Inspection Reports for Evergreen Health and Rehabilitation Center
139 MORAN LAKE ROAD, NE, ROME, GA, 30161
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 2, 2025 found no deficiencies and substantiated no complaints. Earlier inspections showed a pattern of deficiencies related primarily to oxygen therapy care plan adherence and life safety code compliance, including issues with smoke barriers, sprinkler maintenance, and emergency preparedness. Complaint investigations occasionally substantiated concerns such as resident-to-resident abuse and failure to report abuse timely, but these did not result in citations or enforcement actions. Fines, immediate jeopardy findings, or license suspensions were not listed in the available reports. The facility appears to have addressed prior deficiencies effectively, as indicated by multiple revisit surveys confirming correction of cited issues.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
92 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 0
Date: Jan 2, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00251330.
Complaint Details
Complaint GA00251330 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on August 18, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on August 18, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
A Follow-Up Survey was conducted as a desk review to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Deficiencies: 2
Date: Aug 18, 2024
Visit Reason
A State Licensure survey was conducted at Evergreen Health and Rehabilitation from August 16, 2024, through August 18, 2024, to assess compliance with state health regulations.
Findings
The facility failed to follow care plans related to oxygen therapy for multiple residents, including incorrect oxygen flow rates and failure to clean oxygen concentrator filters as ordered. Observations and interviews confirmed these deficiencies, with dirty equipment and oxygen administered at incorrect rates.
Deficiencies (2)
Failed to follow care plan related to correctly administering physician ordered oxygen rate for two residents (R41 and R47).
Failed to follow care plan related to cleaning the oxygen filter on the oxygen concentrator for two residents (R32 and R61).
Report Facts
Residents receiving oxygen therapy: 15
Oxygen flow rate: 2
Oxygen flow rate observed: 3.5
Oxygen flow rate observed: 3
Dates of oxygen tubing change documented: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Nurse (RN) | Acknowledged responsibility for cleaning oxygen concentrator filters and confirmed filters were dirty |
| DD | Licensed Practical Nurse (LPN) | Provided information about cleaning schedules and documentation for oxygen equipment |
| AA | Licensed Practical Nurse (LPN) | Confirmed physician's order for oxygen flow rate and verified oxygen was administered at incorrect rate |
| BB | Licensed Practical Nurse (LPN) | Confirmed care plan requirements for oxygen administration |
| DON | Director of Nursing | Provided expectations for following care plans and handling resident refusals |
| ADON | Assistant Director of Nursing | Confirmed oxygen flow rate discrepancies and resident's past adjustment of flow meter |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Aug 18, 2024
Visit Reason
A standard survey was conducted from August 16 to August 18, 2024, including investigation of multiple complaint intake numbers. The visit was to assess compliance with Medicare/Medicaid regulations and investigate complaints related to the facility.
Complaint Details
Complaint Intake Numbers GA00236704 and GA00247590 were substantiated without citations. Complaint Intake Numbers GA00244713 and GA00237033 were unsubstantiated.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to refer a resident for PASARR Level II screening, failure to follow care plans for oxygen therapy administration and equipment cleaning, and administering oxygen at incorrect flow rates for several residents. Some complaints were substantiated without citations, others were unsubstantiated.
Deficiencies (2)
Failure to refer one resident for PASARR Level II screening despite diagnoses of major depressive disorder, anxiety disorder, and schizoaffective disorder.
Failure to follow care plan related to correctly administering physician-ordered oxygen rates for two residents and failure to clean oxygen concentrator filters as ordered for two residents.
Report Facts
Residents receiving oxygen therapy: 15
Residents reviewed for PASARR screening: 29
Residents with oxygen administration issues: 4
Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Acknowledged responsibility for cleaning oxygen concentrator filters and noted issues with filter cleanliness. |
| LPN DD | Licensed Practical Nurse | Provided information on oxygen concentrator cleaning responsibilities and documentation. |
| Social Service Director | Interviewed regarding failure to submit PASARR Level II screening for resident R61. | |
| Director of Nursing | DON | Interviewed regarding communication failures related to PASARR screening and oxygen therapy care plan adherence. |
| MDS/Care Plan Coordinator | Interviewed regarding responsibilities for notifying SSD of mental health diagnoses and care plan development. | |
| LPN AA | Licensed Practical Nurse | Confirmed oxygen orders and care plan adherence issues for resident R41. |
| LPN BB | Licensed Practical Nurse | Confirmed oxygen administration as medication and care plan adherence for resident R41. |
| Assistant Director of Nursing | ADON | Confirmed oxygen flow rate discrepancies for resident R47. |
| Administrator | Acknowledged oxygen concentrator cleaning responsibilities and issues. |
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 5
Date: Aug 17, 2024
Visit Reason
The visit was a Life Safety Code Survey 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 with life safety requirements, including deficiencies in hazardous area door smoke resistance, sprinkler system maintenance, corridor door openings, smoke barrier wall integrity, and smoking regulations enforcement. These deficiencies could potentially affect all residents.
Deficiencies (5)
Facility failed to ensure all hazardous room doors resist passage of smoke; a gap exceeding 1/2 inch was observed at the Bio Hazard room door.
Sprinkler system was not properly maintained; sprinkler piping was used to support other trades in mechanical rooms.
Facility failed to ensure corridor doors resist passage of smoke; a transfer grill was installed on the beauty shop door used for combustible storage.
Smoke barrier walls were not properly maintained; a large penetration was found in the smoke barrier wall in the Mechanical Room behind the Activity Director's office.
Smoking policy was not followed; combustible trash was discarded in the smoking debris receptacle near the South Nurses' Station.
Report Facts
Census: 92
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 8/17/2024 |
Inspection Report
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Evergreen Health and Rehabilitation Center following a survey completed on August 7, 2023.
Findings
The report contains a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
A desk review survey was conducted on 8/7/2023 for Evergreen Health and Rehabilitation Center to verify correction of deficiencies from the 6/21/2023 survey.
Findings
All deficiencies identified in the 6/21/2023 survey were found to be corrected upon this desk review.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Jun 21, 2023
Visit Reason
A complaint survey was conducted at Evergreen Health and Rehabilitation Center on June 21, 2023, investigating three complaint intake numbers related to alleged resident-to-resident abuse.
Complaint Details
The complaint investigation involved three complaint intake numbers (GA00235354, GA00235450, GA00235625). The allegation was that resident R#2 touched resident R#1 inappropriately. The incident occurred on 5/15/2023 but was not reported to the state agency until 5/16/2023 at 2:49 p.m. The facility delayed reporting the abuse allegation and initially miscommunicated the nature of the incident to the Administrator and state agency.
Findings
The facility failed to protect a resident's right to be free from physical abuse by another resident and failed to report the alleged abuse incident to the state agency within two hours as required. The investigation revealed delays in reporting and inadequate initial communication about the abuse allegation.
Deficiencies (1)
Failure to protect a resident from physical abuse by another resident and failure to report the incident within two hours to the state agency.
Report Facts
Resident census: 90
Complaint intake numbers: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported the incident to the Administrator and was involved in the communication about the abuse allegation |
| LPN #2 | Licensed Practical Nurse | Received initial report from CNA#3 and communicated with LPN#1 about the incident |
| CNA #3 | Certified Nursing Assistant | Witnessed the alleged abuse and provided a written statement to the Director of Nursing |
| Administrator | Facility Administrator | Received the abuse allegation statement the day after the incident and initiated the investigation and reporting to the state agency and police |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
A State Licensure survey was conducted at Evergreen Health and Rehabilitation Center on June 21, 2023 to assess compliance with state health regulations.
Findings
The survey revealed there were no State Health deficiencies cited at the facility.
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Date: May 4, 2023
Visit Reason
A Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00234589 at Evergreen Health and Rehabilitation Center.
Complaint Details
Complaint #GA000234589 was unsubstantiated.
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 has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 91
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Dec 21, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Federal Monitoring Health Comparative Survey conducted on 2022-11-12.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected.
Inspection Report
Monitoring
Census: 91
Deficiencies: 2
Date: Nov 10, 2022
Visit Reason
A Federal Monitoring Health Comparative Survey was conducted by the Centers for Medicaid and Medicare Services from November 7 to November 10, 2022 to assess compliance with 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to deficiencies including failure to ensure confidentiality of resident medical records on one nursing unit and failure to obtain a physician's order for oxygen therapy and properly label/store oxygen delivery devices for one sampled resident.
Deficiencies (2)
Failure to ensure confidentiality of resident medical records for one of two nursing units, with resident charts facing out displaying names and code status visible to anyone at the nurses' station.
Failure to obtain a physician's order for oxygen therapy and failure to label and store oxygen delivery devices according to facility policy for one sampled resident (Resident #246).
Report Facts
Census: 91
Oxygen flow rate: 2.5
Number of resident charts with DNR stickers: 20
Number of resident charts with Full Code stickers: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | Observed and confirmed resident confidential information was visible at the nurses' station | |
| Licensed Practical Nurse (LPN) #1 | Acknowledged Resident #246 had unlabeled nasal cannula and uncovered nebulizer mask; confirmed no physician order for oxygen therapy | |
| Director of Nursing (DON) | Stated there should be an order for oxygen therapy and expected staff to maintain equipment per policy |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 10/18/22 through 10/21/22 to assess compliance for facility licensure.
Findings
No deficiencies were identified during the Licensure Survey conducted from 10/18/22 through 10/21/22.
Inspection Report
Routine
Census: 96
Deficiencies: 0
Date: Oct 21, 2022
Visit Reason
A standard survey was conducted from October 18, 2022 through October 21, 2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00228131, GA00228132, GA00226109, and GA00222476 were investigated with no deficiencies cited.
Findings
No deficiencies were cited as a result of the complaint investigations. The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Inspection Report
Life Safety
Census: 91
Capacity: 100
Deficiencies: 2
Date: Oct 19, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to newly installed screen doors swinging against the direction of egress and corridor doors failing to close to create a smoke tight barrier, affecting all residents and staff in the north hall area.
Deficiencies (2)
Newly installed screen doors on the back screened patio of the north hall swing against the flow of egress.
Corridor doors did not close to create a smoke tight seal in the north hall.
Report Facts
Census: 91
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door swing direction and smoke barrier door closure during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 14, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00216522 and #GA00217322.
Complaint Details
Complaints #GA00216522 and #GA00217322 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 3, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00216216.
Complaint Details
Complaint #GA00216216 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 21, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00214696, #GA002055628, #GA00205284, and #GA00201632.
Complaint Details
Investigation of complaints #GA00214696, #GA002055628, #GA00205284, and #GA00201632; complaints #GA00214696, #GA002055628, and #GA00205284 were unsubstantiated; complaint #GA00201632 was substantiated with no deficiencies cited.
Findings
Complaints #GA00214696, #GA002055628, and #GA00205284 were unsubstantiated with no deficiencies cited. Complaint #GA00201632 was substantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the November 10, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 77
Deficiencies: 1
Date: Nov 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not in compliance with infection control regulations due to failure to ensure proper cleaning and disinfecting of the COVID-19/PUI Unit. Nursing staff were using disinfectant products prior to cleaning surfaces and were not knowledgeable of the disinfecting products' contact times.
Deficiencies (1)
Failure to ensure proper cleaning and disinfecting of the COVID-19/PUI Unit, including improper use of disinfectant products and lack of knowledge of contact times.
Report Facts
Census: 77
Contact time for disinfectant products: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Responsible for cleaning and disinfecting the COVID-19/PUI Unit; stated contact times for disinfectants were 20 to 30 minutes |
| CNA BB | Certified Nursing Assistant | Designated CNA for cleaning and disinfecting the COVID-19/PUI Unit; stated contact times for bleach and Sani-wipes were 3 to 4 minutes |
| LPN CC | Licensed Practical Nurse | Reported CNAs responsible for cleaning and disinfecting; stated contact times were 4 minutes |
| CNA DD | Certified Nursing Assistant | Second shift CNA; stated contact time for bleach wipes was 2 hours |
| DON | Director of Nursing | Provided education and training to CNAs on cleaning and disinfecting the COVID-19/PUI Unit |
| Administrator | Provided education and training with demonstration on cleaning and disinfecting procedures for the COVID-19/PUI Unit | |
| ICP | Infection Control Practitioner | Unaware of correct Sani-wipe contact time initially; confirmed contact time as 3 minutes |
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Oct 5, 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: 78
Deficiencies: 0
Date: Sep 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on September 17-18, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR 483.13 related to emergency preparedness and 42 CFR 483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on July 14 - July 15, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 82
Inspection Report
Re-Inspection
Census: 96
Deficiencies: 0
Date: Oct 31, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted on 2019-09-06.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 15, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 92
Capacity: 100
Deficiencies: 3
Date: Sep 3, 2019
Visit Reason
The inspection was conducted as a Life Safety Code Survey and review of the Emergency Preparedness Plan to assess compliance with Medicare/Medicaid participation requirements and related fire safety codes.
Findings
The facility was found not in substantial compliance with emergency preparedness testing requirements, failing to conduct required full-scale and tabletop exercises. Additionally, deficiencies were found in fire alarm system maintenance, smoke detector sensitivity, and electrical wiring safety, placing residents at risk in emergencies.
Deficiencies (3)
Facility failed to conduct required full-scale and tabletop emergency preparedness exercises within the last year.
Fire alarm system testing and maintenance not in accordance with NFPA standards; smoke detectors not properly maintained with 13 of 25 detectors too old for sensitivity testing.
Electrical wiring deficiencies including use of surge protector for appliances and exposed wiring without junction boxes at exit sign connections.
Report Facts
Census: 92
Total Capacity: 100
Smoke Detectors Too Old: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness exercises, smoke detector testing, and electrical wiring deficiencies | |
| Staff A | Confirmed findings related to emergency preparedness exercises |
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Date: May 30, 2019
Visit Reason
A revisit survey was conducted on May 30, 2019 to verify correction of deficiencies cited in the April 12, 2019 complaint survey #GA00195322.
Complaint Details
The visit was a follow-up to complaint #GA00195322; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 12, 2019 complaint survey were found to be corrected.
Report Facts
Census: 95
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 1
Date: Apr 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00195322 regarding the facility's failure to provide a proper 30-day written discharge notice for one resident.
Complaint Details
Complaint number GA00195322 was substantiated with a deficiency related to failure to provide a proper written 30-day discharge notice for resident #1. The investigation included record reviews, interviews with family members, hospital social worker, Ombudsman, facility staff, and medical director.
Findings
The facility failed to provide a written 30-day discharge notice that included all required information for one resident out of three reviewed. Interviews and record reviews confirmed the notice was verbal and lacked required details such as the right to appeal and specific unmet needs.
Deficiencies (1)
Failure to provide a written 30-day discharge notice including required information such as reasons for transfer, right to appeal, and legal counsel for one resident.
Report Facts
Resident census: 86
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to verbal 30-day notice and discharge process for resident #1. | |
| Social Worker | Hospital Social Worker | Involved in discharge planning and communication about 30-day notice. |
| Medical Director | Facility Medical Director | Interviewed regarding discharge plans and 30-day notice for resident #1. |
Inspection Report
Deficiencies: 1
Date: Apr 12, 2019
Visit Reason
The inspection was conducted to investigate the facility's compliance with regulations regarding the provision of a written 30-day discharge notice to residents, specifically for one resident (R#1) who was discharged without proper written notice.
Findings
The facility failed to provide a written 30-day discharge notice containing all required information for one resident out of three reviewed for transfer/discharge. The notice was given verbally but lacked documentation of specific needs, right to appeal, and legal counsel information. Family members and the Ombudsman were not properly informed in writing.
Deficiencies (1)
Failure to provide a written 30-day discharge notice including required information for one resident.
Report Facts
Residents reviewed for transfer/discharge: 3
Brief Interview for Mental Status score: 3
Date of verbal 30-day notice: Feb 20, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to verbal and written 30-day discharge notice and interviews regarding discharge process | |
| Medical Director | Discussed discharge plans and 30-day notice with Administrator and Director of Nursing | |
| Social Worker | Hospital Social Worker involved in discharge planning and communication with facility |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 15, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00190987, GA00191380, and GA00191866.
Complaint Details
Complaint GA00190987 was substantiated related to resident-to-resident abuse with no regulatory violations.
Findings
Complaint GA00190987 was substantiated related to resident-to-resident abuse, but no regulatory violations were found.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Aug 15, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/14/18 standard survey.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 2, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 12, 2018
Visit Reason
A complaint survey was conducted on 7/12/18 to investigate complaints #GA00189541 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00189541 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Life Safety
Census: 85
Capacity: 100
Deficiencies: 5
Date: Jun 12, 2018
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 with life safety requirements, including failure to provide smoke detectors for door release at cross corridor doors, inadequate emergency lighting, improper fire stopping in smoke barriers, unsafe electrical wiring and equipment, and lack of metal containers with self-closing lids in designated smoking areas.
Deficiencies (5)
Failed to provide smoke detectors for door release at cross corridor doors held open with automatic release devices, placing 21 residents at risk.
Failed to maintain emergency lighting of at least 1-1/2 hour duration; exterior emergency lights did not work on battery power.
Failed to properly fire stop through penetrations in smoke barriers to maintain a ½ hour fire resistant rating.
Failed to ensure electrical wiring and equipment compliance with NFPA 70; issues included use of surge protector as extension cord, improperly mounted receptacle, and open junction box.
Failed to provide metal containers with self-closing lid devices for designated resident smoking areas.
Report Facts
Residents at risk due to missing smoke detectors: 21
Census: 85
Total licensed beds: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 8, 2017
Visit Reason
A complaint survey was conducted to investigate Complaint #182791 at Evergreen Health & Rehabilitation Center.
Complaint Details
Complaint #182791 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 20, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during this follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 25, 2017
Visit Reason
A Health Revisit Survey was conducted to verify correction of previously cited deficiencies.
Findings
The revisit survey revealed that previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 18, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies related to emergency power generator installation and maintenance.
Findings
The facility failed to ensure the emergency power generator was properly installed and maintained, including lack of a required remote annunciator and inadequate testing documentation. These deficiencies could place residents and staff at risk during an emergency.
Deficiencies (2)
Failed to ensure emergency power generator is properly installed; no remote annunciator installed as required by code.
Failed to ensure emergency powered generator was properly tested and maintained; documentation showed weekly runs not under load and no load bank test documentation.
Report Facts
Survey completion date: Sep 18, 2017
Time of observations: 1005
Time of observations: 1015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding emergency power generator installation and maintenance during facility tour |
Inspection Report
Life Safety
Census: 89
Capacity: 100
Deficiencies: 5
Date: Jul 25, 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 the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper installation and monitoring of the fire alarm system, inadequate smoking area safety provisions, lack of emergency lighting in the medication preparation room, absence of a remote annunciator for the emergency generator, and failure to maintain proper records for emergency generator testing and maintenance.
Deficiencies (5)
Fire alarm power circuit breaker is not red or equipped with lockout to prevent power source from being shut off.
Smoking areas lacked proper ashtrays and metal containers with self-closing lids; smoking materials were improperly disposed on the ground.
North wing medication preparation room was not equipped with emergency lighting.
No remote annunciator that is storage battery powered provided outside the emergency generator room to indicate alarm conditions.
Facility failed to maintain proper documentation of run time, run schedule, duration under load, transfer time, or load bank testing for the emergency generator supplying the south wing.
Report Facts
Census: 89
Total Capacity: 100
Residents at risk due to lack of emergency lighting: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the inspection |
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