Inspection Reports for
Gibson Health and Rehabilitation
434 BEALL SPRINGS ROAD, GIBSON, GA, 30810
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Gibson Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the extracted text or image.
Inspection Report
Follow-Up
Census: 65
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
A Health Revisit survey was conducted to verify correction of deficiencies cited in the 2/27/2025 Recertification Survey.
Findings
All deficiencies cited as a result of the 2/27/2025 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, including a Life Safety Code Revisit survey.
Findings
The survey found that all previously cited Life Safety Code deficiencies and survey tags had been corrected.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Gibson Health and Rehabilitation.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan addressing catheter care and treatment for one resident with an indwelling catheter, increasing the risk of infections. Interviews revealed lack of knowledge and documentation regarding catheter care.
Deficiencies (1)
Failure to develop and implement a comprehensive person-centered care plan addressing catheter care and treatment for one resident with an indwelling catheter.
Report Facts
Date of last catheter care documentation: Sep 19, 2024
Catheter change frequency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Certified Nursing Assistant | Interviewed regarding catheter care knowledge |
| CC | Licensed Practical Nurse | Interviewed regarding catheter care policy and documentation |
| Director of Nursing | Director of Nursing | Confirmed lack of catheter care documentation |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
A recertification survey was conducted from February 25 through February 27, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop and implement a comprehensive person-centered care plan for a resident with an indwelling catheter, failure to perform and document catheter care as required, and failure to prime an insulin pen prior to administration for another resident.
Deficiencies (3)
Failed to develop and implement a comprehensive person-centered care plan addressing care and treatment for one resident with an indwelling catheter.
Failed to perform and document catheter care for one resident with an indwelling catheter, increasing risk of infections.
Failed to prime the insulin pen prior to use for one resident during medication administration.
Report Facts
Census: 65
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Certified Nursing Assistant (CNA) | Interviewed regarding catheter care and was unsure of catheter care procedures. |
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding catheter care policy and documentation; confirmed lack of documentation since 9/19/2024. |
| AA | Licensed Practical Nurse (LPN) | Observed administering insulin without priming the insulin pen and admitted forgetting to prime due to nervousness. |
| Director of Nursing (DON) | Director of Nursing | Confirmed no documentation of catheter care for resident R318 and discussed insulin pen priming policy. |
Inspection Report
Life Safety
Census: 66
Capacity: 104
Deficiencies: 5
Date: Feb 27, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including corroded sprinkler heads, a yellow-tagged sprinkler system needing repairs, improperly sealed fire penetrations, an open J-box exposing wires, and powerstrips placed on the floor. These deficiencies affected multiple areas and residents.
Deficiencies (5)
Corroded sprinkler heads observed in the kitchen and cooler areas.
Sprinkler system was yellow tagged for repairs needing to be done.
Fire penetrations on B-hall were not sealed properly.
Open J-box exposing wires in the riser room.
Powerstrips were found on the floor in the front offices, not mounted.
Report Facts
Residents affected: 15
Residents affected: 20
Residents affected: 15
Residents affected: 10
Residents affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00248138.
Complaint Details
Complaint GA00248138 was substantiated with no deficiencies cited.
Findings
The complaint GA00248138 was substantiated but no deficiencies were cited during the survey.
Report Facts
Facility census: 63
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2023
Visit Reason
A Follow-Up Desk Review was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags were noted to have been corrected as of 09/15/2023.
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: Oct 4, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Federal Focus Survey on September 12, 2023.
Findings
All deficiencies cited in the prior Federal Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 2, 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 during the follow-up survey.
Inspection Report
Life Safety
Census: 57
Capacity: 104
Deficiencies: 2
Date: Sep 14, 2023
Visit Reason
An unannounced Emergency Preparedness survey and a Life Safety Code Federal Monitoring Survey were conducted following a prior state survey. The visit was to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with emergency preparedness requirements but not in substantial compliance with life safety code requirements. Deficiencies included failure to install an automatic sprinkler system in the attic of the Therapy Building and failure to maintain positive latching on a corridor door to the C Hall Linen Room.
Deficiencies (2)
Failure to install an automatic sprinkler system in the attic of the Therapy Building, which has a wood roof and is used for resident therapy.
Failure to maintain positive latching on the door to the C Hall Linen Room; a key code dead bolt lock was installed instead.
Report Facts
Census: 57
Total licensed beds: 104
Roof attic clearance: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified lack of sprinklers in attic and presence during deficiency identification | |
| Infection Control Nurse | Verified residents received therapy in the Therapy Building | |
| Corporate Facility Director | Verified roof construction and sprinkler absence in attic | |
| Administrator | Verified building use for resident therapy at exit conference |
Inspection Report
Monitoring
Census: 59
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
A Federal Monitoring Focus Concern Survey (FCS) was conducted due to concerns about the facility's compliance with Medicare/Medicaid regulations, specifically related to safety and hazardous materials handling.
Findings
The facility was found not in substantial compliance due to failure to secure toxic chemicals stored in utility closets, posing immediate jeopardy and substandard quality of care for five residents with severe cognitive impairment who wandered independently. Immediate jeopardy was removed after corrective actions including securing the closets and staff training.
Deficiencies (1)
Failure to ensure two housekeeping utility closets were locked and cleaning supplies stored to prevent access and exposure to toxic chemicals for five residents with severe cognitive impairment.
Report Facts
Residents affected: 5
Census: 59
Utility closets with unsecured chemicals: 2
Housekeeping utility closets total: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor (HKS) | Conducted in-service trainings and provided Safety Data Sheets for chemicals | |
| Maintenance Supervisor (MS) | Confirmed utility closet door was not lockable and stated it should have a lockable doorknob | |
| Director of Nursing (DON) | Acknowledged awareness of unsecured chemicals and confirmed residents wandered independently | |
| Administrator | Made aware of Immediate Jeopardy removal | |
| Housekeeping Aide (HKA) #3 | Confirmed cleaning supplies were stored on top of cart inside unlocked utility closet | |
| Maintenance Assistance #5 | Reported training on chemical safety and locking procedures | |
| Housekeeping Aide (HKA) #8 | Confirmed orientation training on locking chemicals and proper storage |
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
A standard survey was conducted at Gibson Health and Rehabilitation from August 1, 2023, through August 3, 2023, to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 40
Capacity: 50
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to ensure emergency lighting was operable in all areas, specifically emergency lighting units in the kitchen and on the 200 Hall did not operate during testing, potentially placing 15 residents at risk during a power failure.
Deficiencies (1)
Emergency lighting units in the kitchen over the prep table and two units on the 200 Hall did not operate when tested.
Report Facts
Residents at risk: 15
Census: 40
Certified beds: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of inoperable emergency lighting during facility tour |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
A State Licensure survey was conducted at Gibson Health and Rehabilitation from August 1, 2023 through August 3, 2023 to assess compliance with state health regulations.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection period.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00232595.
Complaint Details
Complaint #GA00232595 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/03/2022 recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/03/2022 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 2/03/2022 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/03/2022 recertification survey.
Findings
All deficiencies cited as a result of the 2/03/2022 recertification survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/03/2022 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 54
Deficiencies: 0
Date: Apr 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/03/2022 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Deficiencies: 2
Date: Feb 3, 2022
Visit Reason
The inspection was conducted to assess compliance with nursing care plans and immunization policies at Gibson Health and Rehabilitation.
Findings
The facility failed to implement the comprehensive care plan for catheter tubing placement for one resident and failed to provide evidence that two residents were offered the Pneumococcal vaccine as required.
Deficiencies (2)
Failure to implement the comprehensive care plan related to catheter tubing placement for one resident (R#20), with catheter tubing improperly positioned hanging on the side rail without a privacy bag.
Failure to provide evidence that residents R#20 and R#36 were offered the Pneumococcal vaccine as required by facility policy and regulations.
Report Facts
Resident care plans reviewed: 12
Residents sampled for immunizations: 5
Residents not offered Pneumococcal vaccine: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Confirmed catheter tubing placement issue for resident R#20 | |
| Director of Nursing (DON) | Confirmed expectation for nursing staff to follow care plans and discussed consent issues for Pneumococcal vaccine | |
| Assistant Director of Nursing (ADON) | Discussed consent and vaccine administration issues for residents R#20 and R#36 | |
| Infection Control Preventionist (ICP) | Responsible for obtaining consent for Pneumococcal vaccine but was out with COVID during survey |
Inspection Report
Routine
Census: 49
Deficiencies: 5
Date: Feb 3, 2022
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations at Gibson Health and Rehabilitation from February 1 through February 3, 2022.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to protect a resident from verbal abuse, failure to implement comprehensive care plans related to catheter tubing placement, failure to provide ordered pressure ulcer treatments, improper catheter care, and failure to offer pneumococcal immunizations to residents.
Deficiencies (5)
Failure to protect one resident from verbal abuse by a Certified Nursing Assistant.
Failure to implement comprehensive care plan related to catheter tubing placement for one resident.
Failure to provide treatments as ordered by the physician for two residents with pressure ulcers.
Failure to ensure Foley catheter was placed in a privacy bag and properly positioned for one resident.
Failure to provide evidence that pneumococcal vaccine was offered to two residents.
Report Facts
Resident census: 49
Residents reviewed for care plans: 12
Residents reviewed for pressure ulcers: 3
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Confirmed improper catheter placement for Resident #20 |
| BB | Registered Nurse | Acknowledged missed wound treatment for Resident #41 |
| Administrator | Provided information on verbal abuse incident involving Resident #154 | |
| DON | Director of Nursing | Provided multiple interviews regarding care plan implementation, catheter care, wound treatment, and immunization consent |
| ADON | Assistant Director of Nursing | Discussed pneumococcal vaccine consent and documentation issues |
Inspection Report
Life Safety
Census: 49
Capacity: 104
Deficiencies: 0
Date: Feb 2, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
Gibson Health & Rehabilitation was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with LTC 42 CFR § 483.73.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00213443, #GA00213775, and #GA00215971.
Complaint Details
Complaints #GA00213443, #GA00213775, and #GA00215971 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 62
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for 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 infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 72
Deficiencies: 0
Date: Jun 16, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Date: Nov 13, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2019-09-26.
Findings
All deficiencies cited in the 9/26/19 standard survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 13, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 82
Capacity: 104
Deficiencies: 6
Date: Sep 23, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to properly maintain the fire sprinkler system, corridor doors, electrical system, and use of space heaters, placing 82 residents at risk in the event of a fire.
Deficiencies (6)
Fire sprinkler piping located in the Outside Can Wash Room is not protected from freezing.
Corroded fire sprinkler on Kitchen Loading Dock.
Corridor doors protecting openings do not close fully and latch (Electrical Room, Mechanical Room 4, Pantry).
Cross Corridor C Hall Right Door does not close fully.
Open electrical connection behind dryer #2 not in required junction box with cover.
Space heater located in the MDS Office does not meet established code requirements.
Report Facts
Census: 82
Total Capacity: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 18, 2018
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 during the follow-up survey.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Jun 14, 2018
Visit Reason
A standard survey was conducted at Gibson Health and Rehabilitation from 6/11/18 through 6/14/18 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 82
Capacity: 104
Deficiencies: 5
Date: Jun 12, 2018
Visit Reason
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 with life safety requirements, including failure to maintain emergency lighting, fire alarm components, exit signage lighting, electrical systems, and proper storage of oxygen cylinders, placing all 82 residents at risk in the event of a fire.
Deficiencies (5)
Failed to maintain emergency lighting; emergency light for egress outside hall A patio doors did not work when manually manipulated.
Failed to maintain fire alarm and its components; batteries in Physical Therapy building lacked manufacturer's date.
Failed to maintain exit signage lighting; exit sign on C hall fire doors was not operative on DC power when manually manipulated.
Failed to maintain electrical systems; permanent use of extension cord in Physical Therapy and power strips found on floors under desks in Physical Therapy and MDS office.
Failed to properly store oxygen cylinders; empty and full cylinders were mixed together in storage area.
Report Facts
Residents at risk: 82
Certified beds: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 6, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00184816.
Complaint Details
Complaint GA00184816 was investigated and determined to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 21, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Aug 18, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the June 30, 2017 Recertification Survey.
Findings
All deficiencies cited in the prior June 30, 2017 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 104
Capacity: 85
Deficiencies: 16
Date: Jun 27, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements including emergency lighting, fire alarm system installation and maintenance, sprinkler system installation and supervision, fire extinguisher maintenance, corridor door functionality, smoke barrier integrity, electrical system safety, HVAC installation, fuel-fired heating equipment safety, fire plan completeness, fire drill procedures, and generator maintenance.
Deficiencies (16)
Failed to provide emergency lighting for the full path to public way from Building 2.
Improper installation of paper backed insulation with backing exposed in basement workshop.
Failed to properly maintain fire alarm system; pull stations mounted at incorrect height in Buildings 1 & 2.
Smoke detectors located in air flow stream at Nurse's Station and Hall Lobby in Building 1.
Failed to properly test smoke detectors 1, 9, 10, 19, 20 for sensitivity for past 2 annual inspections.
Failed to properly maintain fire sprinkler system; bathrooms, closets, attic, and part of basement not protected in Building 2; sprinkler piping not protected from freezing in Building 2 attic.
Failed to properly supervise fire sprinkler system; OS&Y valve in vault not supervised by fire alarm in Building 1.
Failed to properly maintain fire sprinkler system; fire sprinkler heads in kitchen, cooler, and freezer loaded with grease; backflow valve not tested.
Failed to properly maintain fire extinguishers; extinguishers mounted too high in Buildings 1 & 2.
Failed to properly maintain sleeping room doors; rooms A 10 and C 5 in Building 1 do not latch.
Failed to properly maintain rated walls and ceilings; unprotected and improperly protected penetrations in corridor smoke walls and rated ceilings in multiple locations in Building 1.
Failed to properly maintain electrical systems; flexible cord running through ceiling in Dining Room Building 1, exposed nonmetallic wiring in basement Building 2, electrical panel blocked in Building 2, laundry extension cord used as permanent wiring in Building 1, exposed wiring above refrigerator in Building 1.
Failed to properly install fuel-fired heating equipment; makeup air from attic through ceiling opening, combustible guard constructed around equipment in laundry, combustibles stored next to fuel-fired equipment in Buildings 1 & 2.
Failed to properly update facility fire plan; plan missing element requiring call to 911 for all alarms.
Fire drills not properly conducted; fire alarm not activated during drills between 9:00 p.m. and 6:00 a.m.
Failed to properly maintain facility generator; missing monthly load tests for December 2016, January and February 2017.
Report Facts
Census: 104
Total Capacity: 85
Deficiencies cited: 15
Missing monthly generator load tests: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during tour and discovery |
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