Deficiencies per Year
16
12
8
4
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 0
Apr 3, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Fairburn Heights to investigate Complaint Intake Number GA00254460.
Findings
The complaint was found unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint Intake Number GA00254460 was investigated and found unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 98
Deficiencies: 0
Feb 25, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00253923 and GA00249853.
Findings
The complaints GA00249853 and GA00253923 were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00249853 and GA00253923 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Oct 10, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification-Complaint Survey concluded on 2024-08-05.
Findings
All deficiencies cited in the prior Recertification-Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Oct 10, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification-Complaint Survey concluded on August 5, 2024.
Findings
All deficiencies cited as a result of the prior Recertification-Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint-related survey concluded on August 5, 2024; all prior deficiencies were corrected.
Report Facts
Facility census: 108
Inspection Report
Follow-Up
Deficiencies: 0
Oct 7, 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
Original Licensing
Census: 112
Deficiencies: 3
Aug 5, 2024
Visit Reason
A Licensure Survey was conducted from 7/30/2024 through 8/5/2024 to assess compliance with regulatory requirements for Fairburn Health Care Center.
Findings
The facility failed to ensure residents were served palatable and appetizing meals, had a medication error rate exceeding 5% for three residents, and failed to document communication between facility staff and dialysis staff for one resident receiving dialysis.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure residents were served meals that were palatable, appetizing, and attractive, potentially affecting 97 of 112 residents on an oral diet. |
| The facility failed to ensure a medication error rate of less than 5% during medication administration for three of six residents, with an observed error rate of 8.57%. |
| The facility failed to ensure communication was documented between facility staff and dialysis staff for one resident receiving dialysis, with missing and incomplete dialysis communication forms. |
Report Facts
Residents affected by dietary deficiency: 97
Total residents census: 112
Medication error rate: 8.57
Medication administration opportunities observed: 35
Medication errors observed: 3
Missing dialysis forms: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Dietary Manager | Named in dietary service deficiency related to meal substitutions and menu deviations |
| LL | Registered Dietitian | Interviewed regarding menu posting and alternate meal choices |
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration errors | |
| DON | Director of Nursing | Interviewed regarding medication administration expectations and dialysis communication form completion |
| LL | Medical Record / Business Office Manager Staff | Interviewed regarding dialysis communication form handling and electronic system uploads |
| LPN II | Licensed Practical Nurse | Confirmed missing dialysis communication documentation |
Inspection Report
Routine
Census: 112
Deficiencies: 13
Aug 5, 2024
Visit Reason
A standard survey was conducted at Fairburn Health Care Center from July 30, 2024, through August 5, 2024, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies in medication administration, resident self-administration assessments, resident rights related to meals and snacks, bed hold policy notification, PASARR screening, discharge summaries, accident hazard prevention, respiratory care, dialysis communication, medication error rates, meal quality, snack availability, food safety and sanitation, and infection control related to labeling and storage of bedpans and urinals.
Complaint Details
Complaints GA00245204, GA00244253, GA00244825, and GA00243196 were substantiated. Other complaints investigated were unsubstantiated.
Severity Breakdown
SS= D: 9
SS= E: 3
SS= F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to assess four of 65 sampled residents for ability to self-administer medications before leaving medications at bedside. | SS= D |
| Failed to honor residents' rights to make choices related to meals and snacks affecting 108 of 112 residents. | SS= D |
| Failed to provide bed hold information in writing at time of transfer or within 24 hours for one resident. | SS= D |
| Failed to identify and submit PASARR Level 2 review for one resident. | SS= D |
| Failed to reconcile all pre-discharge medications with post-discharge medications for one resident. | SS= D |
| Failed to provide a safe environment free from accident hazards for three residents due to hazardous items and clutter. | SS= D |
| Failed to provide effective oxygen therapy for four residents; missing physician orders and improper oxygen management. | SS= D |
| Failed to ensure communication was documented between facility staff and dialysis staff for one resident. | SS= D |
| Medication error rate exceeded 5% with three medication errors out of 35 opportunities. | SS= E |
| Failed to ensure residents were served meals that were palatable, appetizing, and attractive; substitutions and limited menu options noted. | SS= E |
| Failed to ensure meals and snacks were served at times per resident needs and preferences; nourishing snacks not provided at non-traditional times. | SS= D |
| Failed to ensure food was properly labeled, stored, and prepared in sanitary conditions; multiple sanitation and maintenance deficiencies in kitchen. | SS= F |
| Failed to ensure safe, sanitary environment and prevent infection by not labeling and properly storing bath basins, bedpans, and urinals in eight rooms. | SS= E |
Report Facts
Medication error rate: 8.57
Facility census: 112
Residents affected by meal/snack issues: 108
Residents affected by snack availability: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN QQ | Licensed Practical Nurse | Confirmed medication administration issues and oxygen therapy concerns. |
| LPN II | Licensed Practical Nurse | Confirmed medication and oxygen therapy observations. |
| DON | Director of Nursing | Provided multiple confirmations and explanations regarding deficiencies and expectations. |
| DM CC | Dietary Manager | Discussed meal substitutions, snack availability, and kitchen conditions. |
| RD LL | Registered Dietitian | Discussed menu planning and resident meal choices. |
| CNA BB | Certified Nursing Assistant | Discussed labeling and storage of bedpans and urinals. |
| LPN JJ | Licensed Practical Nurse | Reported on snack availability and meal service. |
| Medical Record Staff LL | Medical Record/Business Office Manager | Discussed dialysis communication form handling. |
Inspection Report
Life Safety
Census: 112
Capacity: 120
Deficiencies: 5
Jul 31, 2024
Visit Reason
The visit was a 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 Code requirements, with deficiencies related to kitchen hood extinguishment system maintenance, unsecured ceiling openings allowing smoke transfer, blocked access to fire alarm and electrical panels, and missing fire detection sensitivity documentation.
Severity Breakdown
D: 2
E: 2
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to properly maintain the kitchen hood extinguishment system; one of four nozzles was missing a protective cap. | D |
| Facility failed to secure ceiling openings preventing smoke transfer; broken or missing ceiling tiles in riser and storage rooms. | E |
| Facility failed to secure access to the hood system activation station; it was blocked by a large serving cart. | E |
| Facility failed to maintain evidence of the fire detection sensitivity report; test could not be located. | F |
| Facility failed to maintain access to the electrical panel box in the kitchen; access blocked by a serving cart. | D |
Report Facts
Census: 112
Total Capacity: 120
Number of nozzles in hood extinguishment system: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during tour of facility on 7/31/2024 |
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Jun 18, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00247747.
Findings
The complaint #GA00247747 was substantiated with no deficiency cited.
Complaint Details
Complaint #GA00247747 was substantiated with no deficiency cited.
Report Facts
Census: 101
Inspection Report
Routine
Deficiencies: 1
Dec 11, 2023
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 12/04/2023 and 12/10/2023 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
Deficiencies: 1
Nov 20, 2023
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 11/13/2023 and 11/19/2023 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
Abbreviated Survey
Census: 106
Deficiencies: 0
Oct 30, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00240395 and #GA00239908.
Findings
The complaints #GA00240395 and #GA00239908 were unsubstantiated with no deficiencies cited during the survey.
Complaint Details
Complaints #GA00240395 and #GA00239908 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 12, 2023
Visit Reason
The facility was surveyed due to 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 06/05/2023 and 06/11/2023 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
Abbreviated Survey
Deficiencies: 0
Mar 29, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00233366 and #GA00232111 at Fairburn Health Care Center.
Findings
Complaint #GA00233366 was substantiated with no regulatory violations cited, and complaint #GA00232111 was unsubstantiated with no regulatory violations cited.
Complaint Details
Complaint #GA00233366 was substantiated with no regulatory violations cited. Complaint #GA00232111 was unsubstantiated with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Feb 22, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Fairburn Health Care Center, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided page; only initial comments are noted without further elaboration.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Feb 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 12/15/22 Recertification and Complaint Survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 99
Capacity: 120
Deficiencies: 0
Dec 27, 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 to be in compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Report Facts
Census: 99
Certified Beds: 120
Inspection Report
Renewal
Deficiencies: 3
Dec 15, 2022
Visit Reason
A Licensure Survey was conducted from 12/12/22 through 12/15/22 to assess compliance with licensure requirements for Fairburn Health Care Center.
Findings
The facility failed to provide adequate care and treatment to promote healing and prevent deterioration of pressure ulcers for one sampled resident (R#101), including failure to complete weekly skin assessments, measurements, and treatments as ordered. Additionally, sanitary practices in the kitchen were deficient, including improper dishwashing and food storage practices.
Deficiencies (3)
| Description |
|---|
| Failure to complete weekly skin assessments, measurements, and treatments for pressure ulcers resulting in deterioration of a stage 2 wound to an unstageable wound for resident R#101. |
| Failure to ensure dishes were properly washed and allowed to air dry before stacking/storing in the kitchen. |
| Failure to ensure food items were stored off the floor in the freezer. |
Report Facts
Residents with pressure ulcers identified: 9
Residents potentially affected by kitchen deficiencies: 94
Missed treatments: 14
Missed treatments: 14
Missed treatments: 10
Missed treatments: 3
Missed treatments: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding pressure injury care and skin checks for resident R#101. |
| Consultant Wound Nurse Practitioner | Wound Nurse Practitioner | Provided wound care consultation and assessments for resident R#101. |
| Registered Dietitian | Registered Dietitian | Provided nutrition assessments and recommendations for resident R#101. |
| LPN #5 | Licensed Practical Nurse | Provided care for resident R#101 and discussed wound care and skin assessments. |
| CNA #13 | Certified Nursing Assistant | Provided care for resident R#101 and discussed positioning and wound care. |
| Director of Nursing | Director of Nursing | Discussed expectations for skin assessments, treatments, and wound care. |
| Administrator | Facility Administrator | Discussed facility expectations for wound care, skin assessments, and treatment completion. |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding kitchen sanitation and food storage practices. |
| Dietary Aide #9 | Dietary Aide | Observed improperly stacking dishes and cups in the kitchen. |
| Dietary Aide #10 | Dietary Aide | Observed restacking wet cups and drying them with a cloth. |
| Dietary Aide #11 | Dietary Aide | Observed drying wet plate covers on the lunch tray line. |
Inspection Report
Routine
Census: 101
Deficiencies: 5
Dec 15, 2022
Visit Reason
A standard survey was conducted at Fairburn Health Care Center from December 12, 2022 through December 15, 2022, including investigation of complaint intake numbers GA00226438, GA00226953, and GA00227013.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to thoroughly investigate and report an injury of unknown origin, failure to revise a care plan to include post-fall interventions, failure to provide adequate care and treatment to promote healing of pressure ulcers resulting in deterioration of a wound, failure to obtain a physician's order for oxygen use, and failure to ensure sanitary practices in the kitchen.
Complaint Details
Complaint Intake Numbers GA00226438, GA00226953, and GA00227013 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 3
SS= G: 1
SS= F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to thoroughly investigate an injury of unknown origin and report to the State Agency for one resident. | SS= D |
| Failed to revise a comprehensive care plan to include a post-fall intervention of a fall mat for one resident. | SS= D |
| Failed to provide care and treatment to promote healing of pressure ulcers and prevent new ulcers, resulting in deterioration from stage 2 to unstageable wound for one resident. | SS= G |
| Failed to obtain a physician's order for oxygen use for one resident. | SS= D |
| Failed to ensure sanitary practices in the kitchen including improper washing and drying of dishes and improper food storage off the floor. | SS= F |
Report Facts
Resident census: 101
Fall Risk Evaluation score: 14
BIMS score: 4
BIMS score: 15
Oxygen liters per minute: 2.5
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for skin assessments and reporting injuries | |
| Administrator | Interviewed regarding expectations for incident reporting and wound care | |
| Nurse Practitioner | Consulted on wound care and interviewed about wound assessments and treatments | |
| Hospice Case Manager | Interviewed regarding resident's falls and skin condition during hospice care | |
| Licensed Practical Nurse | Interviewed regarding wound care treatments and skin assessments | |
| Certified Dietary Manager | Interviewed regarding kitchen sanitation and food storage practices | |
| Registered Dietitian | Interviewed regarding nutritional recommendations and wound healing |
Inspection Report
Re-Inspection
Census: 101
Deficiencies: 0
Sep 8, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior inspection dated 7/12/22.
Findings
All deficiencies cited as a result of the 7/12/22 inspection were found to be corrected during the revisit survey.
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 1
Jul 12, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00225621, GA00225126, and GA00224908.
Findings
The facility was found to have an ineffective pest control program, with flies observed in multiple rooms and widespread roach infestations confirmed by staff and residents throughout the facility.
Complaint Details
Complaints GA00225621, GA00224908, and GA00225126 were substantiated with deficiencies related to pest control issues.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain an effective pest control program related to flies observed in one of three halls and pest infestation throughout the facility. | E |
Report Facts
Facility census: 102
Inspection Report
Abbreviated Survey
Census: 102
Deficiencies: 0
Apr 25, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Survey to investigate complaint #GA00220554 was conducted.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices. The complaint was unsubstantiated with no regulatory violations cited.
Complaint Details
Complaint #GA00220554 was unsubstantiated with no regulatory violations cited.
Report Facts
Total census: 102
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 25, 2022
Visit Reason
The inspection was conducted as a complaint investigation; however, the complaint was closed as no regulatory allegations were included and no contact information was provided for the complainant.
Findings
No regulatory allegations were found during the investigation, and the complaint was closed due to lack of contact information for follow-up.
Complaint Details
Complaint closed as no regulatory allegations were included. No contact information was provided so there is no way to contact the complainant for information.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Jul 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating three complaint numbers (#GA00210291, #GA00215877, and #GA00213601).
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
Complaints #GA00210291, #GA00215877, and #GA00213601 were investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Total census: 88
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Dec 16, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous complaint survey dated 11/5/2020.
Findings
All deficiencies cited in the 11/5/2020 complaint survey were found to be corrected during the revisit survey.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Nov 5, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00205138, #GA00205117, and #GA00208002. The survey included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found not in compliance with infection control regulations, specifically failing to ensure staff used masks appropriately to prevent the spread of COVID-19. Complaint #GA00205117 was substantiated with a deficiency, while the other complaints were unsubstantiated.
Complaint Details
Complaint #GA00205117 was substantiated with a deficiency related to infection control and mask usage. Complaints #GA00205138 and #GA00208002 were unsubstantiated.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff were using masks appropriately to prevent the spread of coronavirus (COVID-19) infection, including staff and leadership not wearing facemasks or wearing cloth masks instead of appropriate PPE. | E |
Report Facts
COVID-19 positive residents: 35
COVID-19 positive staff: 4
Complaint investigations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in findings for not wearing facemask and allowing staff to wear cloth masks instead of appropriate PPE |
| Administrator | Administrator | Named in findings for not wearing facemask and lack of infection control policy regarding mask usage |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Wore cloth mask and believed it was acceptable due to lack of instruction |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Wore cloth mask as PPE despite being informed it was not acceptable |
| Licensed Practical Nurse DD | Licensed Practical Nurse | Wore cloth mask as PPE despite being informed it was not acceptable |
| Certified Nursing Assistant EE | Certified Nursing Assistant | Wore cloth mask and was not told it was unacceptable |
| Certified Nursing Assistant FF | Certified Nursing Assistant | Wore cloth mask instead of facility facemask despite availability |
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Jun 23, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at Fairburn Health Care Center on June 23, 2020.
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 for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 4, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00200595 and GA00201417.
Findings
The complaints were found to be unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints GA00200595 and GA00201417 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Sep 27, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey on 8/8/19.
Findings
All deficiencies cited as a result of the 8/8/19 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 24, 2019
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
Census: 88
Deficiencies: 4
Aug 8, 2019
Visit Reason
A standard survey was conducted from August 5 to August 8, 2019, including investigation of Complaint GA00198480, to assess compliance with Medicare/Medicaid regulations for Fairburn Health Care Center.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain resident privacy during financial discussions, inadequate comprehensive care plans for residents with specific needs, failure to follow physician orders for compression wraps, and failure to document and provide adequate incontinence care for residents.
Complaint Details
Complaint GA00198480 was investigated in conjunction with the standard survey, focusing on privacy violations and care deficiencies.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain privacy during discussion of financial matters for resident #52 with roommate present. | SS=D |
| Failure to develop and implement a comprehensive care plan with appropriate goals and interventions for resident #46 with NPO status and failure to follow care plan for resident #83 related to bilateral compression leg wraps. | SS=D |
| Failure to follow physician's order for resident #83 regarding application and removal of compression wraps on both legs. | SS=D |
| Failure to document Activities of Daily Living (ADLs) related to bowel and bladder incontinence for residents #83 and #1, and failure to provide timely incontinence care leading to skin irritation and breakdown. | SS=D |
Report Facts
Resident census: 88
Sample size: 33
Missing documentation days: 9
Missing documentation days: 12
Missing documentation days: 3
BIMS score: 14
BIMS score: 15
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Social Worker (SW) | Involved in privacy violation discussion with resident #52 |
| Business Office Manager | Business Office Manager (BOM) | Involved in privacy violation discussion with resident #52 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan development and compression wrap procedures |
| Licensed Practical Nurse AA | Licensed Practical Nurse (LPN) | Interviewed regarding resident #83 care and compression wrap procedures |
| Certified Nursing Assistant BB | Certified Nursing Assistant (CNA) | Interviewed regarding compression wrap application for resident #83 |
| Certified Nursing Assistant CC | Certified Nursing Assistant (CNA) | Interviewed regarding compression wrap application for resident #83 |
| Certified Nursing Assistant DD | Certified Nursing Assistant (CNA) | Interviewed regarding compression wrap application for resident #83 |
| Treatment Nurse | Treatment Nurse (TN) | Observed skin integrity for resident #1 |
| Licensed Practical Nurse FF | Licensed Practical Nurse (LPN) | Observed skin integrity for resident #1 |
| Certified Nursing Assistant EE | Certified Nursing Assistant (CNA) | Performed peri-care for resident #1 |
| Corporate MDS Director | MDS Director | Interviewed regarding ADL documentation |
| Certified Nursing Assistant GG | Certified Nursing Assistant (CNA) | Interviewed regarding ADL care and rounding |
| Certified Nursing Assistant HH | Certified Nursing Assistant (CNA) | Interviewed regarding ADL care and rounding |
Inspection Report
Routine
Census: 88
Deficiencies: 3
Aug 8, 2019
Visit Reason
The inspection was conducted to evaluate compliance with nursing care, comprehensive care planning, and medical record documentation requirements for residents, including follow-up on physician orders and care plans.
Findings
The facility failed to follow a physician's order for compression wrapping for one resident, failed to develop and implement an appropriate comprehensive care plan for another resident with NPO status, and failed to document activities of daily living related to bowel and bladder incontinence for two residents. Interviews revealed lapses in staff training and documentation.
Deficiencies (3)
| Description |
|---|
| Failure to follow physician's order for compression wrapping for resident R#83. |
| Failure to develop and implement a comprehensive care plan with appropriate goals and interventions for resident R#46 with NPO nutritional status. |
| Failure to document Activities of Daily Living (ADLs) for bowel and bladder incontinence for residents R#83 and R#1. |
Report Facts
Facility census: 88
Sample size: 33
Missing documentation days: 9
Missing documentation days: 12
Missing documentation days: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Interviewed regarding resident R#83's compression wrap care and facility procedures. |
| CNA BB | Certified Nursing Assistant | Interviewed about wrapping resident R#83's legs with compression wraps. |
| CNA CC | Certified Nursing Assistant | Interviewed about care and wrapping of resident R#83. |
| CNA DD | Certified Nursing Assistant | Interviewed regarding allegations of wrapping resident R#83's legs and incontinent care. |
| Director of Nursing | Director of Nursing | Interviewed about staff training and care plan responsibilities related to compression wraps and documentation. |
| Regional Corporate Nurse | Regional Corporate Nurse | Interviewed regarding care plan evaluation and correction for resident R#46. |
Inspection Report
Life Safety
Census: 89
Capacity: 120
Deficiencies: 2
Aug 5, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) standards.
Findings
The facility was found not in substantial compliance with fire safety requirements due to deficiencies including a loaded sprinkler head that could delay activation and blocked access to an electrical shutoff panel. These issues could place staff and residents at risk in the event of fire or electrical incidents.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Sprinkler head in the hallway near the laundry was found loaded and could delay sprinkler activation. | SS= D |
| Items on a cart were blocking access to an electrical panel in the kitchen, impeding prompt access to electrical shutoff devices. | SS= D |
Report Facts
Staff at risk: 3
Residents at risk: 20
Staff at risk: 7
Residents at risk: 30
Census: 89
Total capacity: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler head and electrical panel blockage during facility tour |
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 0
Jun 26, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00197535.
Findings
The complaint was substantiated with no deficiencies found during the survey.
Complaint Details
The complaint was substantiated with no deficiencies.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Jun 25, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on 2019-05-07.
Findings
All deficiencies cited as a result of the 5/7/19 complaint survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 2019-05-07; all cited deficiencies were corrected.
Report Facts
Census: 93
Inspection Report
Complaint Investigation
Deficiencies: 2
May 7, 2019
Visit Reason
An Abbreviated Partial Extended Survey was conducted on 5/7/19 to investigate complaint GA00195735, which was substantiated with deficiencies.
Findings
The facility failed to develop and implement baseline care plans that included instructions needed to provide effective and person-centered care for residents, specifically for two residents reviewed (R#1 and R#4). Both residents were identified as fall risks but their baseline care plans lacked goals and interventions to address falls. Multiple falls occurred for both residents without adequate supervision or documented interventions. Staff interviews revealed lack of written communication and documentation of resident care needs, including falls risk, to nursing assistants.
Complaint Details
The complaint GA00195735 was substantiated with deficiencies related to inadequate baseline care plans and failure to prevent falls for residents R#1 and R#4.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop and implement baseline care plans with goals and interventions for fall risk residents. | SS= D |
| Failure to ensure resident environment was free of accident hazards and provide adequate supervision to prevent falls. | SS= D |
Report Facts
Resident falls: 5
Sample size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding baseline care plans and falls risk; stated she writes summaries and passes information to nurses. |
| Registered Nurse Supervisor AA | Registered Nurse Supervisor | Unable to provide evidence of interventions in EMR or elsewhere in resident records. |
| Certified Nursing Assistants BB and CC | Certified Nursing Assistants | Stated they are not provided written information on resident care or falls risk. |
| Licensed Practical Nurses DD and EE | Licensed Practical Nurses | Stated they give verbal reports to CNAs but no written documentation of resident care needs. |
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
May 6, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on 2019-03-13.
Findings
All deficiencies cited as a result of the 3/13/19 complaint survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 3/13/19; all cited deficiencies were corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 26, 2019
Visit Reason
An abbreviated, partial, extended survey was conducted to investigate complaint # GA00195368.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint # GA00195368 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 13, 2019
Visit Reason
An abbreviated survey was conducted to investigate a complaint (GA Compliant Number 00194807) regarding the care of a resident with a pressure ulcer.
Findings
The facility failed to provide evidence of treatment as ordered for a pressure ulcer for one resident of six sampled residents. The wound care nurse did not recall the resident or have treatment documents, and the Director of Nursing and Regional Nurse Consultant could not provide evidence of wound treatment.
Complaint Details
The complaint was substantiated as the facility failed to provide appropriate treatment and documentation for a resident's pressure ulcer.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide evidence of treatment as ordered for a pressure ulcer for one resident. | SS= D |
Report Facts
Resident sample size: 6
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1
Pressure ulcer measurements: 0.01
Pressure ulcer surface area: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported baseline care plan development and lack of wound treatment documentation for resident #1 |
| Regional Nurse Consultant | Regional Nurse Consultant | Reported lack of wound treatment documentation and care for resident #1 |
| Wound Care Nurse | Wound Care Nurse | Interviewed and reported no recollection or documentation of wound treatment for resident #1 |
Inspection Report
Abbreviated Survey
Census: 90
Deficiencies: 0
Jan 2, 2019
Visit Reason
An abbreviated survey was conducted on 1/2/19 and 1/4/19 to investigate complaint GA00193405.
Findings
The complaint was unsubstantiated.
Complaint Details
Complaint GA00193405 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2018
Visit Reason
A complaint survey was conducted on 8/28/18 to 8/29/18 to investigate complaints #GA 00190394 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 investigation for complaint #GA 00190394; no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Jul 25, 2018
Visit Reason
An unannounced complaint survey was conducted to investigate complaint # GA 00185973 at Fairburn Healthcare Center.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 for Long Term Care Facilities.
Complaint Details
Investigation of complaint # GA 00185973; facility found in substantial compliance.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Jul 18, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the May 24, 2018 Recertification Survey.
Findings
All deficiencies cited in the previous May 24, 2018 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 9, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 95
Capacity: 120
Deficiencies: 5
May 21, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with fire safety requirements, including missing instructional placards on kitchen fire extinguishers, sprinkler system maintenance issues, resident room doors not properly resisting smoke passage, and electrical safety hazards such as unprotected power strips and missing receptacle covers.
Severity Breakdown
D: 1
E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| K-Class Fire extinguisher did not have the required instructional placard posted above the unit. | D |
| Sprinkler system had loaded heads in the laundry and three locations needed height adjustments. | E |
| Two resident room doors (Rm#207 & Rm#408) were not setting tightly in the frame to resist smoke passage and did not close properly without moderate effort. | E |
| Multiple Outlet Power Strips (MOPS) were found unprotected on floors in Business Offices (2 locations). | E |
| An electrical receptacle in the middle of the kitchen was without a receptacle cover to protect from accidental finger insertion. | E |
Report Facts
Staff and Residents at risk: 40
Staff and Residents at risk: 45
Staff at risk: 2
Staff at risk: 3
Census: 95
Total Capacity: 120
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 29, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00186507.
Findings
The complaint investigated during the abbreviated survey was found to be unsubstantiated.
Complaint Details
Complaint #GA00186507 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 6, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00182140 initiated on 2017-12-05 and concluded on 2017-12-06.
Findings
The complaint was unsubstantiated, and no deficiencies with severity levels were reported in the document.
Complaint Details
Complaint GA00182140 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 26, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181209 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Fairburn Health Care Center.
Complaint Details
Complaint #GA00181209 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 14, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180470 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00180470 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 22, 2017
Visit Reason
A follow-up to the Recertification survey of 7/20/2017 was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 8/30/2017.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 7, 2017
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
Life Safety
Census: 106
Capacity: 108
Deficiencies: 6
Jul 17, 2017
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 self-closing doors to hazardous areas, lack of identification and locking of the fire alarm control panel circuit breaker, failure to electronically monitor fire sprinkler system valves, inadequate smoke barrier fire resistance, presence of prohibited portable space heaters, and unprotected electrical wiring connections.
Severity Breakdown
SS= D: 5
SS= E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide self-closing or automatic closing doors to hazardous areas including the Bio Hazard room and storage room in 400 Hall. | SS= D |
| Failed to identify the circuit disconnecting means location and circuit breaker for the fire alarm control panel, and failed to provide a tamper lock on the breaker. | SS= D |
| Failed to electronically monitor the water control valves for the fire sprinkler system, including the post indicator valve and OS&Y valves. | SS= E |
| Failed to maintain smoke barriers to provide a one half hour fire resistance rating; fire sprinkler pipe penetration above suspended ceiling at 400 Hall separation doors not sealed. | SS= D |
| Failed to prohibit portable space heating devices; a portable space heater was found under the administrator's desk. | SS= D |
| Failed to protect electrical wiring connections; open junction box and receptacle without cover plate above suspended ceiling at 400 Hall separation doors. | SS= D |
Report Facts
Residents at risk due to hazardous doors: 24
Residents at risk due to smoke barrier deficiency: 44
Residents at risk due to portable space heaters: 26
Residents at risk due to electrical wiring deficiencies: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 3, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00162310.
Findings
The complaint was found to be unsubstantiated due to lack of evidence.
Complaint Details
Complaint GA00162310 was investigated and found unsubstantiated due to lack of evidence.
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