Inspection Reports for Harborview Health Systems Thomaston
310 AVENUE F, GA, 30286
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Deficiencies: 0
Nov 26, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Health Systems Thomaston, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comments section but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Nov 26, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the October 3, 2024, Complaint Survey and to investigate Complaint Intake Numbers GA00252059 and GA00251377.
Findings
All deficiencies cited in the October 3, 2024, Complaint Survey were found to be corrected. The complaint investigation found the complaints unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00252059 and GA00251377 were investigated and found to be unsubstantiated.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Nov 26, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the October 3, 2024, Complaint Survey and to investigate Complaint Intake Numbers GA00252059 and GA00251377.
Findings
All deficiencies cited in the October 3, 2024, Complaint Survey were found to be corrected. The complaint investigation found Complaint Intake Numbers GA00252059 and GA00251377 to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00252059 and GA00251377 were investigated and found to be unsubstantiated.
Report Facts
Complaint Intake Numbers: GA00252059 and GA00251377 investigated
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 3, 2024
Visit Reason
A State Licensure survey was conducted at Harborview Health Systems Thomaston from October 1, 2024, through October 3, 2024, to assess compliance with state health regulations.
Findings
The survey identified deficiencies related to failure to provide medically-related social services to a resident with behavioral issues and failure to ensure necessary assistance with incontinent care for another resident, placing both at risk for diminished well-being and quality of life.
Deficiencies (2)
| Description |
|---|
| Failure to ensure medically related social services were provided to one resident exhibiting behavioral issues, potentially preventing appropriate treatment and services. |
| Failure to ensure one resident received necessary assistance with incontinent care, placing the resident at risk for unmet needs and diminished quality of life. |
Report Facts
Sampled residents: 15
Warnings issued: 4
Medication dosages: 50
Medication dosages: 100
Medication dosages: 100
Medication dosages: 25
MDS assessment date: May 18, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Named in relation to failure to refer resident R9 for psychological services and involvement in warnings |
| Director of Nursing | Director of Nursing (DON) | Confirmed medication administration and psychological service arrangements for resident R9 |
| Certified Nursing Aide DD | Certified Nursing Aide (CNA) | Provided information on incontinent care frequency for resident R8 |
| Certified Nursing Aide II | Certified Nursing Aide II (CNA II) | Provided information on incontinent care frequency and resident refusals for resident R8 |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 4
Oct 1, 2024
Visit Reason
An abbreviated/partial extended survey was conducted from October 1 to October 3, 2024, investigating multiple complaint numbers related to the facility.
Findings
The survey found deficiencies related to medication administration delays, inadequate assistance with incontinent care, failure to provide medically-related social services for behavioral issues, and failure to maintain a clean environment free of urine odor in multiple units.
Complaint Details
The investigation included multiple complaint intake numbers, some substantiated with deficiencies and others unsubstantiated. Specific complaints involved medication administration delays, inadequate incontinent care, lack of social services for behavioral issues, and unsanitary environmental conditions.
Severity Breakdown
SS= D: 3
SS= E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide medications according to physician orders and professional standards for one resident, resulting in delayed medication administration. | SS= D |
| Failure to ensure necessary assistance with incontinent care for one resident, placing the resident at risk for unmet needs and diminished quality of life. | SS= D |
| Failure to provide medically-related social services to one resident with behavioral issues, resulting in lack of appropriate treatment and services. | SS= D |
| Failure to maintain a safe, clean, and comfortable environment free of strong urine odor in three units of the facility, with stained floors and inadequate cleaning supplies. | SS= E |
Report Facts
Complaint intake numbers investigated: 11
Facility census: 107
Medications administered to resident R14: 8
Warnings issued to resident R9: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in medication administration delay finding for resident R14 |
| AA | Unit Manager (UM) | Interviewed regarding medication administration timing for resident R14 |
| DD | Certified Nursing Aide (CNA) | Interviewed regarding incontinent care for resident R8 |
| II | Certified Nursing Aide (CNA II) | Interviewed regarding incontinent care and resident refusals for resident R8 |
| SSD | Social Service Director | Interviewed regarding failure to provide psychological services for resident R9 |
| DON | Director of Nursing | Interviewed regarding medication management and psychological services for resident R9 |
| DMH | Director of Maintenance and Housekeeping / Environmental Services Manager | Interviewed regarding environmental cleanliness and urine odor issues |
| EE | Housekeeper | Interviewed regarding cleaning frequency and urine odor on units 400, 500, and 600 |
| FF | Housekeeper | Observed cleaning hallways without cleaning cart |
| HH | Housekeeper | Observed cleaning hallways without cleaning cart |
| GG | Housekeeper | Interviewed regarding persistent urine odor on units 400, 500, and 600 |
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
Nov 2, 2023
Visit Reason
A revisit survey was conducted from 10/30/2023 through 11/02/2023, including investigation of two complaint intake numbers GA00239664 and GA00239819.
Findings
The revisit survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. The complaint investigations were unsubstantiated with no deficiencies found.
Complaint Details
Complaint Intake Numbers GA00239664 and GA00239819 were investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Census: 116
Inspection Report
Deficiencies: 0
Nov 2, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Harborview Health Systems Thomaston, 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: 116
Deficiencies: 0
Nov 2, 2023
Visit Reason
A revisit survey was conducted from 10/30/2023 through 11/2/2023, including investigation of two complaint intake numbers GA00239664 and GA00239819.
Findings
The revisit survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. The complaint investigations were unsubstantiated with no deficiencies found.
Complaint Details
Complaint Intake Numbers GA00239664 and GA00239819 were investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Facility census: 116
Inspection Report
Follow-Up
Deficiencies: 0
Oct 19, 2023
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 during the follow-up visit.
Inspection Report
Life Safety
Census: 108
Capacity: 119
Deficiencies: 8
Sep 12, 2023
Visit Reason
The inspection 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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improperly sealed smoke wall penetrations, blocked kitchen hood suppression system pull station, improperly installed sprinkler escutcheon plates, loaded sprinkler heads, fire doors failing to close properly, smoking area violations, and lack of documentation for door maintenance and testing.
Severity Breakdown
D: 3
E: 1
F: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to properly seal penetrations in smoke compartments; foam found in electrical room affecting 1 of 3 smoke compartments. | D |
| Facility failed to provide clear access to kitchen hood suppression system pull; pull station blocked by ice maker. | D |
| Facility failed to properly install escutcheon plates on sprinkler heads in dining room. | F |
| Facility failed to maintain clean sprinkler head in hall leading to laundry area; loaded head observed. | F |
| Facility failed to prevent fire door from closing completely; door sticking on floor at rear hall affecting entire facility. | E |
| Fire door failed to close and was sticking on floor on rear hall. | D |
| Smoking area had cigarette lighter and garbage in metal container designated for cigarette butts only. | F |
| Facility failed to document door maintenance, inspection, and testing; patient doors for rooms 103 and 109 did not close and latch properly. | F |
Report Facts
Census: 108
Total Capacity: 119
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and record review |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 6
Sep 1, 2023
Visit Reason
A State Licensure survey was conducted at Harborview Health Systems Thomaston from August 29, 2023 through September 1, 2023 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to provide care according to resident care plans, inadequate pain medication evaluation and documentation, failure to accommodate call light needs, unlocked medication carts, insufficient recreational activities for a resident with PTSD, and food storage and sanitation issues in the kitchen.
Deficiencies (6)
| Description |
|---|
| Failure to ensure one resident with PTSD received assistance with eating, dressing, and getting out of bed according to care plan. |
| Failure to ensure timely evaluation of pain medication effectiveness and accurate documentation for three residents. |
| Failure to accommodate the need for a special call system for one resident unable to use standard call bell. |
| One of four medication carts was found unlocked, allowing potential resident access to medications. |
| Failure to provide stimulating activities for one resident with PTSD, limiting his participation and increasing risk of symptoms. |
| Food storage and sanitation deficiencies including undated and uncovered food, dented cans, expired milk, and wet stacked containers. |
Report Facts
Residents reviewed: 32
Medication carts: 4
Residents affected: 105
BIMS score: 11
BIMS score: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Responsible for medication cart found unlocked and admitted forgetting to lock it |
| Director of Nursing | DON | Provided statements on pain medication reassessment and call light accommodations |
| Certified Nursing Assistant 4 | CNA | Reported resident #27 could not use call bell due to inability to grip |
| Administrator | Interviewed regarding kitchen food storage and dented cans | |
| Dietary Manager | DM | Interviewed regarding kitchen sanitation and food labeling practices |
| Activity Director | AD | Interviewed about resident #9's participation in activities and awareness of PTSD diagnosis |
Inspection Report
Standard Survey And Complaint Investigation
Census: 107
Deficiencies: 9
Sep 1, 2023
Visit Reason
A Standard survey was conducted from August 29, 2023 through September 1, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to accommodate call light needs for a resident, lack of contingency plan for hot water outage affecting multiple halls, failure to provide care and activities per resident care plans, medication cart security issues, BiPap mask cleanliness, pain medication evaluation and documentation deficiencies, medication administration errors, and food storage and sanitation violations.
Complaint Details
Complaint Intake Numbers GA00237872, GA00235593, GA00233595, GA00230872, GA00229895, GA00229898 and GA00229390 were investigated and found to be unsubstantiated.
Severity Breakdown
D: 7
E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to accommodate the need of a special call system for one resident unable to use the call bell. | D |
| Failed to develop a contingency plan for hot water boiler inoperability affecting three halls. | E |
| Failed to ensure one resident received assistance with eating, dressing, and getting out of bed per care plan. | D |
| Failed to provide stimulating activities for one resident with PTSD. | D |
| Failed to ensure one medication cart was locked to prevent resident access. | D |
| Failed to maintain cleanliness of BiPap mask when not in use for one resident. | D |
| Failed to ensure timely evaluation of pain medication effectiveness and accurate documentation for three residents. | D |
| Failed to ensure medication error rate below five percent; four errors in 29 opportunities (13.79%). | D |
| Failed to ensure opened food was dated, labeled, and sealed; storage free of dented cans; and drying containers not stacked wet. | E |
Report Facts
Resident census: 107
Medication error rate: 13.79
Medication errors: 4
Medication administration opportunities: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Forgot to lock medication cart and administered medication without proper instructions |
| LPN 3 | Licensed Practical Nurse | Forgot to administer artificial tears medication to Resident #67 |
| Director of Nursing | Director of Nursing | Interviewed regarding pain medication reassessment and BiPap mask storage |
| Certified Nurse Assistant 4 | Certified Nurse Assistant | Reported resident unable to use call bell |
| Administrator | Administrator | Provided information about hot water boiler issue and communication |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and sanitation practices |
Inspection Report
Deficiencies: 0
Sep 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 110
Deficiencies: 0
Sep 29, 2022
Visit Reason
A revisit survey was conducted from September 27, 2022 through September 29, 2022 to verify correction of deficiencies cited in the July 22, 2022 Recertification Survey.
Findings
All deficiencies cited as a result of the July 22, 2022 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 27, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags were noted to have been corrected as of September 5, 2022.
Inspection Report
Renewal
Census: 110
Deficiencies: 4
Jul 22, 2022
Visit Reason
A Licensure Survey was conducted from 07/18/22 through 07/22/22 to assess compliance with state and federal regulations for facility licensure renewal.
Findings
The facility was found deficient in multiple areas including failure to ensure availability of physician-ordered medication for a resident, inadequate assistance with activities of daily living (specifically bathing) for nine residents, unsafe and damaged physical environment in resident rooms, and deficiencies in food storage and safety practices in the dietary department.
Deficiencies (4)
| Description |
|---|
| Failure to ensure a resident's physician ordered medication (Baclofen 5mg) was available and dispensed as ordered. |
| Failure to assist nine residents with bathing as per care plans and facility schedules, increasing risk for infections and discomfort. |
| Damaged walls and doors in four resident rooms (102, 107, 108, and 111) creating unsafe and unhomelike environment. |
| Food safety violations including broken trash can lid at handwashing sink, unlabeled and undated food items in coolers, dusty fan blowing on food preparation area, lack of thaw date documentation on Mighty Shakes, and staff food stored improperly in residents' pantry refrigerators and freezers. |
Report Facts
Residents reviewed for ADL care: 34
Residents not assisted with bathing: 9
Census: 110
Medication last filled date: Apr 14, 2022
Medication discontinued date: May 10, 2022
Baclofen tablets sent: 14
Mighty Shakes thaw shelf life: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practice Nurse 3 | LPN | Observed medication administration and reported missing Baclofen medication. |
| Licensed Practice Nurse 2 | LPN | Checked Pyxis system for medication and contacted pharmacy regarding Baclofen. |
| Consulting Pharmacist | Interviewed about medication review process and confirmed no physical check of medication availability. | |
| Pharmacy Technician | Reported Baclofen was discontinued without faxed order and acknowledged error. | |
| Vice President of Clinical Services | VP | Stated expectation that staff provide baths per schedule. |
| Director of Maintenance and Housekeeping | DMH | Acknowledged unawareness of damaged doors and walls needing repair. |
| Administrator | Provided dietary department observations and confirmed food safety issues. | |
| Dietary Manager | DM | Provided manufacturer's thawing guidelines for Mighty Shakes. |
| Licensed Practical Nurse 1 | LPN | Described shower schedule process and inability to locate Master Shower Schedule. |
| Director of Nursing | DON | Described shower schedule process and inability to locate Master Shower Schedule. |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 13
Jul 22, 2022
Visit Reason
A standard survey was conducted from 7/18/22 through 7/22/22 including investigation of multiple complaint intake numbers to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident notification of room changes, notification of physician for significant changes, safe environment maintenance, abuse investigation, transfer/discharge notice, care plan development, ADL assistance, nutrition assessment, tube feeding management, pharmacy services, food safety, and immunization protocols.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, including allegations related to resident notification, abuse, and care deficiencies.
Severity Breakdown
SS= A: 1
SS= D: 9
SS= E: 1
SS= F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to notify one resident of the reason and timing of room transfers prior to transfer. | SS= D |
| Failed to notify attending physician when indwelling urinary catheter was removed and no order to discontinue catheter use was obtained. | SS= D |
| Failed to maintain a safe, clean, comfortable and homelike environment as evidenced by damaged walls and doors in resident rooms. | SS= D |
| Failed to thoroughly investigate an allegation of misappropriation of resident's property. | SS= D |
| Failed to provide written transfer/discharge notice to resident or representative for hospital transfer. | SS= D |
| Failed to ensure accurate Minimum Data Set (MDS) assessment coding for hospice status. | SS= A |
| Failed to develop and implement a person-centered comprehensive care plan with measurable goals for a resident with gastrostomy tube. | SS= D |
| Failed to assist nine residents with bathing per schedule and care plan, resulting in inadequate hygiene. | SS= E |
| Failed to timely assess nutritional status and intervene after significant weight loss for one resident. | SS= D |
| Failed to verify residuals and provide water flushes for gastrostomy tube feeding for one resident. | SS= D |
| Failed to ensure availability of physician ordered medication (Baclofen) for one resident during medication administration. | SS= D |
| Failed to ensure food safety including functional trash can at handwashing sink, proper labeling and dating of food items, clean fan near stove, proper thawing documentation of Mighty Shakes, and proper storage of employee food in resident pantry refrigerator/freezer. | SS= F |
| Failed to offer two residents and/or their representatives pneumococcal conjugate vaccine (PCV15 or PCV20) in accordance with CDC guidelines and facility policy. | SS= D |
Report Facts
Resident census: 110
Weight loss percentage: 14.5
Bathing frequency: 2
Medication dose: 5
Water flush volume: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Confirmed catheter removal without physician notification for Resident R82 |
| LPN3 | Licensed Practical Nurse | Observed missing Baclofen medication for Resident R103 |
| Vice President of Clinical Services | Provided multiple clarifications and confirmations regarding care plan, nutrition, and vaccination deficiencies | |
| Administrator | Confirmed lack of written transfer/discharge notices and food safety issues | |
| Dietary Manager | Provided thawing guidelines for Mighty Shakes and confirmed food storage issues | |
| Registered Dietician | Unaware of significant weight loss until notified late | |
| MDS Coordinator 1 | Acknowledged missed hospice coding for Resident R21 |
Inspection Report
Routine
Census: 109
Capacity: 119
Deficiencies: 4
Jul 19, 2022
Visit Reason
The inspection was conducted as a routine Life Safety Code Survey and Emergency Preparedness Program review to assess compliance with Medicare/Medicaid participation requirements and related federal regulations.
Findings
The facility was found not in substantial compliance with emergency preparedness training and testing requirements, lacking documentation of annual updates and staff training for certain months in 2022. Additionally, exit discharge was obstructed due to a drooping overhang, and the smoking area was not maintained safely with smoking materials found in trash cans.
Severity Breakdown
F: 2
E: 1
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Emergency Preparedness Program was not updated annually; last documented update was in 2019. | F |
| No documentation available for training and testing of staff knowledge from January 2022 through March 2022. | F |
| Exit discharge door leading from the dining room would not open completely due to drooping overhang, obstructing egress. | E |
| Smoking materials were found in the trash can in the outside smoking area, indicating unsafe smoking area maintenance. | D |
Report Facts
Certified beds: 119
Census: 109
Inspection date: Jul 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness and exit discharge obstructions. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Jun 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers from June 11, 2021 through June 16, 2021.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and had implemented recommended COVID-19 practices.
Complaint Details
Complaints #GA00213533, #GA00213636, #GA00213618, #GA00213750, and #GA00213831 were investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Complaint numbers investigated: 5
Inspection Report
Deficiencies: 0
May 17, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
May 17, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on 2021-03-18.
Findings
All deficiencies cited as a result of the 3/18/2021 complaint survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 3/18/2021; all cited deficiencies were corrected.
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 18, 2021
Visit Reason
A Licensure Survey was conducted from 3/17/21 through 3/18/21 to assess compliance with nursing care requirements, specifically focusing on bathing and showering practices for residents dependent on staff for activities of daily living.
Findings
The facility failed to provide showers or baths for four residents dependent on staff for bathing, despite documented schedules and policies. Interviews and documentation reviews revealed inconsistent bathing practices, lack of adherence to bath schedules, and inadequate follow-up by previous staff. The Director of Nursing and Administrator acknowledged the issues and implemented a bath schedule and staff education.
Deficiencies (1)
| Description |
|---|
| Failure to provide showers/baths for four residents dependent on staff for activities of daily living. |
Report Facts
Number of residents in sample: 4
BIMS score: 14
BIMS score: 15
Baths in January 2021: 5
Baths in February 2021: 4
Baths in March 2021: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant (CNA) | Performed peri-care and interviewed regarding bathing practices for residents |
| AA | Licensed Practical Nurse (LPN) | Assisted CNA DD during peri-care observation of Resident #3 |
| BB | Certified Nursing Assistant (CNA) | Interviewed about bathing frequency and responsibilities |
| CC | Certified Nursing Assistant (CNA) | Provided peri-care and interviewed about bathing practices |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding bathing issues, staff education, and bath schedule implementation |
| Administrator | Administrator | Interviewed regarding bath schedule creation and facility staffing challenges |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 18, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00210420 and GA00212668, which were substantiated with deficiencies.
Findings
The facility failed to provide showers or baths for four dependent residents, despite documented care plans and bathing schedules. Interviews and record reviews revealed inconsistent bathing practices and lack of adherence to the bathing schedule, resulting in residents not receiving baths as preferred or required.
Complaint Details
The survey was initiated based on complaints GA00210420 and GA00212668, which were substantiated with deficiencies related to inadequate bathing care.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide showers/baths for four residents dependent on staff for activities of daily living. | E |
Report Facts
Baths in January 2021 for Resident #4: 5
Baths in February 2021 for Resident #4: 4
Baths in March 2021 for Resident #4: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant (CNA) | Interviewed regarding bathing practices for residents including R "A" and R#4 |
| BB | Certified Nursing Assistant (CNA) | Interviewed regarding bathing schedule and practices for residents including R#3 |
| CC | Certified Nursing Assistant (CNA) | Interviewed regarding bathing practices and resident care |
| Director of Nursing (DON) | Interviewed regarding bathing deficiencies, identified problems, and corrective actions | |
| Administrator | Interviewed regarding bathing schedule, staffing issues, and corrective actions | |
| AA | Licensed Practical Nurse (LPN) | Assisted CNA DD during observation of peri-care for Resident #3 |
Inspection Report
Deficiencies: 0
Feb 24, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Health Systems Thomaston, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Feb 24, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 3, 2020 Complaint Survey.
Findings
All deficiencies cited as a result of the December 3, 2020 Complaint Survey were found to be corrected.
Complaint Details
The revisit survey was conducted following a complaint survey on December 3, 2020; all cited deficiencies were corrected.
Inspection Report
Routine
Census: 102
Deficiencies: 0
Jan 12, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on January 12, 2021 by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and infection control. No deficiencies were cited during this survey.
Inspection Report
Renewal
Deficiencies: 0
Dec 3, 2020
Visit Reason
The inspection was conducted as a Licensure Survey from 11/30/2020 through 12/3/2020 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from 11/30/2020 through 12/3/2020.
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 3
Dec 3, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from November 30, 2020 to December 3, 2020 to investigate multiple complaints (GA00205018, GA00205004, GA00205681, GA00207619, GA00208698, and GA00209027).
Findings
The facility was found deficient in developing and implementing comprehensive smoking care plans for residents, ensuring adequate supervision during smoking, and maintaining infection prevention and control practices including proper PPE use, hand hygiene, and cleaning protocols. Some complaints were partially substantiated with deficiencies, while others were unsubstantiated.
Complaint Details
Complaints GA00205018 and GA00205004 were partially substantiated with deficiencies. Complaint GA00207619 was partially substantiated with no deficiencies. Complaints GA00205681, GA00208698, and GA00209027 were unsubstantiated.
Severity Breakdown
Level D: 1
Level E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to develop smoking care plans for three of 16 residents who smoke (Residents #15, #16, and #17). | Level D |
| Failed to ensure five of 16 residents (#14, #15, #16, #17, and #18) were assessed and provided supervision while smoking, including leaving residents and smoking materials unsupervised and use of a propane grill in the smoking area. | Level E |
| Failed to maintain infection prevention and control practices including improper hand hygiene during glucose checks, failure to wear appropriate PPE on observation unit, failure to clean items before leaving observation unit, and improper cleaning and sanitizing techniques by housekeeping and floor tech staff. | Level E |
Report Facts
Residents smoking without care plans: 3
Residents assessed and supervised while smoking: 5
Facility census: 103
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA LL | Certified Nursing Assistant | Provided supervision during smoking breaks and reported on smoking list and supervision practices |
| LPN AA | Licensed Practical Nurse | Observed entering observation unit room without proper PPE and acknowledged PPE requirements |
| HSK BB | Housekeeper | Observed improper cleaning practices and failure to change mop water and sanitize equipment |
| PT CC | Physical Therapist | Observed delivering oxygen and handling meal trays without proper PPE or sanitizing |
| CNA EE | Certified Nursing Assistant | Observed dropping meal tickets on floor and improper handling |
| LPN GG | Licensed Practical Nurse | Observed not changing gloves prior to blood sugar check |
| Floor Tech FF | Floor Technician | Observed improper sweeping and failure to sanitize equipment |
| Administrator | Confirmed deficiencies and described expectations for care plans, supervision, and infection control | |
| Infection Preventionist | Reported on hand hygiene training and infection control practices | |
| HSK and Laundry Supervisor | Reported on cleaning protocols and equipment use |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Sep 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 92
Deficiencies: 0
Jun 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on June 29-30, 2020.
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 to prepare for COVID-19.
Report Facts
Census: 92
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 27, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00201461 and GA00199252.
Findings
Complaint GA00201461 was substantiated without deficiencies, and complaint GA00199252 was unsubstantiated.
Complaint Details
Complaint GA00201461 was substantiated without deficiencies; Complaint GA00199252 was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 2, 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 the follow-up survey.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Jun 18, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2019-04-26.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Jun 17, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
The facility failed to provide complete sprinkler protection throughout the facility, specifically a new wooden porch at the dining area exceeding 4 feet in all directions lacked sprinkler coverage, placing residents at risk in the event of fire.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide complete sprinkler protection throughout the facility; new wooden porch at dining area exceeding 4 feet in all directions without sprinkler protection. | D |
Report Facts
Survey date: Jun 17, 2019
Porch size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings at time of discovery |
Inspection Report
Routine
Census: 102
Deficiencies: 7
Apr 26, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility failed to maintain food safety standards including improper labeling and dating of food items, inadequate cleaning of kitchen equipment and resident food pantries, failure to follow puree meal recipes, and dishwasher temperature issues. These deficiencies affected 100 residents receiving oral diets.
Severity Breakdown
F: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to label and date thawed concentrated orange juices and bread items. | F |
| No step to open trash cans by hand washing sinks. | F |
| Containers of flour, sugar, rice, corn meal, and thickener were not labeled or dated; thickener container lacked a tight-fitting lid. | F |
| Ice machine lip had black buildup. | F |
| Dishwasher did not consistently reach required wash and rinse temperatures; sanitizing solution not checked daily. | F |
| Resident food pantry was unclean with buildup on floor and baseboards; items in resident refrigerator not stored appropriately or labeled. | F |
| Pureed fish meal preparation did not follow recipe; water used instead of broth for thinning. | F |
Report Facts
Resident census: 102
Residents affected: 100
Dishwasher wash temperature: 164
Dishwasher rinse temperature: 153
Dishwasher rinse temperature after adjustment: 190
Fish patties used: 9
Fish patties needed: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook CC | Cook | Observed preparing puree meals and did not follow recipe. |
| Cook JJ | Cook | Directed to get additional fish patties for puree meal. |
| Dietary Manager | Dietary Manager | Interviewed and observed during kitchen tours; reported on food safety practices and dishwasher issues. |
| Unit Manager BB | Unit Manager | Interviewed regarding pantry cleaning and resident refrigerator practices. |
| Director of Maintenance | Director of Maintenance | Reported on dishwasher temperature adjustments. |
Inspection Report
Routine
Census: 102
Deficiencies: 6
Apr 26, 2019
Visit Reason
The inspection was conducted to assess compliance with physical plant standards related to food storage, preparation, and cleanliness in the facility's kitchen and resident food pantries.
Findings
The facility failed to ensure proper labeling and dating of food items, maintain cleanliness of kitchen equipment and resident food pantries, and follow recipes for puree meal preparation. Dishwasher temperatures were often below required levels, and food storage practices did not comply with policy, affecting 100 residents receiving oral diets.
Deficiencies (6)
| Description |
|---|
| Items in the kitchen were not labeled or dated, including thawed concentrated orange juice, bread, and dry goods such as flour and sugar. |
| No step to open trash cans by hand washing sinks. |
| Can opener had buildup and ice machine lip had black buildup. |
| Dishwasher did not consistently reach required wash and rinse temperatures throughout April 2019. |
| Resident food pantry and refrigerator were not properly cleaned or organized; food items were not stored appropriately or labeled. |
| Pureed fish meal preparation did not follow recipe instructions, using water instead of broth for thinning. |
Report Facts
Facility census: 102
Residents affected: 100
Dishwasher wash temperature: 164
Dishwasher rinse temperature: 153
Dishwasher rinse temperature after adjustment: 190
Number of fish patties used for puree meal: 9
Additional fish patties directed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook CC | Cook | Observed preparing puree meal and did not follow recipe |
| Cook JJ | Cook | Directed to get additional fish patties and used water instead of broth in puree preparation |
| Dietary Manager | Dietary Manager | Conducted kitchen tours, reported on food labeling, dishwasher temperatures, and puree preparation |
| Unit Manager BB | Unit Manager | Reported on housekeeping responsibilities and food storage practices in resident refrigerator |
| Director of Maintenance | Director of Maintenance | Reported adjustments made to dishwasher temperatures |
Inspection Report
Life Safety
Census: 103
Capacity: 119
Deficiencies: 4
Apr 24, 2019
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 life safety requirements, including failure to provide exit ramps with proper slope, exit doors with electrical locks that fail safely, complete sprinkler protection in all areas, and proper maintenance and testing of the emergency generator.
Severity Breakdown
SS= D: 2
SS= F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide exit ramps with a slope of no more than 1 inch in 12 inches, with the new ramp exceeding this slope. | SS= D |
| Failed to provide exit doors with electrical locks that fail safely to release upon loss of power, activation of sprinkler system, or smoke detection. | SS= D |
| Failed to provide complete sprinkler protection throughout the facility, specifically a new wooden porch at the dining area lacking sprinkler coverage. | SS= F |
| Failed to maintain the emergency generator, including lack of records for monthly generator testing. | SS= F |
Report Facts
Census: 103
Total Capacity: 119
Ramp slope measurement: 5.5
Generator exercise frequency: 12
Generator exercise duration: 30
Generator long test interval: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and involved in observations related to exit ramp slope, exit door locks, sprinkler protection, and generator maintenance |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 14, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195280.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint GA00195280 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194918.
Findings
The complaint was substantiated but no deficiencies were identified during the investigation.
Complaint Details
Complaint GA00194918 was substantiated without deficiencies.
Inspection Report
Re-Inspection
Census: 103
Deficiencies: 0
Feb 14, 2019
Visit Reason
A revisit survey was conducted from 2/13/19 to 2/14/19 to investigate Complaint Intake Number GA00194269 in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 12/31/18-1/2/19 Complaint Survey GA00193663 were found to be corrected. The Complaint Investigation GA00194269 was unsubstantiated.
Complaint Details
Complaint Intake Number GA00194269 was investigated and found to be unsubstantiated.
Report Facts
Facility census: 103
Inspection Report
Re-Inspection
Census: 103
Deficiencies: 0
Feb 14, 2019
Visit Reason
A revisit survey was conducted from 2/13/19 to 2/14/19 to investigate Complaint Intake Number GA00194269 in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 12/31/18-1/2/19 Complaint Survey GA00193663 were found to be corrected. The Complaint Investigation GA00194269 was unsubstantiated.
Complaint Details
Complaint Intake Number GA00194269 was investigated and found to be unsubstantiated.
Report Facts
Facility census: 103
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 15, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192766 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00192766 was investigated and found to have no deficiencies.
Inspection Report
Routine
Census: 107
Deficiencies: 0
Mar 15, 2018
Visit Reason
A standard survey was conducted at Harborview Health Systems of Thomaston from March 12, 2018 through March 15, 2018 to assess compliance with Federal and State Long Term Care Requirements.
Findings
The standard survey revealed the facility was in compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B.
Inspection Report
Life Safety
Census: 106
Capacity: 119
Deficiencies: 0
Mar 13, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan met the requirements set forth in Appendix Z.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 1, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00179297, along with a related complaint GA00178729 from the same family.
Findings
The facility was found to be in compliance with the Federal and State Long Term Care Regulations 42 CFR, Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
The complaint GA00179297 was investigated and found to be unsubstantiated as the facility was in compliance with regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 15, 2017
Visit Reason
A complaint was investigated to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint numbers GA00176612 and GA00176887 were investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 21, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 0
Mar 2, 2017
Visit Reason
A standard survey was conducted in conjunction with an abbreviated survey to investigate multiple complaint intake numbers at Harborview Health Systems Thomaston from February 27, 2017 through March 2, 2017.
Findings
The abbreviated survey found no deficiencies, and the standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Complaint Details
Multiple complaint intake numbers were investigated, but no deficiencies were cited related to the abbreviated survey.
Report Facts
Complaint Intake Numbers Investigated: 12
Inspection Report
Life Safety
Census: 111
Capacity: 117
Deficiencies: 5
Feb 28, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain corridor doors to resist smoke passage, inadequate smoke barrier construction, failure to conduct required quarterly fire drills, improper maintenance of smoking-related safety equipment, and use of an extension cord as permanent wiring.
Severity Breakdown
E: 1
F: 1
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Corridor doors were not properly maintained to resist the passage of smoke, with gaps greater than 0.5 inch noted on several room doors. | E |
| Smoke barrier walls were not maintained with the required fire resistance rating of at least one-half hour; penetrations and top seals were not properly sealed in multiple wings. | F |
| The facility failed to conduct the required quarterly fire drills, missing a drill for the first quarter of 2016 on the third shift. | D |
| The facility failed to properly maintain ashtrays of noncombustible material and safe design, and the metal container for ash disposal was used improperly as a receptacle for yard debris and combustible trash. | D |
| An extension cord was used as permanent wiring for the water heater controller in the 400 wing. | D |
Report Facts
Residents at risk due to corridor door deficiencies: 18
Residents at risk due to smoke barrier deficiencies: 90
Residents at risk due to fire drill deficiencies: 111
Residents at risk due to smoking regulation deficiencies: 15
Residents at risk due to electrical equipment deficiencies: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Staff H confirmed multiple findings during the inspection including door gaps, smoke barrier issues, fire drill records, smoking regulation deficiencies, and electrical equipment issues. |
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