Inspection Report Summary
The most recent inspection on February 5, 2025, found that all previously cited deficiencies had been corrected. Prior inspections showed some deficiencies related mainly to employee tuberculosis testing, fire alarm system installation, and emergency call light functionality in resident bathrooms. Complaint investigations were generally unsubstantiated, with one substantiated case in 2018 involving failure to follow a resident’s care plan that resulted in a fall and pressure sore. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with earlier issues addressed and corrected by the latest follow-up survey.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
92 residents
Based on a December 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 5, 2025
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 had been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
A State Licensure survey was conducted at Effingham Care & Rehabilitation Center from December 17, 2024, through December 19, 2024, to assess compliance with state health regulations.
Findings
The facility failed to obtain an annual purified protein derivative (PPD) skin test for tuberculosis or chest x-ray every five years for three of ten employees reviewed, placing residents at risk of communicable diseases from untested staff.
Deficiencies (1)
Failure to obtain annual PPD skin test or chest x-ray every five years for three of ten employees reviewed.
Report Facts
Employees without required PPD or chest x-ray: 3
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Employee file revealed no PPD skin test and most recent chest x-ray dated 6/12/2016. | |
| Dietary Manager | Employee file revealed a TB assessment dated 5/31/2024 but no PPD skin test. | |
| Director of Nursing | Employee file revealed a TB assessment dated 8/10/2024 but no PPD skin test. | |
| Director of Employee Health Services | Interviewed on 12/19/24; stated facility no longer performed annual PPD skin tests as part of annual employee health screening. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
A standard survey was conducted from December 17, 2024, through December 19, 2024, including an investigation of Complaint Intake Number GA00236572 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00236572 was investigated in conjunction with the standard survey.
Findings
The standard survey revealed the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 1
Date: Dec 19, 2024
Visit Reason
A State Licensure survey was conducted at Effingham Care & Rehabilitation Center from December 17, 2024, through December 19, 2024, to assess compliance with state health regulations.
Findings
The facility failed to obtain an annual purified protein derivative (PPD) skin test for tuberculosis or chest x-ray every five years for three of ten employees reviewed, placing residents at risk of communicable diseases from untested staff.
Deficiencies (1)
Failure to obtain an annual PPD skin test or chest x-ray every five years for three of ten employees reviewed.
Report Facts
Employees without required PPD or chest x-ray: 3
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Employee file revealed no PPD skin test and most recent chest x-ray dated 6/12/2016. | |
| Dietary Manager | Employee file revealed a TB assessment dated 5/31/2024 but no PPD skin test. | |
| Director of Nursing | Employee file revealed a TB assessment dated 8/10/2024 but no PPD skin test. | |
| Director of Employee Health Services | Interviewed on 12/19/24; stated facility no longer performed annual PPD skin tests as part of employee health screening. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
A standard survey was conducted from December 17, 2024, through December 19, 2024, including an investigation of Complaint Intake Number GA00236572 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00236572 was investigated in conjunction with the standard survey.
Findings
The standard survey revealed the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 92
Capacity: 105
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to deficiencies in the installation of the fire alarm system and electrical equipment. Specifically, the fire alarm panel circuit breaker lacked a lockout, and a power strip in the Social Worker's office was not properly mounted off the floor.
Deficiencies (2)
Fire alarm panel circuit breaker did not have a lockout.
Power strip found under the desk in the Social Worker's office was not properly mounted off the floor.
Report Facts
Census: 92
Total Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm panel circuit breaker and power strip installation |
Inspection Report
Life Safety
Census: 92
Capacity: 105
Deficiencies: 2
Date: Dec 18, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with fire safety and related National Fire Protection Association standards as required for Medicare/Medicaid participation.
Findings
The facility was found not in substantial compliance with fire alarm system installation and electrical equipment installation requirements. Specific deficiencies included the lack of a lockout on the fire alarm panel circuit breaker and a power strip not properly mounted off the floor in the Social Worker's office.
Deficiencies (2)
Fire alarm system installation did not include a lockout on the fire alarm panel circuit breaker.
Electrical equipment installation deficiency: power strip found under desk and not properly mounted off the floor in the Social Worker's office.
Report Facts
Census: 92
Total Capacity: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm panel circuit breaker and electrical equipment installation |
Inspection Report
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Effingham Care & Rehabilitation Center following a survey completed on 11/22/2022.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: Nov 22, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2022-09-25.
Findings
All deficiencies cited as a result of the 9/25/2022 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 84
Capacity: 105
Deficiencies: 0
Date: Oct 3, 2022
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 compliance with the Life Safety Code requirements and the Emergency Preparedness Program was in compliance with 42 CFR § 483.73.
Report Facts
Certified beds: 105
Census: 84
Inspection Report
Routine
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
A State Licensure survey was conducted from September 23, 2022, through September 25, 2022, to assess compliance with physical plant standards and other regulatory requirements.
Findings
The facility failed to ensure that the emergency call light system in four of eight resident bathrooms on the secured memory unit was functioning properly. Call lights in bathrooms of Rooms 322/324, 318/320, 313/315, and 311 did not activate when tested.
Deficiencies (1)
Emergency call light system in resident bathrooms (Rooms 322/324, 318/320, 313/315, and 311) was not functioning properly.
Report Facts
Resident bathrooms with non-functioning call lights: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Confirmed that call lights in bathrooms were not functioning |
| Safety Officer | Stated maintenance director was out and confirmed cords were too tight causing call lights to malfunction | |
| Administrator | Discussed expectations and maintenance routines for call light cords |
Inspection Report
Routine
Census: 87
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
A standard survey was conducted at Effingham Care Center from September 23, 2022, through September 25, 2022, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to non-functioning emergency call light systems in four of eight resident bathrooms on the secured memory unit, which failed to activate when tested.
Deficiencies (1)
Emergency call light system in resident bathrooms (Rooms 322/324, 318/320, 313/315, and 311) on the secured memory unit were not functioning properly.
Report Facts
Resident census: 87
Number of resident bathrooms with non-functioning call lights: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant AA | Certified Nursing Assistant | Confirmed that the call lights were not functioning during testing |
| Safety Officer | Stated maintenance director was out and confirmed cords were too tight causing malfunction | |
| Administrator | Discussed with maintenance to routinely treat bathroom call light cords to ensure proper function |
Inspection Report
Routine
Census: 88
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 9/13/2021 to 9/14/2021 to assess the facility's 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.
Inspection Report
Routine
Census: 81
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 94
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's 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 for COVID-19 preparedness.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Feb 27, 2020
Visit Reason
The inspection was conducted as a Licensure Survey to assess compliance for facility licensure.
Findings
No deficiencies were identified during the Licensure Survey.
Inspection Report
Routine
Census: 100
Deficiencies: 0
Date: Feb 27, 2020
Visit Reason
A standard survey was conducted at Effingham Care and Rehabilitation Center from February 24, 2020 through February 27, 2020 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 99
Capacity: 105
Deficiencies: 0
Date: Feb 25, 2020
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 Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00195621, GA00196099, and GA197946.
Complaint Details
Complaints investigated were unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Oct 16, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey conducted on August 13-16, 2018.
Findings
All deficiencies cited in the prior standard survey were found to be corrected, and the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 1, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 16, 2018
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to follow the care plan for Resident #60, specifically related to bed positioning and skin monitoring.
Complaint Details
The complaint investigation found substantiated failures related to Resident #60's care plan, including bed safety and skin monitoring. CNA AA was terminated for failure to follow safety policy and care plan.
Findings
The facility failed to keep Resident #60's bed in the lowest position, resulting in a fall and hip fracture. Additionally, the facility failed to ensure weekly skin assessments by licensed nursing staff and proper communication of skin issues by CNAs, leading to an unstageable pressure sore.
Deficiencies (2)
Failure to follow the plan of care for Resident #60 to keep her bed in the lowest position, resulting in a fall and hip fracture.
Failure to perform weekly skin assessments by licensed nursing staff and failure of CNAs to notify nurses of skin issues, resulting in an unstageable pressure sore.
Report Facts
Sample size: 26
Pressure sore size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant | Named in failure to follow safety policy and care plan leading to resident fall and termination |
| Director of Nursing | Director of Nursing | Interviewed regarding investigation of fall and skin care failures |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 2
Date: Aug 16, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for Effingham Care & Rehabilitation Center, focusing on resident care plans, pressure ulcer prevention and treatment, and fall prevention.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to keep a resident's bed in the lowest position resulting in a fall and hip fracture, failure to perform weekly skin assessments leading to delayed identification of a pressure sore, and inadequate fall prevention supervision.
Deficiencies (2)
Failure to keep resident #60's bed in the lowest position, resulting in a fall and left hip fracture.
Failure to perform weekly skin assessments for resident #60, resulting in delayed identification and treatment of a pressure sore.
Report Facts
Resident census: 94
Sample size: 26
Pressure sore size: 1
Pressure sore size: 0.5
Braden scale score: 12
BIMS score: 3
BIMS score: 9
Fall incident date: 2018
Fall incident date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in fall incident where resident's bed was left in high position, resulting in fall and hip fracture; terminated for failure to follow safety policy. |
| CNA BB | Certified Nursing Assistant | Interviewed regarding skin checks and fall prevention practices for resident #60. |
| LPN CC | Licensed Practical Nurse | Interviewed regarding skin assessments and fall prevention interventions. |
| Director of Nursing | Director of Nursing | Interviewed regarding investigation of fall incidents, staff responsibilities, and facility policies. |
Inspection Report
Life Safety
Census: 94
Capacity: 105
Deficiencies: 2
Date: Aug 14, 2018
Visit Reason
The visit was a Life Safety Code Survey 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 with fire safety requirements, specifically failing to maintain proper fire sprinkler coverage in the kitchen food prep sink area and walk-in cooler, and failing to maintain four corridor doors from resident rooms with positive latching hardware as required.
Deficiencies (2)
Failed to maintain fire sprinkler coverage in the food prep sink area of the kitchen and in the walk-in cooler.
Failed to maintain four corridor doors from resident rooms with positive latching hardware as required by the Life Safety Code.
Report Facts
Census: 94
Total Capacity: 105
Number of doors not positively latching: 4
Number of staff at risk due to sprinkler deficiency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during observation and interviews |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Sep 28, 2017
Visit Reason
A standard survey was conducted in conjunction with complaint #GA00179459 at Effingham Care Center from September 25, 2017 through September 28, 2017.
Complaint Details
Complaint #GA00179459 was investigated and no deficiencies were cited related to this complaint.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. No deficiencies were cited related to complaint #GA00179459.
Inspection Report
Life Safety
Census: 103
Capacity: 105
Deficiencies: 0
Date: Sep 26, 2017
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
Effingham Care Center was found in substantial compliance with the Life Safety Code requirements during the survey.
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