Inspection Reports for Fort Valley Health and Rehab
604 BLUEBIRD BOULEVARD, FORT VALLEY, GA, 31030
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 17, 2025 found no deficiencies, though one complaint was substantiated without regulatory violations. Earlier inspections showed a pattern of deficiencies primarily related to dietary management, infection control practices, and Life Safety Code compliance, including issues with emergency preparedness, environmental sanitation, and medication management. Complaint investigations were mostly unsubstantiated or substantiated without deficiencies, with no fines, immediate jeopardy findings, or license actions listed in the available reports. Prior enforcement actions were not noted in the records. The facility appears to have corrected many previously cited deficiencies, indicating some improvement over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
46 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00254209 and GA00254033.
Complaint Details
Complaint GA00254209 was substantiated. Complaint GA00254033 was unsubstantiated.
Findings
Complaint GA00254209 was substantiated, complaint GA00254033 was unsubstantiated, and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Fort Valley 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
Re-Inspection
Census: 46
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
A revisit survey was conducted from October 9, 2024 to October 10, 2024 to verify correction of deficiencies cited in the August 18, 2024 Recertification survey.
Findings
All deficiencies cited as a result of the August 18, 2024 Recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 4, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 3
Date: Aug 18, 2024
Visit Reason
A State Licensure survey was conducted at Fort Valley Health and Rehab from August 16, 2024, through August 18, 2024, to assess compliance with state health regulations.
Findings
The survey identified deficiencies including lack of required certification for the Dietary Manager affecting 42 of 45 residents, failure to follow puree diet recipes risking nutritional intake for 10 residents, and improper infection control practices during ophthalmic drop administration placing one resident at risk of infection.
Deficiencies (3)
The facility failed to ensure that the staff designated as the Director of Food and Nutrition Services was a certified dietary or food service manager or had a similar certification or degree.
The facility failed to ensure recipes for the puree diet were followed to preserve nutritional value and failed to serve recommended amounts of protein and vegetables to residents on a puree diet.
The facility failed to ensure infection control practices were followed during administration of ophthalmic drops for one resident, risking cross-contamination.
Report Facts
Residents affected by dietary certification deficiency: 42
Residents receiving puree diet: 10
Residents observed for medication administration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in infection control deficiency during ophthalmic drop administration |
| Cook AA | Named in puree diet preparation deficiency | |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices |
| Administrator | Interviewed regarding dietary staff qualifications and expectations | |
| Dietary Manager | Dietary Manager | Named in dietary certification and puree diet deficiencies |
Inspection Report
Routine
Census: 45
Deficiencies: 6
Date: Aug 18, 2024
Visit Reason
A standard survey was conducted at Fort Valley Health and Rehab from August 16, 2024, through August 18, 2024, including investigation of Complaint Intake Number GA00246756, which was substantiated with no deficiencies cited.
Complaint Details
Complaint Intake Number GA00246756 was investigated in conjunction with the standard survey and was found to be substantiated with no deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to obtain required physician signatures on POLST forms, failure to submit PASARR Level II for a resident with new mental illness diagnosis, lack of physician order and inadequate cleaning for oxygen therapy, dietary manager lacking required certification, failure to follow puree diet recipes and portion sizes, and improper infection control during ophthalmic drop administration.
Deficiencies (6)
Failed to obtain a concurring Physician's signature for POLST Do Not Resuscitate documents for two residents; failed to ensure cognitive status and Power of Attorney documentation were properly obtained.
Failed to submit PASARR Level II for one resident after new qualifying mental illness diagnosis was added.
Failed to obtain physician's order for oxygen administration and failed to clean oxygen concentrator for one resident receiving oxygen therapy.
Facility failed to ensure the Director of Food and Nutrition Services was certified as a dietary or food service manager.
Failed to follow puree diet recipes and ensure residents received recommended protein and vegetable portions, risking decreased nutritional intake.
Failed to follow infection control practices during administration of ophthalmic drops, including not wearing gloves and not sanitizing hands, risking cross-contamination.
Report Facts
Residents present: 45
Deficiency severity D: 4
Deficiency severity F: 2
Residents receiving oral diet: 42
Residents receiving puree diet: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in infection control deficiency during ophthalmic drop administration |
| Dietary Manager | Dietary Manager | Named in deficiency for lack of required certification and failure to follow puree diet recipes |
| Social Services Director | Social Services Director | Named in POLST documentation deficiency and PASARR submission deficiency |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including POLST documentation, oxygen therapy orders, and infection control |
| Administrator | Facility Administrator | Named in multiple interviews confirming deficiencies and expectations |
Inspection Report
Life Safety
Census: 45
Capacity: 75
Deficiencies: 5
Date: Aug 17, 2024
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including blocked means of egress, exit doors not swinging outward, missing self-closing door hardware in the kitchen dry storage room, lack of exit signage operating under emergency power, and improper placement of the Class K fire extinguisher placard in the kitchen.
Deficiencies (5)
Exit door located on 200 Hall and next to the nurse's station was partially blocked by carts.
Exit door located in the back of the kitchen did not swing outward in the direction of egress travel.
Facility failed to have self-closing door hardware for the kitchen dry storage room.
Exit sign located above the rear exit corridor in the kitchen did not operate under emergency power.
Placard for the Class K fire extinguisher was not placed above the proper fire extinguisher in the kitchen.
Report Facts
Census: 45
Total Capacity: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the facility tour and observations |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Date: May 7, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00246401.
Complaint Details
Complaint number GA00246401 was substantiated with no deficiencies cited.
Findings
The complaint was substantiated with no deficiencies cited.
Report Facts
Census: 47
Inspection Report
Abbreviated Survey
Census: 48
Deficiencies: 0
Date: Apr 11, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint numbers from March 14, 2024 to April 11, 2024.
Complaint Details
The survey investigated complaint numbers GA00244840, GA00237301, GA00237306, GA00237462, GA00237848, GA00241031, GA00241384, GA00243327, GA00244569, GA00244677, and GA00245057. No deficiencies were found related to these complaints.
Findings
No deficiencies were cited related to the investigated complaints during the survey period.
Report Facts
Complaint numbers investigated: 11
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 12, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Fort Valley Health and Rehab, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided document.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the May 21, 2023 Recertification Survey.
Findings
All deficiencies cited in the May 21, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 47
Capacity: 75
Deficiencies: 11
Date: May 22, 2023
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program and compliance with Life Safety Code requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with emergency preparedness plan requirements and multiple Life Safety Code deficiencies were identified, including missing ceiling tiles, unsecured fire alarm breaker, unlabeled fire alarm batteries, dirty sprinkler heads, missing escutcheon rings, blocked panel boxes, missing light globes, exposed wiring, untreated combustible decorations, and unsecured oxygen cylinders.
Deficiencies (11)
Emergency preparedness plan was not reviewed and updated annually as required.
Missing ceiling tile in kitchen washroom and riser room allowing transfer of smoke.
Fire alarm breaker missing breaker lock and not marked in red.
Fire alarm batteries not labeled with manufactured date.
Sprinkler head in laundry room loaded with lint.
Missing escutcheon rings in medication room and electrical room.
Panel boxes in kitchen blocked by a cart.
Missing globe on light fixtures in kitchen washroom, copy room, and activities storage room.
Exposed/open wiring above double doors.
Combustible decorations on dining room exit door not treated with fire-retardant.
Oxygen cylinder not secured in oxygen storage room.
Report Facts
Census: 47
Total Capacity: 75
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 6
Date: May 21, 2023
Visit Reason
A standard survey was conducted from 5/19/23 through 5/21/23, including investigation of Complaint Intake Number GA00231830, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00231830 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to apply for Level II PASRR for a resident with mental illness, improper cleaning and storage of nebulizer equipment, improper disposal of unused narcotic medication, lack of antibiotic stewardship program implementation, failure to offer influenza and pneumococcal vaccines to residents, and failure to offer/administer COVID-19 vaccine to a resident.
Deficiencies (6)
Failed to apply for a Level II PASRR for a resident with mental illness diagnoses.
Failed to prevent spread of infections by not cleaning and storing a nebulizer mask properly.
Failed to ensure proper disposal of unused narcotic medication in medication cart.
Failed to provide evidence of periodic review and documentation of antibiotic prescribing practices for 12 months.
Failed to provide evidence that residents were offered influenza and pneumococcal vaccines.
Failed to offer and/or administer COVID-19 vaccine to a resident.
Report Facts
Resident census: 47
Sample size: 18
Medication dosage: 50
Medication dosage: 10
Medication dosage: 7.5
Medication dosage: 0.63
Medication dosage: 37.5
BIMS score: 12
BIMS score: 7
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interim Social Worker responsible for PASARR duties | |
| Marketing Director | Reported process for PASARR screening and confirmed failure for Resident #41 | |
| Administrator | Stated expectations for PASARR screenings and vaccine administration | |
| Director of Nursing (DON) | Confirmed failures in nebulizer storage, narcotic disposal, antibiotic stewardship, and vaccine administration | |
| LPN AA | Licensed Practical Nurse | Observed improperly handling narcotic medication |
| Interim Director of Nursing | Confirmed vaccine documentation failures and responsibility changes | |
| Transitioning/Newly hired Director of Nursing | Confirmed lack of infection control documentation and vaccine administration |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 21, 2023
Visit Reason
A State Licensure survey was conducted from 5/19/23 through 5/21/23 to determine compliance with State Long Term Care Requirements.
Findings
The facility was cited for failure to ensure proper disposal of unused narcotic medication and failure to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccines for two residents of five sampled. Interviews and record reviews revealed noncompliance with medication disposal policies and vaccine offering/documentation requirements.
Deficiencies (2)
The facility failed to ensure proper disposal of unused narcotic medication in one of two medication carts.
The facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for two residents (R#4 and R#28) of five sampled residents reviewed for immunizations.
Report Facts
Residents sampled for immunizations: 5
Residents not offered vaccines: 2
Date survey completed: May 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed improperly handling narcotic medication on 5/21/23. |
| Director of Nursing | Director of Nursing | Interviewed regarding narcotic disposal policy and vaccine documentation expectations. |
| Interim DON | Interim Director of Nursing | Interviewed regarding vaccination consent and documentation responsibilities. |
| Transitioning DON | Director of Nursing | Interviewed regarding vaccine documentation and record audits. |
| Administrator | Facility Administrator | Interviewed regarding vaccine offering and documentation expectations. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 12, 2023
Visit Reason
An Abbreviated Survey was conducted to investigate complaints #GA00222835, #GA00228985, and #GA00230408.
Complaint Details
Complaints #GA00222835, #GA00228985, and #GA00230408 were unsubstantiated with no regulatory violations cited.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
The document is a state inspection report for Fort Valley Health and Rehab, indicating a regulatory survey was conducted.
Findings
The report contains a statement of deficiencies and plan of correction, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 0
Date: Mar 8, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/13/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 1/13/22 Recertification Survey were found to be corrected.
Inspection Report
Renewal
Census: 39
Deficiencies: 3
Date: Jan 13, 2022
Visit Reason
A Licensure Survey was conducted from 1/11/22 through 1/13/22 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to have a qualified Infection Preventionist with required training and did not implement infection prevention policies effectively. One resident did not receive scheduled bathing care. Environmental sanitation issues were noted including dirty walls, peeling paint, stained privacy curtains, and missing or stained tiles in resident rooms and bathrooms.
Deficiencies (3)
Facility failed to have a qualified Infection Preventionist who completed required training and failed to implement infection prevention policies.
One resident (#36) did not receive scheduled shower/bath as required by care plan.
Facility failed to maintain a clean, sanitary, and homelike environment with issues such as dirty walls, peeling paint, stained privacy curtains, and missing or stained tiles in resident rooms and bathrooms.
Report Facts
Facility census: 39
Resident sample size: 39
Baths documented: 5
Months without antibiotic stewardship reports: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Restorative Certified Nursing Assistant | Verified bath schedule and confirmed resident #36 was not on the bath schedule |
| DD | Certified Nursing Assistant | Described bath schedule duties and knowledge |
| Administrator | Responsible for bath schedule and confirmed resident #36 was not on the schedule | |
| Director of Nursing | Director of Nursing (DON) | Assigned Infection Preventionist, not certified, went on leave during survey |
| Maintenance Supervisor | Interviewed about environmental sanitation concerns |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 3
Date: Jan 13, 2022
Visit Reason
A standard survey was conducted from 1/11/22 through 1/13/22, including investigation of Complaint Intake Number GA00218394, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00218394 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain a safe, clean, and homelike environment, failure to provide scheduled bathing for a dependent resident, and failure to have a qualified Infection Preventionist with an effective infection prevention program.
Deficiencies (3)
Facility failed to maintain a clean, sanitary, and homelike environment related to dirty walls, doorframes, peeling paint, stained privacy curtains, and missing or stained tiles in resident rooms and bathrooms.
Facility failed to ensure one resident received scheduled bathing and personal hygiene care as required.
Facility failed to have a qualified Infection Preventionist who completed required specialized training and failed to implement an effective infection prevention and control program.
Report Facts
Resident census: 39
Bathing schedule documentation: 5
Bathing schedule documentation: 2
Months without antibiotic stewardship reports: 3
Inspection Report
Life Safety
Census: 37
Capacity: 75
Deficiencies: 0
Date: Jan 11, 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 and Life Safety Code standards during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212342.
Complaint Details
Complaint #GA00212342 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint #GA00212342 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Date: Jan 26, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with the investigation of Complaint Intake Number GA00211469.
Complaint Details
Complaint Intake Number GA00211469 was investigated and substantiated with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations. The complaint was substantiated with no deficiencies.
Report Facts
Total census: 45
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00205149, #GA00210097, and #GA00210179.
Complaint Details
Complaint #GA00205149 was unsubstantiated. Complaints #GA00210179 and #GA00210097 were substantiated with no regulatory violations.
Findings
Complaint #GA00205149 was unsubstantiated. Complaints #GA00210179 and #GA00210097 were substantiated but with no regulatory violations found.
Inspection Report
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Fort Valley 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 on the page provided.
Inspection Report
Follow-Up
Census: 56
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
A COVID-19 Infection Control revisit survey was conducted to verify correction of deficiencies cited in the prior July 28, 2020 COVID-19 Infection Control survey.
Findings
The deficiency cited in the July 28, 2020 COVID-19 Infection Control survey was found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Deficiencies: 2
Date: Jul 28, 2020
Visit Reason
A Licensure Survey was conducted to assess compliance with environmental sanitation and housekeeping regulations, specifically focusing on laundry handling and infection control.
Findings
The facility failed to prevent possible cross contamination during the transport of residents' clothes and linens on two of three halls due to uncovered laundry carts and improper handling of linens by staff. Staff training on proper laundry transport was incomplete but has since been addressed.
Deficiencies (2)
Laundry carts used for transporting residents' clothes and linens were uncovered, risking cross contamination on two of three halls (200 and 300 hall).
Staff member was observed placing towels that fell on the floor back onto the clean linen cart instead of placing them in the dirty laundry container.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Aide CC | Observed delivering linens in uncovered carts and confirmed items were not covered during transport. | |
| CNA AA | Observed placing towels that fell on the floor back onto the clean linen cart and acknowledged improper handling. | |
| Housekeeping/Laundry Supervisor | Confirmed linens should be transported covered and reported on staff training related to laundry transport. |
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 3
Date: Jul 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control regulations due to failures in preventing possible cross contamination during meal delivery and transport of residents' linens and clothing. Observations and interviews revealed improper handling of meal trays and uncovered linen carts, as well as failure to properly handle linens that fell on the floor.
Deficiencies (3)
Failure to prevent possible cross contamination during meal delivery service in one resident's room (room 213).
Failure to prevent cross contamination during transport of residents' clothes/linens on two of three halls (200 and 300 hall) due to uncovered carts.
Failure to properly handle linens that fell to the floor by placing them back on the clean linen cart.
Report Facts
Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed during meal delivery and acknowledged improper handling of linens |
| CNA BB | Certified Nursing Assistant | Interviewed regarding meal tray handling procedures |
| Laundry Aide CC | Laundry Aide | Observed delivering linens in uncovered carts and confirmed items were not covered |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding meal tray and linen handling policies |
| Housekeeping/Laundry Supervisor | Housekeeping/Laundry Supervisor | Interviewed regarding staff training and linen transport procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
The inspection was conducted to investigate complaints #GA00201668 and #GA00201803 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The survey was complaint-related, investigating two specific complaints, and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 12/31/2019 through 01/02/2020.
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 0
Date: Oct 17, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/8/19 Standard Survey.
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
Date: Sep 20, 2019
Visit Reason
A follow-up survey was conducted to verify correction of previously cited emergency preparedness and survey deficiencies.
Findings
The follow-up survey noted that all previously cited emergency preparedness and survey tags have been corrected.
Inspection Report
Annual Inspection
Census: 60
Capacity: 75
Deficiencies: 4
Date: Aug 6, 2019
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and compliance with Life Safety Code requirements, including emergency lighting and evacuation policies.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with federal requirements, including outdated contracts for patient transportation and transfer agreements, and failure to review and update the plan annually. Additionally, the facility failed to provide emergency lighting in required areas, specifically the medication room at the nurse's station.
Deficiencies (4)
Emergency Preparedness Plan was not in substantial compliance with Appendix Z requirements, including failure to renew evacuation transportation contract since 09/06/2017.
Transfer agreements with other facilities had not been renewed annually, with last renewals on 05/08/2017 and 03/08/2018.
Emergency Preparedness Plan had not been reviewed and updated since 11/08/2017.
Facility failed to provide emergency lighting in the medication room located at the nurse's station.
Report Facts
Residents at risk: 60
Certified Beds: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed findings related to emergency preparedness plan deficiencies and emergency lighting. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 19, 2019
Visit Reason
A complaint survey was conducted on 6/19/19 to investigate complaint GA00197533 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00197533 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2019
Visit Reason
The inspection was conducted to investigate complaints #GA00195723 and #GA00195757 to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
The survey was complaint-related for complaints #GA00195723 and #GA00195757 and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 4/8/19 through 4/9/19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 14, 2019
Visit Reason
An abbreviated / Partial Extended Survey was conducted to investigate complaint GA00194400.
Complaint Details
Complaint GA00194400 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 23, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00192296.
Complaint Details
Complaint GA00192296 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00191235 and GA00191322.
Complaint Details
The survey investigated complaints GA00191235 and GA00191322, both of which were unsubstantiated.
Findings
The complaints were found to be unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Sep 12, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the Abbreviated/Partial Extended Survey conducted on July 24 and 25, 2018.
Findings
All deficiencies resulting from the prior survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 10, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
All previously cited violations were corrected as noted during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
A revisit survey was conducted on July 2-3, 2018 to verify correction of deficiencies cited in the May 18, 2018 Recertification survey.
Findings
All deficiencies cited as a result of the May 18, 2018 Recertification survey were found to be corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 3, 2018
Visit Reason
A revisit survey was conducted on July 2-3, 2018 to verify correction of deficiencies cited during the April 6, 2018 complaint survey.
Findings
All deficiencies cited as a result of the April 6, 2018 complaint survey were found to be corrected.
Inspection Report
Routine
Census: 62
Deficiencies: 10
Date: May 18, 2018
Visit Reason
A standard survey was conducted from 4/18/18 to 5/17/18, including a Quality Assurance review of complaint #GA00187441, to assess compliance with Medicare/Medicaid regulations and investigate additional concerns.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain resident privacy, failure to respect resident self-determination regarding bathing schedules, failure to address resident grievances about call light response and snacks, unsafe environment issues such as odor and unclean shower rooms, failure to follow physician orders for scabies treatment and tuberculosis screening, inadequate infection control and antibiotic stewardship programs, and failure to maintain safe resident environments such as unsecured handrails and beds left in high positions.
Deficiencies (10)
Failure to maintain privacy for residents due to removal of privacy curtains in rooms and communal shower areas.
Failure to allow residents choice in bathing schedules and failure to provide timely showers.
Failure to act upon resident grievances regarding call light response and snack availability.
Failure to provide a safe, clean, comfortable environment including unclean shower room, lack of running water in shower sink, dirty razors, hole in shower wall, and strong odors.
Failure to follow physician orders for scabies treatment for multiple residents and failure to obtain tuberculosis screening and follow-up for residents.
Failure to ensure safe environment by leaving a resident's bed in high position and unsecured handrails in hallways.
Failure to dispose of expired medications in a timely manner on medication cart.
Failure to administer facility in a manner to use resources effectively to maintain resident well-being, including oversight failures related to tuberculosis screening and scabies outbreak management.
Failure to establish and maintain an effective infection prevention and control program including surveillance and control of scabies outbreak and tuberculosis management.
Failure to establish an antibiotic stewardship program including antibiotic use protocols and monitoring.
Report Facts
Resident census: 62
Sample size: 43
Handrails unsecured: 5
Expired medications: 3
Residents treated for scabies: 6
Staff diagnosed with scabies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding privacy curtain removal, infection control, and medication administration | |
| Administrator | Interviewed regarding infection control, QAPI, and oversight of tuberculosis and scabies management | |
| Medical Director | Interviewed regarding tuberculosis management and scabies outbreak | |
| Infection Control Nurse | Interviewed regarding infection control program and surveillance | |
| Head of Maintenance | Interviewed regarding maintenance issues including handrails and shower room repairs | |
| Licensed Practical Nurse | Interviewed regarding medication cart and resident care | |
| Certified Nursing Assistant | Interviewed regarding resident care and observations of resident conditions |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 7
Date: May 18, 2018
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with state regulations including resident rights, privacy, pharmacy management, nursing care, safety, and infection control.
Findings
The facility was found deficient in multiple areas including failure to address resident grievances about call light response, failure to maintain resident privacy due to removal of privacy curtains, expired medications on medication carts, failure to follow physician orders for scabies treatment, inadequate tuberculosis screening and follow-up, unsafe environmental conditions including odors, unclean shower rooms, unsecured handrails, and failure to maintain a safe environment for residents at risk of falls. Infection control program was ineffective with delayed identification and treatment of scabies outbreaks and inadequate tuberculosis management.
Deficiencies (7)
Facility failed to act upon grievances and recommendations of residents regarding call lights not being answered timely and snacks not offered.
Facility failed to maintain privacy for residents by removing all privacy curtains in rooms of residents treated for scabies, causing embarrassment.
Expired medications found on medication cart including Pink Bismuth, Geri Care Pain Liquid, Acetaminophen, and Sodium Bicarbonate.
Failure to follow physician orders for treatment of scabies for five residents, including missed or delayed second applications of Elimite cream.
Failure to obtain sputum samples for tuberculosis testing and failure to administer purified protein derivative (PPD) testing for residents at risk or after exposure.
Facility failed to provide odor-free environment, maintain clean resident care equipment in shower room, maintain privacy curtains, repair water leakages, ensure safe bed positioning, and secure handrails.
Infection control program ineffective with incomplete surveillance, delayed identification and treatment of scabies outbreak, and failure to isolate residents with positive tuberculosis tests.
Report Facts
Resident census: 62
Medication carts observed: 2
Residents reviewed for scabies treatment: 15
Residents reviewed for TB screening: 10
Handrails unsecured: 5
Grievance logs reviewed: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Mentioned in relation to call light response observation and medication cart expired medications |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding call light response, medication cart, infection control, and environmental issues |
| Administrator | Facility Administrator | Interviewed regarding infection control program, scabies outbreak, and facility environment |
| Housekeeping Manager | Housekeeping Manager | Interviewed regarding removal of privacy curtains and shower room cleanliness |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding facility repairs including shower room and handrails |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding infection control surveillance and tuberculosis screening |
Inspection Report
Life Safety
Census: 75
Capacity: 62
Deficiencies: 10
Date: May 15, 2018
Visit Reason
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 requirements including improper maintenance of exit and emergency lighting, hazardous area enclosures, sprinkler system maintenance, corridor doors, smoke/fire barriers, electrical system, fire drills, smoking regulations, and oxygen cylinder storage.
Deficiencies (10)
Failed to properly maintain exit lights with no documentation of monthly and annual testing.
Failed to provide emergency lighting from exit discharge to public way at kitchen staff exit and 300 hall exit.
Hazardous areas (former beauty shop and kitchen stock room) lacked self-closing doors to make storage areas smoke tight.
Failed to properly maintain sprinkler system including missing inspection reports, improperly supported piping, missing escutcheon plates, and corroded sprinkler heads.
Corridor doors (break room door) did not properly close and latch.
Smoke/fire barrier above therapy office had unsealed piping and wiring penetrations.
Electrical system deficiencies including unsecured outlet, unapproved adapters and extension cords, unlabeled breakers, missing coverplates, improper venting of boiler relief valve, and uncovered light fixture.
Failed to properly maintain fire drills including lack of policy for fire department notification and incomplete fire drill documentation for night shift.
Failed to properly maintain designated smoking areas; missing approved ashtrays and improper use of metal cans as trash receptacles.
Failed to properly maintain portable oxygen cylinder storage; full and empty cylinders not properly separated and stored together.
Report Facts
Census: 75
Total Capacity: 62
Residents at risk: 36
Residents at risk: 11
Residents at risk: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 14, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA001860266.
Complaint Details
Complaint GA001860266 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
Abbreviated Survey
Deficiencies: 0
Date: Mar 2, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00185908.
Complaint Details
Complaint GA00185908 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
The inspection was conducted to investigate complaint GA0018366 and determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA0018366 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2017
Visit Reason
A complaint survey was conducted at Fort Valley Health and Rehabilitation on October 19, 2017 and October 22, 2017.
Complaint Details
Complaint survey was conducted with no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 5, 2017
Visit Reason
A follow-up to the Recertification survey of July 16, 2017 was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of August 28, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 29, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 65
Capacity: 75
Deficiencies: 3
Date: Jul 17, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's 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 protect hazardous areas with smoke resisting partitions and doors, an incomplete evacuation and relocation plan lacking provisions for relocating patients between smoke barriers, and improper use of extension cords as fixed wiring in the kitchen.
Deficiencies (3)
Facility failed to protect hazardous areas with smoke resisting partitions and doors, including missing ceiling tile, pipe penetrations, and a door that does not close and latch.
Evacuation and relocation plan did not include provisions for relocating patients from one smoke barrier to another.
Facility was substituting extension cords for fixed wiring in the kitchen, posing risk of electrocution or severe shock.
Report Facts
Census: 65
Total Capacity: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member identified as 'staff M' confirmed findings during the inspection | ||
| Staff member identified as 'staff A' confirmed evacuation plan deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 18, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints (GA00171247, GA00165609, GA00171883, and GA00172758).
Complaint Details
The complaints investigated were unsubstantiated without deficiencies.
Findings
The complaints investigated during the survey were found to be unsubstantiated and no deficiencies were identified.
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