of Nursing | Named in findings related to COVID testing and staffing |
| NN | Registered Nurse | Named in findings related to COVID testing and staffing |
| PP | Certified Nursing Assistant | Named in findings related to pest control observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 8, 2020
Visit Reason
The inspection was conducted to investigate multiple complaints filed against the facility, including complaint numbers GA00204906, GA00206173, GA00205592, GA00205589, GA00205064, GA00204937, GA00203548, GA0019986, and GA00199881, and to assess infection control practices related to COVID-19.
Findings
The complaint investigations were unsubstantiated with no deficiencies cited. The desk review of infection control practices related to COVID-19 also found no deficiencies.
Complaint Details
The complaint survey conducted from 6/30/2020 to 7/08/2020 found the complaints unsubstantiated with no deficiencies cited. The earlier complaint investigation from 5/1/2020 to 5/4/2020 for complaint GA00204906 was also unsubstantiated with no deficiencies.
Inspection Report
Routine
Census: 79
Deficiencies: 0
Jun 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 79
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Nov 20, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 9/13/19 Complaint Survey.
Findings
All deficiencies cited as a result of the 9/13/19 Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00196498 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint GA00196498 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 23, 2019
Visit Reason
A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Mar 11, 2019
Visit Reason
An unannounced, abbreviated survey was initiated and concluded on 3/11/19 to investigate Complaint # GA00195020, Event # QZ2L11.
Findings
The complaint was substantiated without citation.
Complaint Details
Complaint # GA00195020 was substantiated without citation.
Report Facts
Facility census: 92
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2019
Visit Reason
The inspection was conducted to investigate complaint #GA00194306 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted on 2/18/19 and 2/20/19.
Complaint Details
Complaint #GA00194306 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 22, 2019
Visit Reason
A complaint survey was conducted from 1/22/2019 through 1/23/2019 to investigate complaints #GA00193741, GA001939833, and GA00193967.
Findings
The investigation determined compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, and no deficiencies were cited.
Complaint Details
Complaints #GA00193741, GA001939833, and GA00193967 were investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Nov 26, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 23, 2018 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected as of October 16, 2018.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Sep 23, 2018
Visit Reason
A standard survey was conducted from September 17 through September 23, 2018, in conjunction with complaint investigations (GA00191086 and GA00191420) related to infection control and professional standards of care regarding sanitizing glucometers.
Findings
The facility failed to ensure licensed nursing staff properly sanitized glucometers between resident uses, risking cross contamination of blood borne pathogens including HIV and Hepatitis C. Licensed staff lacked training on proper sanitization techniques. The facility's Infection Preventionist was not performing required oversight. Immediate Jeopardy was identified and removed after the facility implemented staff training, competency checks, audits, and revised policies. The QAPI committee was found not to have effectively monitored infection control practices prior to the survey.
Complaint Details
Complaint Intake Numbers GA00191086 and GA00191420 were investigated in conjunction with the standard survey. Immediate Jeopardy was identified related to infection control failures in sanitizing glucometers, posing risk of serious injury or death to residents.
Severity Breakdown
Level K: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure professional standards of care were met regarding cleaning and sanitizing glucometers for seven out of 23 residents receiving blood glucose checks, risking cross contamination of blood borne illnesses. | Level K |
| Failure to ensure licensed nursing staff were appropriately trained to sanitize glucometers to avoid cross contamination, with no documentation of training provided to licensed staff. | Level K |
| Failure of facility administration and QAPI committee to identify and correct deficient infection control practices related to sanitizing glucometers between residents, causing immediate jeopardy. | Level K |
| Failure to establish and maintain an infection prevention and control program that prevents transmission of communicable diseases, including proper sanitization of glucometers. | Level K |
Report Facts
Resident census: 86
Residents receiving finger stick blood glucose checks: 23
Residents with infectious disease diagnosis: 7
Licensed nurses trained: 22
Licensed nurses total: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Observed performing blood glucose checks without proper glucometer sanitization; stated lack of training |
| LPN FF | Licensed Practical Nurse | Observed performing blood glucose checks without proper glucometer sanitization; stated inconsistent cleaning practices and lack of training |
| LPN AA | Licensed Practical Nurse | Observed performing blood glucose checks with proper sanitization after training; stated residents with infectious diseases have individual glucometers |
| LPN EE | Licensed Practical Nurse | Observed sanitizing glucometers; stated lack of training but demonstrated proper cleaning after instruction |
| LPN GG | Licensed Practical Nurse | Stated no training on glucometer cleaning |
| LPN RR | Licensed Practical Nurse | Received telephone training on glucometer sanitization; demonstrated proper cleaning |
| LPN QQ | Licensed Practical Nurse | Observed sanitizing glucometers properly after self-correcting initial errors |
| LPN OO | Licensed Practical Nurse | Demonstrated proper glucometer cleaning technique |
| LPN PP | Licensed Practical Nurse | Received training and demonstrated proper glucometer cleaning |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided training, developed policies, monitored compliance, and reported to QAPI |
| Administrator | Facility Administrator | Unaware of infection control failures prior to survey; received training and assumed QAPI oversight |
| Regional Director of Operations | Regional Director of Operations | Provided training to Administrator and staff; monitored AOC implementation |
| Director of Nursing | Director of Nursing | Infection Control Nurse; responsible for staff training and monitoring; was on leave during survey |
| Pharmacy Nurse Consultant | Pharmacy Nurse Consultant | Conducted monthly medication pass observations; did not observe glucometer cleaning deficiencies due to timing |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 1
Sep 23, 2018
Visit Reason
The inspection was conducted due to concerns about improper cleaning and disinfecting of blood glucose meters used for multiple residents, including those with infectious diseases, potentially risking cross-contamination.
Findings
The facility failed to follow its infection control policy and manufacturer's guidelines for cleaning and disinfecting blood glucose meters, with multiple licensed nurses observed not properly sanitizing the glucometers between resident uses. The facility implemented corrective actions including staff training, individual glucometers for residents with infectious diseases, and ongoing audits.
Complaint Details
The investigation was complaint-driven based on observations and interviews revealing noncompliance with infection control practices related to blood glucose meter sanitization. The complaint was substantiated with immediate jeopardy removed after corrective actions.
Deficiencies (1)
| Description |
|---|
| Failure to clean and disinfect blood glucose meters according to facility policy and manufacturer's guidelines, risking cross-contamination among residents. |
Report Facts
Residents receiving finger stick blood sugar checks: 23
Residents with infectious disease diagnosis: 7
Licensed nurses trained on glucometer cleaning: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Observed cleaning glucometer improperly with alcohol swabs instead of approved wipes |
| LPN FF | Licensed Practical Nurse | Observed not cleaning glucometer between resident uses and admitted to inconsistent cleaning practices |
| LPN AA | Licensed Practical Nurse | Observed cleaning glucometer with alcohol swabs and trained on new policy 9/20/18 |
| Unit Manager BB | Unit Manager/Assistant Director of Nursing | Provided education and competency training on glucometer cleaning |
| Regional Nurse Consultant | Regional Nurse Consultant | Reviewed policies, conducted training, and monitored corrective actions |
| Administrator | Facility Administrator | Interviewed regarding oversight and training responsibilities; received education on infection control and QAPI |
| Pharmacy Nurse Consultant | Pharmacy Nurse Consultant | Conducted monthly medication pass observations but did not observe glucometer cleaning issues due to timing |
Inspection Report
Life Safety
Census: 85
Capacity: 94
Deficiencies: 0
Sep 17, 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 to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan was also in substantial compliance with Appendix Z requirements.
Report Facts
Certified Beds: 94
Census: 85
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00189594 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00189594 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 11, 2018
Visit Reason
A complaint survey was conducted on 6/8/2018 and 6/11/2018 to investigate complaints #GA00188670 and GA00189168 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaints #GA00188670 and GA00189168 were investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 1, 2018
Visit Reason
A complaint survey was conducted to investigate complaint # GA00187425 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint # GA00187425 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2018
Visit Reason
A complaint survey was conducted on 2/20/18 - 2/21/18 to investigate complaints GA00184540 and GA00184945 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiency was cited during the complaint survey.
Complaint Details
The survey was conducted in response to complaints GA00184540 and GA00184945; no deficiencies were found.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 18, 2017
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility East Lake Arbor, indicating a regulatory inspection was conducted and corrective actions are planned.
Findings
The document contains no detailed findings or deficiencies; it only includes an initial comments section without specific content.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 70
Capacity: 103
Deficiencies: 1
Oct 24, 2017
Visit Reason
The visit was a life safety code survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to have the sprinkler system annually tested within the required 12-month period, with the last test dated October 3, 2016, making it 21 days overdue at the time of inspection.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have the sprinkler system annually tested within the 12 month period, with the last test dated October 3, 2016, 21 days overdue. | SS= D |
Report Facts
Days overdue for sprinkler inspection: 21
Census: 70
Total capacity: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings during the inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 1, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaints GA00180111, GA00179878, and GA00179777 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted on 09/29/17 and 09/30/17 at East Lake Arbor.
Complaint Details
The survey was conducted to investigate three complaints identified as GA00180111, GA00179878, and GA00179777. No deficiencies were found, indicating the complaints were not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00171241 and GA00171660 and to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted at East Lake Arbor.
Complaint Details
The survey was complaint-related, investigating two complaints, and no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 5, 2017
Visit Reason
A health follow-up visit survey was conducted to a Standard Extended Survey in addition to a Complaint Survey to investigate multiple complaints (#GA00165252, #GA00164512, #GA00164476, #GA00163786, and #GA00163751) from August 28, 2016 through September 19, 2016.
Findings
The follow-up survey conducted January 3-5, 2017 determined that the previous deficiencies had been corrected.
Complaint Details
The visit was complaint-related, investigating five complaints identified by their numbers, but the previous deficiencies were found corrected.
Loading inspection reports...
