Inspection Reports for Florence Hand Home
200 MEDICAL DRIVE, LAGRANGE, GA, 30240
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 10, 2024, found no deficiencies after a revisit survey confirmed correction of prior issues cited in July 2024. Earlier inspections showed deficiencies related to dining assistance, chemical storage hazards, and food storage and sanitation, but these were addressed by the time of the latest revisit. Prior complaint investigations were mostly unsubstantiated, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility also had a past enforcement action in August 2022 for incomplete COVID-19 reporting but has since demonstrated compliance with infection control and emergency preparedness requirements. The overall trend suggests improvement, with recent inspections showing resolution of previously cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
108 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Florence Hand Home, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the report; only initial comments are noted without further elaboration.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Date: Sep 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the July 25, 2024 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 106
Deficiencies: 3
Date: Jul 25, 2024
Visit Reason
A State Licensure survey was conducted at Florence Hand Home from July 23, 2024, through July 25, 2024, to assess compliance with state health and safety regulations.
Findings
The survey revealed deficiencies including failure to provide proper dining assistance to a resident, unsafe chemical storage in a resident's bathroom, and improper food storage and labeling in the kitchen cooler and resident nourishment pantries, placing residents at risk for unmet care needs, chemical incidents, and foodborne illness.
Deficiencies (3)
Failed to provide dining assistance to one of 13 residents (R38), with flatware left wrapped and inaccessible during meal setup.
Failed to provide an environment free from chemical hazards for one of four residents (R91), with multiple chemical products found in the resident's bathroom.
Failed to ensure food items in the kitchen cooler and resident nourishment pantries were properly stored and labeled with open or discard dates, and failed to maintain the ice maker in a clean and sanitary manner.
Report Facts
Residents consuming oral diet: 106
Residents observed for dining assistance: 13
Residents reviewed for accident hazards: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Unit Support Associate | Interviewed regarding meal tray delivery and flatware setup for resident R38 |
| HH | Licensed Practical Nurse | Interviewed and confirmed flatware was wrapped and inaccessible during meal setup for resident R38 |
| II | Certified Nursing Assistant | Interviewed and acknowledged responsibility for meal tray delivery and flatware setup for resident R38 |
| EE | Wound Care Nurse | Confirmed presence and removal of aerosol spray can with unknown substance in resident R91's bathroom |
| DD | Bath Technician | Interviewed regarding observation of household chemicals in resident R91's bathroom |
| FF | Registered Nurse | Confirmed expectation for staff to remove chemical items from resident rooms and take them to the nurse |
| BB | Sous Chef | Interviewed about food labeling and storage practices in the kitchen |
| CDM | Certified Dietary Manager | Interviewed about food labeling education and ice maker cleaning practices |
| Administrator | Provided information on ice maker cleaning schedule |
Inspection Report
Routine
Census: 108
Deficiencies: 3
Date: Jul 25, 2024
Visit Reason
A standard survey was conducted at Florence Hand Home from July 23, 2024, through July 25, 2024, to assess compliance with Medicare/Medicaid regulations for long-term care facilities.
Findings
The survey identified multiple deficiencies including failure to provide proper dining assistance to a resident, failure to maintain a chemical-free environment for residents, and failure to ensure proper food storage and sanitation in the kitchen and nourishment pantries, placing residents at risk for unmet care needs, chemical hazards, and foodborne illness.
Deficiencies (3)
Failed to provide dining assistance to one resident (R38), including unwrapping flatware and proper meal setup.
Failed to provide an environment free from chemical hazards for one resident (R91), with chemical items found in the resident's bathroom.
Failed to ensure food items in the kitchen cooler were properly stored and labeled with open or discard dates, failed to dispose of expired foods in a resident nourishment pantry, and failed to maintain an ice maker in a clean and sanitary manner.
Report Facts
Residents present: 108
Residents consuming oral diet: 106
Dates of survey: July 23, 2024 through July 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Unit Support Associate | Interviewed regarding meal tray delivery and flatware setup for resident R38 |
| HH | Licensed Practical Nurse | Confirmed flatware was wrapped and should have been unwrapped for resident R38 |
| II | Certified Nursing Assistant | Delivered meal tray to resident R38 and acknowledged oversight in unwrapping flatware |
| EE | Wound Care Nurse | Removed chemical aerosol spray from resident R91's bathroom and confirmed policy on chemical items |
| DD | Bath Technician | Interviewed about chemical hazards in resident rooms |
| FF | Registered Nurse | Confirmed expectation to remove chemical items from resident rooms and staff education |
| BB | Sous Chef | Interviewed about food labeling and storage practices |
| CDM | Certified Dietary Manager | Interviewed about food safety practices and staff education on labeling |
| Administrator | Interviewed about ice maker cleaning schedule |
Inspection Report
Life Safety
Census: 110
Capacity: 150
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Inspection Report
Follow-Up
Census: 111
Deficiencies: 0
Date: Feb 3, 2023
Visit Reason
A desk review revisit was conducted to verify correction of deficiencies cited in the December 15, 2022 Recertification survey.
Findings
All deficiencies cited in the December 15, 2022 Recertification survey were found to be corrected during the revisit.
Inspection Report
Routine
Census: 108
Deficiencies: 1
Date: Dec 15, 2022
Visit Reason
A standard survey was conducted at Florence Hand Home from December 13, 2022, through December 15, 2022, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to update the care plan for one resident (R#17) regarding code status, where the care plan indicated Do Not Intubate (DNI) but the physician's order was Do Not Resuscitate (DNR).
Deficiencies (1)
Failure to update the care plan for one of five sampled residents related to code status, specifically for Resident #17.
Report Facts
Resident census: 108
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed discrepancy between physician order and care plan code status |
| Registered Nurse 1 | Registered Nurse | Confirmed discrepancy between physician order and care plan code status |
| Senor Care Coordinator | Senior Care Coordinator | Provided information on code status review process |
| MDS Coordinator | MDS Coordinator | Described care plan update process during morning meetings |
Inspection Report
Life Safety
Census: 105
Capacity: 150
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
Florence Hand Home 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.
Report Facts
Stories: 3
Construction Type: Type I (3,3,2) construction
Year Constructed: 1980
Fully Sprinklered: 1
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) during a required seven-day reporting period.
Findings
The facility failed to report complete information about COVID-19 infections, deaths, supplies, staffing, vaccine status, and therapeutics to the NHSN between 08/15/2022 and 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 103
Deficiencies: 0
Date: Feb 21, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 83
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with federal regulations related to emergency preparedness and infection control.
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, including implementation of CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
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.
Report Facts
Total census: 110
Inspection Report
Abbreviated Survey
Census: 134
Deficiencies: 0
Date: Mar 11, 2020
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00203408 from March 10 to March 11, 2020.
Complaint Details
Complaint GA00203408 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated. The facility census on March 10, 2020 was 134 residents.
Report Facts
Resident census: 134
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 4, 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
Routine
Census: 132
Deficiencies: 0
Date: Aug 29, 2019
Visit Reason
A standard survey was conducted at Florence Hand Home from August 26, 2019 through August 29, 2019. In addition, two complaint intake numbers were investigated in conjunction with this standard survey.
Complaint Details
Complaint Intake Number GA00198764 and GA00198793 were investigated and found to be unsubstantiated.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. The complaints investigated were unsubstantiated.
Report Facts
Resident census: 132
Inspection Report
Life Safety
Census: 132
Capacity: 150
Deficiencies: 1
Date: Aug 27, 2019
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 due to failure to maintain smoke barrier walls with a ½ hour fire resistance rating, which could place residents in one of three smoke compartments on floor B at risk in the event of fire. Specifically, there was penetration in the smoke barrier above the ceiling at the cross corridor doors on floor B near resident room B19.
Deficiencies (1)
Failed to maintain smoke barrier walls to provide a ½ hour fire resistant rating, with penetration above the ceiling at cross corridor doors on floor B near resident room B19.
Report Facts
Census: 132
Certified beds: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of smoke barrier penetration during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 29, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00192442 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00192442 was investigated and found to have no deficiencies.
Findings
No deficiency was cited during the complaint survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 30, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Florence Hand Home, indicating a regulatory inspection was conducted and corrective actions are being planned or reported.
Findings
The document contains no detailed findings or deficiencies; it only includes initial comments with no specific deficiencies or severity levels noted.
Inspection Report
Routine
Census: 144
Deficiencies: 4
Date: Jun 7, 2018
Visit Reason
A standard survey was conducted at Florence Hand Home from June 4, 2018 to June 7, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to provide written advance directive information to residents, failure to provide Skilled Nursing Facility Advance Beneficiary Notice upon discharge from Medicare Part A services, failure to assess resident's ability to self-administer nebulizer treatments, and failure to follow infection control isolation precautions.
Deficiencies (4)
Failure to provide written documentation of advance directive information to one of four residents reviewed.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to residents discharged from Medicare Part A services.
Failure to assess ability of resident to self-administer Albuterol nebulizer treatments.
Failure to ensure staff followed contact isolation procedures for a resident on contact isolation.
Report Facts
Resident census: 144
Residents reviewed: 48
Residents with advance directive documentation issue: 1
Residents with SNFABN issue: 2
Residents with nebulizer assessment issue: 1
Residents with infection control issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nurse Aide | Observed failing to wear gown when entering isolation room and not sanitizing hands upon exit |
| PTA BB | Physical Therapy Assistant | Observed entering isolation room without gown or gloves and not sanitizing hands upon exit |
| Charge Nurse CC | Registered Nurse | Described expectations for staff regarding contact isolation procedures |
| Staff Development/Infection Control Nurse | Licensed Practical Nurse | Provided infection control training and policy information |
| Director of Nursing | Provided information on expectations for infection control and resident self-administration assessment | |
| Patient Financial Services Representative | Reported no advance directive information provided during admissions | |
| Social Services Director | Described facility process for providing advance directive information | |
| MDS Representative GG | Reported lack of use of SNFABN forms prior to survey |
Inspection Report
Life Safety
Census: 142
Capacity: 150
Deficiencies: 0
Date: Jun 6, 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 to be in substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards during the survey.
Report Facts
Stories: 3
Construction Type: 1
Year Constructed: 1980
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 4, 2018
Visit Reason
The inspection was conducted to investigate a complaint regarding failure of staff to follow contact isolation procedures for a resident with drug-resistant bacteria.
Complaint Details
The visit was complaint-related due to allegations that staff did not follow contact isolation precautions for Resident #38 with MRSA. The complaint was substantiated based on observations and interviews.
Findings
The facility failed to ensure staff consistently followed contact isolation protocols for Resident #38, who had drug-resistant bacteria in urine. Multiple staff members were observed not wearing gowns or gloves as required, and hand hygiene was not consistently performed upon entering or exiting the resident's room.
Deficiencies (1)
Failure to ensure staff members followed contact isolation procedures when entering the room of Resident #38.
Report Facts
Sampled residents: 48
Resident BIMS score: 2
Date of Admission Record: May 25, 2018
Date of Admission MDS: Jun 1, 2018
Date of Care Plan: Jun 4, 2018
Date of Care Plan Revision: Jun 5, 2018
Date of Health Status Progress Note: Jun 2, 2018
Date of CNA DD training completion: Apr 12, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nurse Aide | Observed not following contact isolation procedures; interviewed about isolation practices |
| CNA GG | Certified Nurse Aide | Observed following isolation procedures and instructing CNA DD |
| PTA BB | Physical Therapy Assistant | Observed not wearing PPE when entering isolation room; interviewed about isolation procedures |
| Charge Nurse CC | Registered Nurse | Interviewed regarding staff expectations for contact isolation |
| Staff Development/Infection Control Nurse | Licensed Practical Nurse | Interviewed about infection control expectations and training |
| Director of Nursing | Director of Nursing | Interviewed about staff expectations for isolation precautions |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 25, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00180988.
Complaint Details
Complaint GA00180988 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Routine
Census: 129
Deficiencies: 0
Date: May 25, 2017
Visit Reason
A standard survey was conducted at Florence Hand Home from May 22, 2017 through May 25, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 129
Capacity: 150
Deficiencies: 0
Date: May 23, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
Florence Hand Home was found in substantial compliance with the Life Safety Code requirements during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 10, 2017
Visit Reason
A follow-up visit was conducted on 5/10/2017 to verify correction of deficiencies identified during a complaint survey completed on 3/25/2017.
Complaint Details
The visit was a follow-up to a complaint survey; the deficiency was corrected.
Findings
The deficiency cited in the prior complaint survey was corrected as of the follow-up visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 26, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate a complaint (GA001).
Complaint Details
The complaint was substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 25, 2017
Visit Reason
An Abbreviated Survey was conducted on 3/25/17 at Florence Hand Home to investigate complaints GA00172139 and GA00170468 to determine compliance with Federal and State Long Term Care Regulations.
Complaint Details
The survey was conducted to investigate complaints GA00172139 and GA00170468. Complaint GA00170468 was unsubstantiated. Complaint GA00172139 was substantiated with findings of late medication administration for two residents. The facility confirmed prior issues with late medications and disciplinary action was taken against a nurse involved.
Findings
The complaint GA00170468 was unsubstantiated, while complaint GA00172139 was substantiated with deficiencies cited related to failure to follow physician's orders and administer medications as ordered for two residents, resulting in late medication administration.
Deficiencies (1)
Failure to follow physicians orders to administer medications as ordered for two residents, resulting in late medication administration.
Report Facts
Number of residents involved: 2
Total residents: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | RN identified as #AA was observed preparing late medications for Resident #3. | |
| Licensed Practical Nurse (LPN) | LPN identified as #BB was observed administering late medications for Resident #4. | |
| Administrator | Interviewed regarding medication administration issues. | |
| Director of Nursing (DON) | Interviewed regarding medication administration issues. |
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