Inspection Reports for Haralson Nsg & Rehab Center
315 FIELD STREET, BREMEN, GA, 30110
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 15, 2025, identified deficiencies related to incomplete and inaccurate medical record documentation for pressure ulcer treatment. Earlier inspections showed a pattern of similar documentation issues, along with problems maintaining sanitary shower conditions and a resident burn injury caused by hot liquids served in a faulty wheelchair cupholder. Complaint investigations substantiated these findings, including the burn injury, while other complaints were unsubstantiated. Prior reports also noted concerns with nursing staffing adequacy, unsafe water temperatures, and life safety code violations, but enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with documentation and environmental safety, with no clear improvement trend in recent inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
109 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
A State Licensure survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025, through April 15, 2025, to assess compliance with state health regulations.
Findings
The survey revealed deficiencies related to incomplete and/or inaccurate medical record documentation for one of three residents reviewed for pressure ulcers, specifically missing treatment documentation on several dates in June 2024.
Deficiencies (1)
The facility failed to ensure that the medical record documentation was completed and/or accurate for one of three residents reviewed for pressure ulcers, with missing treatment documentation on multiple dates.
Report Facts
Dates missing treatment documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Stated she performed sacral wound treatment on 6/4/2024 but did not sign the Treatment Administration Record |
| Administrator | Stated expectation that all treatments be documented after completion |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Date: Apr 15, 2025
Visit Reason
A complaint survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025 through April 15, 2025, investigating multiple complaint intake numbers related to facility compliance and resident safety.
Complaint Details
Complaint Intake Numbers GA00247417, GA00247892, GA00252719 were substantiated with cited deficiencies. Complaint Intake Number GA00248657 was unsubstantiated. Harm was identified related to a resident burn on November 12, 2024, caused by hot liquids served in a faulty wheelchair cupholder.
Findings
The survey found the facility was not in substantial compliance with Medicare/Medicaid regulations, citing deficiencies including unsanitary shower room conditions and a resident burn injury caused by hot liquids served in a faulty wheelchair cupholder. Additionally, documentation deficiencies related to pressure ulcer treatment were identified.
Deficiencies (3)
Failed to maintain shower rooms in a clean condition, with dark brown to black fuzzy and slimy substances on walls in two halls.
Failed to ensure one resident was free from accident hazards, resulting in a second-degree burn from hot liquids served in a wheelchair cupholder with a loose screw causing a punctured cup.
Failed to ensure medical record documentation was completed and accurate for one resident reviewed for pressure ulcers.
Report Facts
Complaint Intake Numbers Investigated: 4
Residents sampled for accident hazards: 14
Resident census: 109
BIMS score: 15
BIMS score: 13
Pressure ulcer treatment missing documentation dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Performed sacral wound treatment for R2 and discussed documentation |
| Activity Director | Activity Director | Recalled coffee spill incident and described cupholder defect |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Recalled resident condition after coffee spill and assisted resident |
| Nurse Practitioner 19 | Nurse Practitioner | Commented on unsafe temperature of hot beverages |
| Medical Director | Medical Director | Acknowledged hot beverage temperature concerns |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
A State Licensure survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025, through April 15, 2025, to assess compliance with state health regulations.
Findings
The survey revealed deficiencies related to incomplete and/or inaccurate medical record documentation for one of three residents reviewed for pressure ulcers, specifically missing treatment documentation on several dates in June 2024.
Deficiencies (1)
Failure to ensure medical record documentation was completed and/or accurate for one resident reviewed for pressure ulcers, including missing documentation of wound treatment on specified dates.
Report Facts
Dates missing treatment documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)4 | Stated she performed sacral wound treatment on 6/4/2024 but did not sign the Treatment Administration Record afterwards | |
| Administrator | Stated expectation that all treatments be documented after completion |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Date: Apr 15, 2025
Visit Reason
A complaint survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025, through April 15, 2025, investigating multiple complaint intake numbers related to facility compliance and resident safety.
Complaint Details
Complaint Intake Numbers GA00247417, GA00247892, and GA00252719 were substantiated with cited deficiencies. Complaint Intake Number GA00248657 was unsubstantiated. Harm was identified on November 12, 2024, when Resident 4 was burned by hot liquids served in a defective cupholder.
Findings
The survey found the facility was not in substantial compliance with Medicare/Medicaid regulations, citing deficiencies including unsanitary shower room conditions and a resident burn injury caused by hot liquids served in a defective cupholder. Additionally, incomplete medical record documentation for pressure ulcer treatment was identified.
Deficiencies (3)
Failed to maintain shower rooms in a clean condition, with dark brown to black fuzzy and slimy substances on walls in two halls.
Failed to ensure one resident (R4) was free from accident hazards, resulting in a second-degree burn from hot liquids served in a defective wheelchair cupholder.
Failed to ensure medical record documentation was completed and/or accurate for one resident (R2) reviewed for pressure ulcers.
Report Facts
Census: 109
Residents sampled: 14
BIMS score: 15
BIMS score: 13
Treatment dates missing documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | LPN | Performed sacral wound treatment for Resident 2 but failed to document treatment on TAR. |
| Activity Director | AD | Recalled the coffee spill incident involving Resident 4 and noted the loose screw in the wheelchair cupholder. |
| Certified Nursing Assistant 5 | CNA | Recalled bringing Resident 4 to room after coffee spill and described resident's pain and blisters. |
| Assistant Director of Nursing | ADON | Indicated cupholders were donated by family members and installed by maintenance. |
| Maintenance Director | Maintenance Director | Revealed cupholders were ordered from vendor and installed by maintenance staff. |
| Nurse Practitioner 19 | NP | Stated 160 degrees F was not appropriate temperature for serving hot beverages to elderly residents. |
| Medical Director | Medical Director | Acknowledged hot beverages at 160 degrees F were too hot for residents. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
A State Licensure survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025, through April 15, 2025, to assess compliance with state health regulations.
Findings
The survey revealed deficiencies related to incomplete and/or inaccurate medical record documentation for one of three residents reviewed for pressure ulcers, specifically missing treatment documentation on several dates in June 2024.
Deficiencies (1)
Failure to ensure that medical record documentation was completed and/or accurate for one resident reviewed for pressure ulcers, including missing treatment documentation on specified dates.
Report Facts
Dates missing treatment documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Stated she performed sacral wound treatment on 6/4/2024 but did not sign the Treatment Administration Record |
| Administrator | Administrator | Stated expectation that all treatments be documented after completion |
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 3
Date: Apr 15, 2025
Visit Reason
A complaint survey was conducted at Haralson Nursing & Rehab Center from April 8, 2025, through April 15, 2025, investigating multiple complaint intake numbers related to facility compliance and resident safety.
Complaint Details
Complaint Intake Numbers GA00247417, GA00247892, and GA00252719 were substantiated with cited deficiencies. Complaint Intake Number GA00248657 was unsubstantiated. Harm was identified on November 12, 2024, when Resident 4 was burned by hot liquids served in a faulty wheelchair cupholder.
Findings
The survey found the facility was not in substantial compliance with Medicare/Medicaid regulations, citing deficiencies including unsanitary shower room conditions and a resident burn injury caused by hot liquids served in a faulty wheelchair cupholder. Additionally, documentation deficiencies related to pressure ulcer treatment were identified.
Deficiencies (3)
Failed to maintain shower rooms in a clean condition, with dark brown to black fuzzy and slimy substances on walls in two halls.
Failed to ensure one resident (R4) was free from accident hazards, resulting in a second-degree burn from hot liquids served in a faulty wheelchair cupholder.
Failed to ensure accurate and complete medical record documentation for pressure ulcer treatment for one resident (R2).
Report Facts
Complaint Intake Numbers Investigated: 4
Residents Sampled for Hot Beverage Policy: 14
Census: 109
Dates with Missing Treatment Documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Performed sacral wound treatment but failed to document on TAR |
| Activity Director | Activity Director | Recalled coffee activity and described faulty wheelchair cupholder |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Observed resident after burn incident and described resident's pain |
| Nurse Practitioner 19 | Nurse Practitioner | Commented on unsafe temperature of hot beverages served |
| Medical Director | Medical Director | Acknowledged hot beverage temperatures were too high for residents |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 22, 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
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Haralson Nursing & Rehab Center, 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: 109
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/30/2024 Recertification Survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Report Facts
Census: 109
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 3
Date: May 30, 2024
Visit Reason
A State Licensure survey was conducted from May 28, 2024 through May 30, 2024 to assess compliance with state health regulations at Haralson Nursing and Rehabilitation Center.
Findings
The facility was found deficient in nursing staffing adequacy affecting 104 residents and failed to maintain safe water temperatures above 110 degrees Fahrenheit in 27 resident rooms and the shower room on one wing, posing a risk of skin burns. Additionally, the facility failed to change bed linen for one resident.
Deficiencies (3)
Facility failed to ensure adequate nursing staff, impacting care for 104 residents.
Water temperatures exceeded 110 degrees Fahrenheit in 27 resident rooms and the shower room on one wing, risking skin burns.
Failed to change bed linen for one resident (R103).
Report Facts
Resident census: 104
Rooms with water temperature above 110 F: 27
Water temperatures: 119.3
Water temperatures: 121.5
Water temperatures: 121.4
Water temperatures: 120.3
Water temperatures: 119.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Admitted issues with mixing valve causing high water temperatures and verified temperature logs |
| Administrator | Administrator | Notified of water temperature issues and described corrective actions including turning off hot water on affected wing |
| Human Resources Director | Human Resources Director | Provided information on nursing staffing and scheduling |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 4
Date: May 30, 2024
Visit Reason
A standard survey was conducted from 5/28/2024 through 5/30/2024, including investigation of multiple complaint intake numbers. One complaint was substantiated with federal deficiency, while others were unsubstantiated.
Complaint Details
Complaint Intake Number GA00244500 was substantiated with federal deficiency; other complaint intake numbers investigated were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe water temperatures above 110°F affecting 27 resident rooms and a shower room, failure to change bed linens for one resident, failure to administer oxygen therapy as ordered for one resident, and inadequate nursing staff levels.
Deficiencies (4)
Water temperatures above 110 degrees Fahrenheit in 27 resident rooms and shower room on one wing, posing risk of skin burns.
Failure to change bed linens for one resident after showers.
Failure to administer oxygen therapy as ordered for one resident, with oxygen concentrator set at 3 LPM instead of ordered 2 LPM.
Insufficient nursing staff as evidenced by payroll-based journal data triggering a One-Star Staffing Rating and high turnover.
Report Facts
Resident census: 104
Water temperature readings: 27
Oxygen flow rate: 3
PBJ Staffing Data Report Quarter 1 2024: 75
PBJ Staffing Data Report Quarter 1 2024: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R412 | Resident | Interviewed about water temperature concerns |
| Maintenance Director | Verified water temperatures were high and out of compliance; reported issues with mixing valve | |
| Administrator | Notified of water temperature concerns and described plan to manage hot water availability | |
| R103 | Resident | Reported bed linens were not changed after showers |
| Certified Nursing Assistant BB | CNA | Stated bed sheets must be changed after showers |
| Director of Nursing | DON | Stated expectation for nurses to follow physician's orders and monitor oxygen levels |
| Assistant Director of Nursing/Infection Preventionist | ADON/IP | Reported daily rounds to check oxygen concentrators and settings |
| LPN AA | LPN | Confirmed oxygen flow rate was set incorrectly and adjusted it |
| Human Resources Director | HR Director | Discussed staffing levels, scheduling, and agency staff usage |
Inspection Report
Life Safety
Census: 105
Capacity: 118
Deficiencies: 4
Date: May 28, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed means of egress, missing and broken ceiling tiles compromising fire sprinkler activation, undated fire alarm system batteries, and an open electrical panel posing shock hazards. These deficiencies affected one of three smoke compartments.
Deficiencies (4)
Means of egress in corridors were obstructed by a wheelchair and lift device while not in use.
Ceiling tiles missing, broken, and not in place could allow smoke and flame to bypass the fire sprinkler system.
Fire alarm system batteries were not dated with the manufacturer's date as required.
An open circuit in the electrical panel was not protected by a cover, posing a risk of personal shock or electrocution.
Report Facts
Census: 105
Total Capacity: 118
Smoke Compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint numbers GA00240998, GA00241068, GA00241735, GA00242054, and GA00242980.
Complaint Details
The survey investigated five complaint numbers. Three complaints were unsubstantiated, and two were substantiated with no deficiencies.
Findings
Complaint numbers GA00241735, GA00242054, and GA00242980 were unsubstantiated. Complaint numbers GA00240998 and GA00241068 were substantiated but with no deficiencies found.
Report Facts
Complaint numbers investigated: 5
Facility census: 101
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00237570 and #GA00237183.
Complaint Details
Complaints #GA00237183 and #GA00237570 were substantiated with no federal citations.
Findings
The complaints #GA00237183 and #GA00237570 were substantiated with no federal citations.
Report Facts
Census: 101
Inspection Report
Abbreviated Survey
Census: 99
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An Abbreviated Survey was conducted to investigate multiple complaints (#GA00230874, #GA00231598, #GA00234596, #GA00229295, and #GA00234837) from May 02, 2023 to May 03, 2023.
Complaint Details
Complaint #GA00230874 was substantiated; other complaints investigated were unsubstantiated.
Findings
Complaint #GA00230874 was substantiated, while complaints #GA00231598, #GA00234596, #GA00229295, and #GA00234837 were unsubstantiated. No regulatory violations were cited during the survey.
Report Facts
Resident Census: 99
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 4, 2022
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 deficiencies had been corrected.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
A revisit survey was conducted from 09/27/2022 through 09/29/2022 to investigate Complaint Intake Numbers GA00226204 and GA00228217 and to verify correction of deficiencies cited in the 07/21/2022 Recertification Survey.
Complaint Details
Complaint Intake Numbers GA00226204 and GA00228217 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 07/21/2022 Recertification Survey were found to be corrected. The complaint investigations for GA00226204 and GA00228217 were found to be unsubstantiated.
Report Facts
Census: 98
Inspection Report
Deficiencies: 0
Date: Sep 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Haralson Nursing & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
The visit was conducted to investigate complaints GA00228217 and GA00226204 in conjunction with a revisit survey following the 7/22/22 Recertification Survey.
Complaint Details
Complaint Intake Numbers GA00228217 and GA00226204 were investigated and found unsubstantiated with no regulatory violations cited.
Findings
All deficiencies cited in the 7/22/22 Recertification Survey were found to be corrected. The complaint investigation found both complaints unsubstantiated and no regulatory violations were cited.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 27, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags at the facility.
Findings
The facility failed to properly maintain construction of smoke walls to resist the transfer of smoke, affecting 3 of 3 smoke compartments due to unsealed penetrations in smoke partitions.
Deficiencies (1)
Facility failed to properly maintain construction of smoke walls to resist the transfer of smoke; penetrations were present and not properly sealed in smoke partitions in 3 of 3 compartments.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings of unsealed penetrations in smoke partitions during the tour. |
Inspection Report
Life Safety
Census: 102
Capacity: 118
Deficiencies: 1
Date: Jul 22, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to properly maintain construction of smoke walls to resist the transfer of smoke. Penetrations were observed in smoke partitions in all 3 smoke compartments and were not properly sealed, as confirmed by staff.
Deficiencies (1)
Facility failed to properly maintain construction of the smoke walls to resist the transfer of smoke; penetrations present in smoke partitions in 3 of 3 compartments were not properly sealed.
Report Facts
Census: 102
Total Capacity: 118
Smoke Compartments Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unsealed penetrations in smoke partitions during facility tour |
Inspection Report
Renewal
Deficiencies: 6
Date: Jul 21, 2022
Visit Reason
The inspection was a Licensure Survey conducted from July 18, 2022 through July 21, 2022 to assess compliance with state regulations for licensure renewal.
Findings
The facility was found deficient in multiple areas including failure to ensure safe discharge procedures, improper use of personal protective equipment (PPE) in the COVID-19 Isolation Unit, inadequate housekeeping and infection control practices, lack of certification and training for the Dietary Manager, failure to provide adequate activities of daily living (ADL) care such as nail care, environmental sanitation issues including broken tiles and rust in shower rooms, and multiple deficiencies in food safety and kitchen operations including improper food labeling, expired food storage, lack of hair nets, malfunctioning equipment, and grease trap issues.
Deficiencies (6)
Failed to ensure safe discharge procedures including physician notification and education when resident left against medical advice.
Failed to ensure proper PPE use and infection control in COVID-19 Isolation Unit and housekeeping.
Dietary Manager was not certified and lacked onsite training or supervision.
Failed to provide adequate ADL care including nail care for a dependent resident.
Facility failed to maintain clean, homelike environment; observed broken tiles, exposed concrete, holes in walls, and rust in shower room.
Failed to ensure proper food labeling, storage, and discarding of expired food items; staff lacked hair nets; malfunctioning milk freezer, dishwasher, and grease trap.
Report Facts
Residents receiving oral diet: 101
Milk cartons in chest freezer: 141
Dishwasher wash temperature: 110
Dishwasher rinse temperature: 110
Dishwasher sanitation temperature: 118
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DM XX | Dietary Manager | Not certified as Certified Dietary Manager, lacked onsite training and supervision. |
| LPN EE | Licensed Practical Nurse | Interviewed regarding AMA discharge procedures. |
| SSD QQ | Social Services Director | Interviewed regarding AMA discharge procedures and notifications. |
| DON CC | Director of Nursing | Interviewed regarding AMA discharge procedures, PPE use, and dietary manager certification. |
| Administrator AAA | Administrator | Interviewed regarding AMA discharge, PPE use, housekeeping, dietary manager certification, and kitchen issues. |
| CNA FF | Certified Nurse Aide | Observed and interviewed regarding PPE use in COVID-19 unit. |
| HSK GG | Housekeeper | Observed cleaning isolation room without proper PPE and procedures. |
| SDC JJ | Staff Development Coordinator | Provided infection control training and interviewed regarding PPE. |
| CDM VV | Certified Dietary Manager | Did not provide onsite training to new Dietary Manager. |
| CDM YY | Certified Dietary Manager | Did not provide onsite training to new Dietary Manager. |
| Corporate CDM ZZ | Corporate Certified Dietary Manager | Limited visits and training provided to new Dietary Manager. |
| RD NN | Registered Dietician | Did not provide training or supervision to new Dietary Manager. |
| CNA II | Certified Nurse Aide | Interviewed regarding ADL care and nail care. |
| LPN PP | Licensed Practical Nurse | Interviewed regarding ADL care and nail care. |
| LPN/WCN KK | Licensed Practical Nurse/Wound Care Nurse | Provided nail care to resident and interviewed regarding nail care. |
| DA LLL | Dietary Aide/Cook | Observed food safety violations and interviewed regarding food labeling and storage. |
| DA NNN | Dietary Aide | Interviewed regarding food safety training. |
| DA RRR | Dietary Aide | Interviewed regarding food safety training. |
| DA QQQ | Dietary Aide | Interviewed regarding food safety training. |
| DA MMM | Dietary Aide | Observed working without hair net and interviewed regarding hair net availability. |
| DA OOO | Dietary Aide | Observed operating dishwasher and interviewed regarding dishwasher operation. |
| Maintenance Director | Interviewed regarding environmental and kitchen maintenance issues. | |
| Maintenance Supervisor | Interviewed regarding grease trap issues. | |
| Housekeeping Supervisor Trainee | Interviewed regarding housekeeping cleaning procedures. |
Inspection Report
Routine
Census: 103
Deficiencies: 17
Date: Jul 21, 2022
Visit Reason
A standard survey was conducted from July 18, 2022 through July 21, 2022, including complaint investigations, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including safe environment, freedom from abuse, PASARR screening, care planning, discharge planning, ADL care, accident prevention, respiratory care, dialysis communication, dietary staffing and menu compliance, food safety, garbage disposal, hospice care coordination, bedrail use, medication administration, and infection control.
Deficiencies (17)
Failed to maintain a clean, comfortable, and homelike environment in resident rooms and shower room with broken tiles, exposed concrete, holes in walls, and rust-colored substances.
Failed to protect two residents from abuse by another resident with documented incidents of hitting and inadequate supervision.
Failed to ensure PASARR Level 1 screening accurately reflected residents' mental illness diagnoses.
Failed to ensure reasonable efforts to facilitate participation of resident's responsible party in care plan meetings.
Failed to ensure safe discharge for resident leaving against medical advice with physician notification and education.
Failed to provide nail care for a dependent resident.
Failed to identify root cause and develop person-centered interventions after resident falls; post-fall documentation incomplete.
Failed to ensure oxygen was administered at physician-ordered flow rate, oxygen saturation regularly checked and documented, and oxygen administration accurately documented.
Failed to ensure communication documentation between facility and dialysis staff was complete and accurate.
Failed to ensure dietary manager was certified or had equivalent certification and failed to provide onsite training for newly hired dietary manager.
Failed to ensure menus were followed, food items dated and labeled, expired foods discarded, hair nets worn by dietary staff, dishwasher and grease trap properly maintained.
Failed to maintain dumpster in sanitary condition with tightly fitted lids to prevent pest access.
Failed to integrate hospice and facility care plans to delineate responsibilities of hospice and facility staff for resident care.
Failed to fully assess, obtain physician order, consent, and care plan for use of side rails/bed rails for resident.
Medication error rate of 13.79% observed with incorrect doses and unauthorized medication administration.
Failed to ensure proper oxygen administration and documentation for resident receiving oxygen therapy.
Failed to ensure proper infection prevention and control practices including appropriate PPE use in COVID-19 isolation unit and proper housekeeping cleaning and sanitation.
Report Facts
Resident census: 103
Medication error rate: 13.79
Medication administration opportunities: 29
Medication errors: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AAA | Licensed Practical Nurse | Observed making medication errors during medication administration on 7/19/22 |
| DM XX | Dietary Manager | Newly hired dietary manager without certification or onsite training |
| ADON HH | Assistant Director of Nursing | Discussed fall interventions and infection control training |
| DON CC | Director of Nursing | Provided information on falls, oxygen administration, infection control, and hospice care plan expectations |
| Administrator AAA | Administrator | Provided expectations on menus, dietary staffing, infection control, and medication administration |
| MDS RN SS | Minimum Data Set Coordinator/Register Nurse | Reviewed hospice care plan and PASARR screening |
| CNA FF | Certified Nurse Aide | Observed not wearing full PPE in COVID-19 Observation Unit |
| HSK GG | Housekeeper | Observed not wearing proper PPE and improper cleaning in isolation room |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 7, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00204685 and #GA00207969.
Complaint Details
Complaint #GA00204685 was unsubstantiated with no deficiencies. Complaint #GA00207969 was substantiated with no deficiencies.
Findings
Complaint #GA00204685 was unsubstantiated with no deficiencies found. Complaint #GA00207969 was substantiated, but no deficiencies were identified.
Inspection Report
Routine
Census: 90
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to determine whether the facility is implementing proper infection prevention and control practices to prevent the development and transmission of COVID-19 and other communicable diseases and infections.
Findings
The facility was found to be in compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 90
Inspection Report
Routine
Census: 93
Deficiencies: 0
Date: Nov 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 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 recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 101
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and 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 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 101
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey investigation was conducted in response to complaint number GA00201105 on August 19, 2020.
Complaint Details
Complaint number GA00201105 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Routine
Census: 96
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 96
Inspection Report
Renewal
Census: 112
Deficiencies: 0
Date: Aug 22, 2019
Visit Reason
A revisit survey was conducted from 8/20/19 to 8/22/19 for the Recertification Survey originally conducted from 6/17/19 to 6/20/19. Additionally, Complaint Intake Number GA00197980 was investigated in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00197980 was investigated and Complaint Investigation GA00197706 was unsubstantiated.
Findings
The revisit survey revealed that all previously cited deficiencies were found to be corrected. Complaint Investigation GA00197706 was unsubstantiated.
Report Facts
Census: 112
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: Aug 21, 2019
Visit Reason
A revisit survey was conducted from 8/20/19 to 8/22/19 for the Recertification Survey originally conducted from 6/17/19 to 6/20/19. Additionally, Complaint Intake Number GA00197980 was investigated in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00197980 was investigated and Complaint Investigation GA00197706 was unsubstantiated.
Findings
The revisit survey revealed that all previously cited deficiencies were found to be corrected. Complaint Investigation GA00197706 was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 5, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this Follow-Up Survey.
Inspection Report
Routine
Census: 110
Deficiencies: 8
Date: Jun 20, 2019
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The survey revealed multiple deficiencies including failure to maintain resident dignity, failure to update advance directives and care plans timely, medication administration errors, improper catheter management, expired medications on medication carts, and lack of qualified dietary staff.
Deficiencies (8)
Failure to ensure dignity of resident with visible catheter and drainage bag.
Failure to update code status from full code to DNR in clinical records after hospice enrollment.
Failure to follow/implement care plan for therapy referral after fall and insulin administration errors.
Failure to revise care plan timely after psychiatric hospitalization and behavior changes.
Failure to consistently administer sliding scale insulin and perform fingerstick blood sugar as ordered.
Failure to assess continued catheter use and obtain physician order; failure to use catheter strap.
Failure to remove expired medications and label opened medications with open date on medication cart.
Failure to employ a qualified dietary manager with required certification or degree.
Report Facts
Resident census: 110
Medication administration errors: 11
Medication administration errors: 2
Expired medications: 2
Medication without open date: 1
Residents receiving oral diet: 109
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Registered Nurse Hospice nurse | Obtained DNR form signature for resident #37 |
| EE | Licensed Practical Nurse | Described process to identify resident code status for resident #37 |
| JJ | Regional Director of Operations | Provided information about dietary manager certification requirements |
| KK | Corporate Registered Dietician | Provided information about dietary staffing and contract company |
| AA | Licensed Practical Nurse | Confirmed resident #207 had catheter without physician order |
| BB | Licensed Practical Nurse Charge Nurse | Confirmed catheter strap should be used for resident #82 |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 20, 2019
Visit Reason
The inspection was conducted to assess compliance with medical, dental, and nursing care regulations, specifically focusing on care plan implementation, medication administration, and catheter use for residents.
Findings
The facility failed to follow or implement care plans for multiple residents, including failure to provide therapy referrals after falls, incorrect insulin administration, and lack of physician orders for catheter use. Additionally, catheter care was deficient due to the absence of catheter straps for a resident.
Deficiencies (4)
Failure to follow/implement care plan for resident #23 regarding therapy referral after fall injury.
Incorrect sliding scale insulin administration and missed fingerstick blood sugar tests for resident #58.
Failure to assess continued catheter use or obtain physician's order for catheter for resident #207.
Failure to ensure use of catheter strap for resident #82 during catheter care.
Report Facts
Sample size: 67
Incorrect insulin administrations: 11
Missed FSBS tests: 2
Catheter size: 16
Catheter bulb size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Confirmed resident #207 had a urinary catheter without physician order |
| Licensed Practical Nurse BB | Charge Nurse | Stated residents with catheters should have catheter straps |
| Director of Nursing | Director of Nursing | Provided information on resident #23 fall and care plan issues, verified insulin concerns for resident #58, and explained catheter order procedures |
| Director of Rehabilitation | Director of Rehabilitation | Reported no therapy referral received for resident #23 and discussed resident's therapy history |
| Physician of Resident #207 | Physician | Discussed catheter removal protocol and gave order to remove catheter for resident #207 |
Inspection Report
Life Safety
Census: 108
Capacity: 120
Deficiencies: 3
Date: Jun 19, 2019
Visit Reason
The survey was conducted to assess compliance with emergency preparedness and life safety code requirements, including review of the Emergency Preparedness Plan and a Life Safety Code Survey.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with Appendix Z requirements, including reliance on a portable generator with extension cords. Life Safety Code deficiencies included exit doors that were sticking and hard to open, and cross corridor smoke compartment doors that would not close properly, placing residents at risk during emergencies.
Deficiencies (3)
Emergency Preparedness Plan not in substantial compliance with Appendix Z, including reliance on portable generator with extension cords.
Exit doors at room 102, Linen Closet 1, and room 202 were sticking and hard to open.
Cross corridor smoke compartment doors at Nurse Station 2 would not close due to door dragging on frame.
Report Facts
Census: 108
Total Capacity: 120
Number of exit doors sticking: 3
Number of smoke compartments with door issues: 3
Number of smoke compartments with cross corridor door issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings related to Emergency Preparedness Plan and door issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00193928 and GA00194454 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00193928 and GA00194454; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 6, 2018
Visit Reason
A re-visit survey was conducted at Haralson Nursing and Rehabilitation Center to verify correction of deficiencies found in the Abbreviated/Partial Extended Surveys conducted from August 20, 2018 through October 5, 2018.
Findings
All deficiencies resulting from the prior Abbreviated/Partial Extended Surveys were found to be corrected during this re-visit survey.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 7
Date: Oct 5, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints alleging improper resident transfers, failure to report injuries, and unsafe environment conditions.
Complaint Details
The investigation was initiated due to complaints alleging improper resident transfers, failure to report injuries timely, and unsafe environment conditions. The complaint was substantiated with findings of actual harm to Resident #33 due to improper transfer and failure to report injury for Resident #18.
Findings
The facility was found not in compliance with Federal and State Long Term Care Requirements. Actual harm was identified when Resident #33 was improperly transferred without a mechanical lift, resulting in bilateral femur fractures. The facility also failed to report an injury of unknown origin timely for Resident #18 and failed to follow physician orders for wound care for Resident #1. Environmental deficiencies included dirty air conditioning coils and damaged drywall in resident rooms.
Deficiencies (7)
Failure to provide a safe, clean, comfortable, and homelike environment, evidenced by dirty, dust-covered air-conditioning coils and damaged drywall and baseboards in multiple resident rooms.
Failure to report an injury of unknown origin within required timeframes for Resident #18 who sustained a distal femur fracture.
Failure to accurately assess and care plan for contractures and improper transfer of Resident #33 resulting in bilateral femur fractures.
Failure to develop and implement a comprehensive care plan consistent with assessments for Resident #33, including use of mechanical lift for transfers.
Failure to provide services in accordance with professional standards, including failure of licensed nurses to properly assess and report injury and communicate critical X-ray results for Resident #33.
Failure to ensure physician orders were followed related to wound care for Resident #1.
Failure to ensure resident environment was free of accident hazards and adequate supervision to prevent accidents, evidenced by improper transfer of Resident #33 causing bilateral femur fractures.
Report Facts
Resident census: 104
Dates of complaint investigation: 2018-08-20 to 2018-10-05
Date of injury report delay: 6
Date of resident discharge: Sep 7, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJJ | Licensed Practical Nurse | Named in improper transfer and failure to assess Resident #33; arrested for neglect |
| LPN FF | Licensed Practical Nurse | Provided nursing care and documented pain for Resident #18 |
| LPN YYY | Licensed Practical Nurse | Failed to accurately report X-ray results to physician for Resident #33; received disciplinary action |
| CNA KKK | Certified Nursing Assistant | Assisted in improper transfer of Resident #33 |
| CNA LLL | Certified Nursing Assistant | Assisted in improper transfer of Resident #33 |
| LPN EEE | Staff Development Licensed Practical Nurse | Provided staff education after incident |
| RN SS | Registered Nurse, Corporate Nurse Consultant | Interviewed regarding reporting requirements and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 5, 2018
Visit Reason
The inspection was conducted following a complaint investigation regarding improper transfer of a resident (R#33) resulting in bilateral femur fractures and failure to follow nursing procedures and care plans.
Complaint Details
The investigation was triggered by allegations of abuse and neglect related to the improper transfer of resident #33 by CNAs and failure of licensed nurses to properly assess and report injuries. The local police arrested LPN JJJ for neglect. The investigation confirmed the resident sustained bilateral femur fractures likely caused by improper transfers.
Findings
The facility failed to ensure licensed nurses followed proper procedures for assessing a resident after a fall and accurately reporting X-ray findings to the physician, resulting in actual harm due to bilateral femur fractures. Additionally, the facility failed to follow the care plan requiring mechanical lift transfers for the resident. Environmental sanitation deficiencies were also noted, including dirty air-conditioning coils and damaged drywall and baseboards in multiple rooms.
Deficiencies (3)
Licensed nurses failed to follow procedures for assessing residents who had a fall and failed to accurately relay X-ray findings of a fracture to the physician, resulting in actual harm due to bilateral femur fractures for resident #33.
Facility failed to follow the care plan related to use of a mechanical lift for resident #33, resulting in improper transfer and bilateral femur fractures.
Facility failed to provide a safe, functional, sanitary, and comfortable environment as evidenced by dirty, dust-covered air-conditioning coils and damaged drywall, paint, and baseboards in multiple resident rooms.
Report Facts
Incident dates: 2
Date of resident discharge: Sep 7, 2018
Date of investigation report: Sep 18, 2018
Date of arrest: Sep 10, 2018
Date of emergency QAPI meeting: Sep 19, 2019
Number of rooms with environmental issues: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJJ | Licensed Practical Nurse | Named in findings for failing to properly assess resident after fall, failing to document incident, and arrested for neglect |
| LPN YYY | Licensed Practical Nurse | Failed to provide accurate information to physician regarding critical X-ray results; received written reprimand |
| CNA KKK | Certified Nursing Assistant | Attempted transfer of resident without mechanical lift; notified LPN JJJ of incident |
| CNA LLL | Certified Nursing Assistant | Assisted in improper transfer of resident without mechanical lift |
| Administrator | Provided information on investigation, staff education, and disciplinary actions | |
| Director of Nursing | Involved in investigation and staff education | |
| Staff Development LPN EEE | Staff Development Licensed Practical Nurse | Provided information on CNA competency checklists and training |
| Corporate Clinical Nurse SS | Registered Nurse | Participated in investigation and environmental observations |
| Maintenance staff BB | Observed and confirmed dirty air-conditioning coils and debris | |
| Maintenance Director CC | Conducted observations of air-conditioning units and maintenance records | |
| LPN WW | Licensed Practical Nurse | Agreed with observations of missing baseboards and need for painting in resident room |
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Date: Sep 5, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00191132.
Complaint Details
Complaint GA00191132 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 11, 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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 14, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 27, 2018 Standard Survey.
Findings
All deficiencies cited during the April 27, 2018 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 11, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags at Haralson Nursing & Rehab Center.
Findings
The facility had corrected all previously cited deficiencies except for an issue with the automatic sprinkler system. The freezer/cooler unit attached to the building was not protected by the sprinkler system, posing a fire risk to kitchen staff and residents in the dining room.
Deficiencies (1)
Failure to completely protect the facility with an automatic sprinkler system; the freezer/cooler unit attached to the building is not protected by the sprinkler system.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the sprinkler system deficiency at the time of discovery. |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Date: Apr 27, 2018
Visit Reason
A standard survey was conducted from 4/24/18 through 4/27/18, including investigation of Complaint Intake Number GA00186928, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00186928 was investigated in conjunction with the standard survey.
Findings
The facility failed to ensure that one resident (R#17) with a physical restraint was provided the least restrictive restraint for the least amount of time and was not adequately supervised or monitored. The care plan lacked specific and effective interventions to ensure adequate supervision and monitoring of the resident with a history of multiple falls and cognitive impairment.
Deficiencies (2)
Failure to ensure resident was free from physical restraints imposed for discipline or convenience and failure to provide least restrictive restraint and adequate supervision.
Failure to develop and implement a comprehensive care plan with specific and effective interventions to ensure adequate supervision and monitoring of a resident with a physical restraint and history of falls.
Report Facts
Resident census: 102
Sample size: 21
Falls recorded: 27
Falls with injuries: 2
Falls with minimal injury: 3
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) EE | Interviewed regarding resident's ability to remove restraint and supervision. | |
| Licensed Practical Nurse (LPN) HH | Observed resident and discussed supervision and room placement. | |
| Director of Nursing | Interviewed regarding therapy screening and fall history. | |
| DD | Corporate Nurse Consultant | Interviewed regarding therapy screening and fall history. |
| Certified Occupational Therapy Assistant (COTA) II | Provided therapy evaluation and referral information. |
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 1
Date: Apr 27, 2018
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate supervision and monitoring for a resident (R#17) with a physical restraint and a history of falls.
Complaint Details
The visit was complaint-related focusing on the supervision and monitoring of resident R#17 who had multiple falls and was physically restrained. The complaint was substantiated by observations and record reviews showing inadequate supervision and care planning.
Findings
The facility failed to include specific and effective interventions in the care plan to ensure adequate supervision and monitoring of resident R#17, who had a history of multiple falls and was physically restrained with a T-cushion. Observations showed the resident was often unsupervised while restrained and walking unsteadily, and documentation lacked evidence of proper monitoring or restraint-free times.
Deficiencies (1)
Failure to include specific and effective interventions in the care plan to ensure adequate supervision and monitoring of resident R#17 with a physical restraint and history of falls.
Report Facts
Sample size: 21
Falls recorded: 27
Falls with injuries: 2
Falls with minimal injury: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Certified Nursing Assistant (CNA) | Interviewed regarding resident R#17's ability to remove T-cushion restraint and supervision |
| HH | Licensed Practical Nurse (LPN) | Observed resident R#17 and provided information about room location and supervision |
| DD | Corporate Nurse Consultant | Interviewed regarding fall screening and therapy evaluations for resident R#17 |
Inspection Report
Life Safety
Census: 102
Capacity: 120
Deficiencies: 2
Date: Apr 24, 2018
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to perform a Life Safety Code Survey to assess compliance with federal and NFPA fire safety standards.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with Appendix Z requirements, potentially placing residents at risk during emergencies. Additionally, the facility failed to fully protect the building with an automatic sprinkler system, specifically the freezer/cooler unit area outside the kitchen was not covered, posing fire risk to kitchen staff and residents.
Deficiencies (2)
Emergency Preparedness Plan was not fully updated to meet Appendix Z requirements.
Failure to completely protect the facility with an automatic sprinkler system, specifically the freezer/cooler unit area outside the kitchen was not protected.
Report Facts
Census: 102
Total Capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Confirmed findings related to Emergency Preparedness Plan | |
| Staff M | Confirmed findings related to Emergency Preparedness Plan and sprinkler system deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 9, 2017
Visit Reason
An Abbreviated Survey was conducted on 9/9/17 at Haralson Nursing and Rehab to investigate complaints # GA00179132.
Complaint Details
Complaint investigation # GA00179132 was conducted and the facility was found to be in compliance.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 12, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags had been corrected during the follow-up visit.
Inspection Report
Census: 104
Deficiencies: 0
Date: May 10, 2017
Visit Reason
A standard survey was conducted from 4/11/17 through 4/14/17, with a re-entrance on 5/10/17 for further investigation. Complaint intake numbers GA00172087 and GA00171510 were also investigated in conjunction with this standard survey.
Complaint Details
Complaint intake Numbers GA00172087 and GA00171510 were investigated in conjunction with this standard survey.
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: 104
Capacity: 120
Deficiencies: 5
Date: Apr 11, 2017
Visit Reason
The visit was a Life Safety Code Survey 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 life safety requirements, including failure to provide emergency lighting of at least 1.5 hours duration, improperly installed fire alarm system components, penetrations in smoke barriers, electrical system issues at HVAC units, and lack of proper smoking area safety equipment.
Deficiencies (5)
Failed to provide emergency lighting of at least 1.5 hours duration at front entrance, rear entrance smoking area, and wing 1 and wing 2 nurses stations.
Fire alarm system improperly installed: no smoke detector over fire alarm control panel, circuit breaker not marked red, appears to be a GFCI, and lacks mechanical lock.
Failed to maintain smoke barriers without penetrations at multiple locations including above ceiling at main entry double doors and wing 2 nurses station.
Failed to maintain electrical system at HVAC units; metal electrical conduit attached outside unit wiring without junction box or proper attachment.
Failed to provide ashtrays of noncombustible material and metal containers with self-closing cover devices at designated smoking area.
Report Facts
Census: 104
Total Capacity: 120
Residents at risk due to smoke barrier penetrations: 57
Residents at risk due to electrical/HVAC deficiencies: 57
Residents at risk due to smoking area deficiencies: 4
Residents at risk due to fire alarm deficiencies: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
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