Inspection Reports for Fort Gaines Health and Rehab
101 HARTFORD ROAD, WEST, FORT GAINES, GA, 39851
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 12, 2025, found that all previously cited deficiencies had been corrected. Earlier inspections showed multiple citations related mainly to medication management, resident care including personal hygiene, food storage and sanitation, and failure to provide proper transfer and discharge notices. Complaint investigations included several unsubstantiated cases, with one substantiated complaint in 2017 that did not result in deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record indicates improvement over time, with recent surveys showing correction of prior issues.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
59 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Fort Gaines Health and Rehab, summarizing deficiencies identified during the inspection completed on June 12, 2025.
Findings
The report contains initial comments but does not provide detailed findings or specific deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
A revisit survey was conducted at Fort Gaines Health & Rehab from June 11, 2025, through June 12, 2025 to verify correction of previous deficiencies cited in the 4/30/2025 recertification survey.
Findings
All citations from the 4/30/2025 recertification survey have been corrected as of this revisit survey.
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 0
Date: Apr 30, 2025
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 Emergency Preparedness Program requirements under 42 CFR § 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Report Facts
Census: 53
Certified beds: 60
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 30, 2025
Visit Reason
A State Licensure survey was conducted at Fort Gaines Health & Rehab from April 27, 2025 through April 30, 2025 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to provide written transfer/discharge notices to residents and representatives, failure to clarify medication orders leading to potential adverse consequences, failure to act timely on pharmacist recommendations, inadequate personal care such as nail care and showers for residents, improper food storage and sanitation in the kitchen, and failure to administer pneumococcal vaccine despite signed consent.
Deficiencies (6)
Facility failed to provide written transfer/discharge notices stating reason, place, and appeal rights to three residents transferred to hospital.
Failure to clarify medication orders for two residents, including abrupt discontinuation of antidepressant and unclear antipsychotic medication frequency.
Consultant pharmacist failed to identify medication irregularities timely and facility failed to act on pharmacist recommendations for two residents.
Failure to ensure nail care and showers were provided for three residents, resulting in unmet care needs.
Failure to discard expired food, cover and date food in refrigerators, and clean kitchen slicer and knives before storage.
Failure to provide pneumococcal vaccine to a resident after responsible party signed consent form.
Report Facts
Sampled residents reviewed: 23
Residents affected by transfer notice deficiency: 3
Residents affected by medication order deficiency: 2
Residents affected by personal care deficiency: 3
Residents served by kitchen: 51
Resident sample for vaccine deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed transfer notices were not sent; discussed medication order clarifications and pharmacy recommendations |
| Administrator | Facility Administrator | Provided information on verbal notification of transfers and physician discontinuation error |
| Pharmacist Supervisor | Pharmacist Supervisor (RPHS) | Discussed risks of abrupt discontinuation of duloxetine |
| Mental Health Nurse Practitioner | MHNP | Discussed duloxetine discontinuation and resident's behavioral health |
| Dietary Manager | Dietary Manager (DM) | Confirmed expired and uncovered food in kitchen and unclean slicer and knives |
| Infection Preventionist | Infection Preventionist (IP) | Confirmed consent signed for pneumococcal vaccine but vaccine not administered |
Inspection Report
Standard Survey Complaint Investigation
Census: 53
Deficiencies: 12
Date: Apr 30, 2025
Visit Reason
A standard survey was conducted from April 27 through April 30, 2025, including investigations of four complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
The survey included investigations of Complaint Intake Numbers GA00237883, GA00243566, GA00247211, and GA00248117.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written information on advance directives, failure to provide written transfer/discharge notices, inaccurate Minimum Data Set assessments, failure to clarify medication orders, failure to provide adequate nail care and showers, improper storage of respiratory equipment, failure in antibiotic stewardship, failure to serve palatable and hot food, failure to maintain kitchen sanitation, incomplete medical record documentation, and failure to provide pneumococcal vaccination after consent.
Deficiencies (12)
Failure to provide residents or their representatives with written information on the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for 5 of 23 sampled residents.
Failure to provide written transfer/discharge notices stating reason, place, and other information to 3 of 23 sampled residents transferred to hospital.
Failure to ensure accuracy of Minimum Data Set assessments for 1 of 23 sampled residents.
Failure to follow professional standards by not clarifying medication orders for 2 of 23 sampled residents.
Failure to ensure nail care and/or showers were provided for 3 of 23 sampled residents.
Failure to store Trilogy ventilator mask in a manner to prevent contamination for 1 of 23 sampled residents.
Failure to ensure Consultant Registered Pharmacist identified irregularities and timely acted on medication recommendations for 2 of 5 residents reviewed for unnecessary medications.
Failure to provide pneumococcal vaccine after consent for 1 of 23 sampled residents.
Failure to serve food that was palatable and hot to 3 of 23 sampled residents.
Failure to discard food with expired use by dates, cover and date food stored in kitchen refrigeration units, and ensure kitchen slicer and knives were clean prior to storage.
Failure to have a complete and accurate medical record regarding documentation of a change in condition for 1 of 23 sampled residents.
Failure to have an Antibiotic Stewardship Program that followed current standards for prescribing antibiotics for 3 of 23 sampled residents.
Report Facts
Residents sampled: 23
Census: 53
Deficiency counts: 11
Temperature: 125
Temperature: 126
BIMS score: 0
BIMS score: 4
BIMS score: 10
BIMS score: 11
BIMS score: 12
BIMS score: 13
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in relation to failure to document assessment of resident R15's change in condition. |
| Director of Nursing | Director of Nursing | Named in relation to multiple deficiencies including medication errors and failure to act on pharmacy recommendations. |
| Infection Preventionist | Infection Preventionist | Named in relation to antibiotic stewardship and infection control deficiencies. |
| Consultant Registered Pharmacist | Consultant Registered Pharmacist | Named in relation to failure to identify medication irregularities. |
| Administrator | Administrator | Named in relation to transfer/discharge notice deficiencies and medication errors. |
| Admissions/Marketing Director | Admissions/Marketing Director | Named in relation to failure to provide written information on advance directives. |
| Mental Health Nurse Practitioner | Mental Health Nurse Practitioner | Named in relation to medication discontinuation and documentation errors. |
| Pharmacist Supervisor | Pharmacist Supervisor | Named in relation to medication discontinuation and side effects. |
| Certified Nursing Assistant 9 | Certified Nursing Assistant | Named in relation to failure to provide nail care and showers. |
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Named in relation to failure to provide nail care and showers. |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Named in relation to failure to provide nail care and showers. |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Named in relation to failure to provide nail care and showers. |
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Named in relation to failure to provide nail care and showers. |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Named in relation to failure to provide nail care and showers. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
A Life Safety Code (LSC) revisit was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited Life Safety Code deficiencies have been corrected as of the revisit date.
Inspection Report
Follow-Up
Census: 54
Deficiencies: 0
Date: Jul 7, 2023
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the May 25, 2023 Standard Recertification Survey.
Findings
All deficiencies cited in the May 25, 2023 Standard Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Deficiencies: 0
Date: Jul 7, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Fort Gaines Health and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 25, 2023
Visit Reason
The inspection was a State Licensure survey conducted from May 22, 2023 through May 25, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to provide proper transfer/discharge notices and bed hold notices to residents and representatives, inadequate nutritional assessments and follow-ups by the Registered Dietitian for residents with weight loss, failure to administer medications per physician orders, inadequate assistance with activities of daily living, failure to implement bowel protocols, inaccurate documentation of tube feeding, ineffective antibiotic stewardship program, and food safety violations in the dietary department.
Deficiencies (7)
Failure to provide written transfer/discharge notices to residents and representatives and failure to send notices to the State Long Term Care Ombudsman.
Failure to provide written bed hold notices to residents and representatives for emergent hospital transfers.
Failure to assess nutritional status for weight loss and tube feeding for two residents, including failure of Registered Dietitian to perform timely assessments and follow-ups.
Failure to administer nicotine patches as ordered for one resident, resulting in missed doses over multiple days.
Failure to assist one resident with activities of daily living, specifically bathing and shaving, and failure to implement bowel protocol and accurately document tube feeding.
Failure to develop an effective Antibiotic Stewardship Program, including prescribing antibiotics without diagnostic testing or documented symptomology for multiple residents.
Failure to ensure expired foods were removed, all food items were labeled and dated, thawing chicken was labeled and dated, shelves for clean pots and pans were free of white powder, and freezer was free of frost build-up in the dietary department.
Report Facts
Weight loss percentage: 8.2
Weight loss percentage: 3.4
Missed nicotine patch doses: 12
Missed nicotine patch doses: 23
Antibiotics ordered without clinical symptoms or diagnostic testing: 13
Antibiotics ordered without clinical symptoms or diagnostic testing: 6
Antibiotics ordered without clinical symptoms or diagnostic testing: 8
Antibiotics ordered without clinical symptoms or diagnostic testing: 5
Antibiotics ordered without clinical symptoms or diagnostic testing: 9
Antibiotics ordered without clinical symptoms or diagnostic testing: 8
Antibiotics ordered without clinical symptoms or diagnostic testing: 4
Antibiotics ordered without clinical symptoms or diagnostic testing: 5
Antibiotics ordered without clinical symptoms or diagnostic testing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Mentioned in relation to failure to administer nicotine patches to Resident R34 |
| CNA2 | Certified Nursing Assistant | Mentioned in relation to Resident R34's behavior and medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding weight loss, medication administration, and facility protocols |
| Medical Director | Medical Director | Interviewed regarding weight loss and medication administration issues |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional assessments and follow-ups |
| Dietary Manager | Dietary Manager | Interviewed regarding nutritional monitoring and communication with Registered Dietitian |
| Infection Preventionist | Infection Preventionist | Interviewed regarding antibiotic stewardship program and antibiotic use |
| Administrator | Administrator | Interviewed regarding medication ordering and food safety issues |
| CNA/CMA1 | Certified Nurse Aide/Certified Medication Aide | Interviewed regarding bathing and shaving care for Resident R35 |
| LPN3 | Licensed Practical Nurse | Interviewed regarding tube feeding bag and rate for Resident R10 |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 14
Date: May 25, 2023
Visit Reason
A standard recertification survey was conducted at Fort Gaines Health and Rehabilitation by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health from May 22, 2023 through May 25, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to provide proper transfer/discharge notices, incomplete baseline care plans, lack of timely care plan conferences, inadequate assistance with activities of daily living, failure to implement bowel protocols, inadequate nutritional assessments, inaccurate nurse staffing postings, failure to administer medications as ordered, incomplete hospice care coordination, and ineffective antibiotic stewardship program.
Deficiencies (14)
Failure to provide written transfer/discharge notices to residents and the State Long Term Care Ombudsman.
Failure to provide written bed hold notices to residents transferred to hospital.
Failure to refer resident with mental health diagnosis for PASRR Level II screening.
Failure to develop baseline care plans within 48 hours of admission and failure to provide summary to residents or representatives.
Failure to ensure timely care plan conferences and resident participation.
Failure to assist resident with activities of daily living, specifically bathing and shaving.
Failure to implement bowel protocol for constipation medication administration.
Failure to assess nutritional status and provide monthly Registered Dietitian evaluations for residents with weight loss and tube feeding.
Failure to accurately document and implement physician orders for tube feeding including start/end times and amount infused.
Failure to ensure accurate nurse staffing information was posted and retained for 18 months.
Failure to administer nicotine patches as ordered for smoking cessation.
Failure to ensure expired foods were removed, food properly labeled and dated, clean storage areas free of contamination, and freezer free of frost buildup.
Failure to ensure comprehensive hospice care plans and collaboration with hospice for residents receiving hospice services.
Failure to develop an effective Antibiotic Stewardship Program with appropriate diagnostic testing and documentation to support antibiotic use.
Report Facts
Resident census: 55
Weight loss: 22
Missed nicotine patch doses: 12
Missed nicotine patch doses: 23
Expired milk: 1
Antibiotics ordered without clinical symptoms or diagnostic testing: 13
Antibiotics ordered without clinical symptoms or diagnostic testing: 6
Antibiotics ordered without clinical symptoms or diagnostic testing: 8
Antibiotics ordered without clinical symptoms or diagnostic testing: 5
Antibiotics ordered without clinical symptoms or diagnostic testing: 9
Antibiotics ordered without clinical symptoms or diagnostic testing: 8
Antibiotics ordered without clinical symptoms or diagnostic testing: 4
Antibiotics ordered without clinical symptoms or diagnostic testing: 5
Antibiotics ordered without clinical symptoms or diagnostic testing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Mentioned in relation to failure to administer nicotine patches and transfer/discharge notices |
| CNA2 | Certified Nursing Assistant | Mentioned in relation to resident behavior and nicotine patch administration |
| Medical Director | Mentioned in relation to weight loss and nicotine patch administration | |
| Director of Nursing | Mentioned in relation to bowel protocol, staffing, and nicotine patch administration | |
| Infection Preventionist | Mentioned in relation to antibiotic stewardship program | |
| Hospice Nurse | Mentioned in relation to hospice care coordination | |
| Registered Dietitian | Mentioned in relation to nutritional assessments and tube feeding | |
| Dietary Manager | Mentioned in relation to nutritional assessments and communication with RD | |
| Human Resources Director | Mentioned in relation to nurse staffing records |
Inspection Report
Life Safety
Census: 55
Capacity: 60
Deficiencies: 3
Date: May 23, 2023
Visit Reason
The 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 not in substantial compliance with Life Safety Code requirements, with deficiencies including non-functioning emergency lights in the kitchen, penetrated fire walls above smoke doors in the lobby, and improperly covered J boxes above Mercury Hallway fire doors.
Deficiencies (3)
Emergency lights failed to work in kitchen when tested.
Fire Wall above Smoke doors in lobby were penetrated.
J boxes above Mercury Hallway Fire doors were not properly covered.
Report Facts
Census: 55
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Deficiencies: 0
Date: Mar 31, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Fort Gaines Health and Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 0
Date: Mar 31, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 27, 2022 Recertification Survey.
Findings
All deficiencies cited in the January 27, 2022 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 27, 2022
Visit Reason
A licensure survey was conducted at Fort Gaines Health & Rehabilitation from January 25, 2022, through January 27, 2022. In addition, Complaint Intake Number GA00216617 was investigated in conjunction with this standard survey.
Complaint Details
Complaint Intake Number GA00216617 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated. The standard survey revealed that the facility was not in substantial compliance, but there were no State Health deficiencies cited.
Inspection Report
Routine
Census: 50
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
A standard survey was conducted from January 25, 2022 through January 27, 2022, including investigation of Complaint Intake Number GA00216617, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00216617 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a safe, clean, and homelike environment due to peeling and chipped paint affecting 23 of 50 rooms, and failure to develop a care plan for hypoxemia for one resident receiving oxygen therapy.
Deficiencies (2)
Facility failed to maintain an environment free from peeling and chipped paint on two of four halls affecting 23 of 50 rooms.
Facility failed to develop a care plan to address hypoxemia for one of five residents receiving oxygen therapy.
Report Facts
Resident census: 50
Rooms affected: 23
Residents on oxygen therapy: 5
Oxygen flow rate: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and acknowledged awareness of painting needs on 200 and 300 halls | |
| Regional Director of Operations | Interviewed and acknowledged awareness of painting needs on 200 and 300 halls | |
| LPN AA | Licensed Practical Nurse | Confirmed resident #13 was receiving oxygen at 3 LPM but order was not entered |
| Director of Nursing | Interviewed regarding missing oxygen order for resident #13 |
Inspection Report
Life Safety
Census: 50
Capacity: 60
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
A Life Safety Code Survey was conducted to review the facility's 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 requirements set forth in 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also in substantial compliance with 42 CFR & 483.73.
Inspection Report
Routine
Census: 43
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess 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 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 47
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess 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 CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 53
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Fort Gaines Health and Rehab on July 21-22, 2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
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 recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00199176 and GA00199712.
Complaint Details
Complaints GA00199176 and GA00199712 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 5, 2019
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 survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 0
Date: Jul 2, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/16/19 Standard Survey.
Findings
All deficiencies cited as a result of the 5/16/19 Standard Survey were found to be corrected.
Inspection Report
Life Safety
Census: 49
Capacity: 60
Deficiencies: 1
Date: May 13, 2019
Visit Reason
The 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 due to sprinkler piping obstructions caused by electrical wiring attached to sprinkler piping in the west wing hallway above the smoke doors, potentially placing 40 percent of residents at risk during an emergency.
Deficiencies (1)
Sprinkler piping was obstructed by electrical wiring laying on and attached to sprinkler piping on the west wing hallway above the smoke doors.
Report Facts
Census: 49
Total Capacity: 60
Percentage of residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of electrical wiring on sprinkler piping during facility tour |
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Jun 14, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 12, 2018 survey.
Findings
All deficiencies cited in the April 12, 2018 survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 4, 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 had been corrected.
Inspection Report
Life Safety
Census: 52
Capacity: 60
Deficiencies: 2
Date: Apr 9, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess the facility's compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improperly directed exit signage and a smoke barrier in hallway 300 that was not smoke tight and did not maintain the required 1/2-hour fire resistance rating.
Deficiencies (2)
Exit signage in the main hallway was not pointing in the proper direction, potentially placing 40% of residents and staff at risk during an emergency.
Smoke barrier in hallway 300 was not properly sealed due to mud being used to seal penetration, failing to maintain a 1/2-hour fire resistance rating and smoke tightness, potentially placing 50% of residents at risk.
Report Facts
Census: 52
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to exit signage and smoke barrier during facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 14, 2017
Visit Reason
A follow-up visit was conducted on 6/14/17 to verify correction of deficiencies identified during the recertification inspection on 4/20/17.
Findings
The deficiencies identified during the recertification inspection on 4/20/17 had been corrected as of the follow-up visit on 6/14/17.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 5, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 56
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to ensure that all smoke barriers were smoke tight, properly sealed, and maintained a 1/2 hour fire resistance rating. Tape and mud were used improperly to seal penetrations at multiple locations, placing 100% of residents at risk in an emergency.
Deficiencies (1)
Smoke barriers throughout the facility were not smoke tight, properly sealed, and maintained a 1/2 hour fire resistance rating due to use of tape and mud to seal penetrations.
Report Facts
Census: 56
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of improperly sealed smoke barriers during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00172638.
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 but no deficiencies were cited.
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