Inspection Reports for Harborview Satilla
1600 RIVERSIDE AVE, WAYCROSS, GA, 31501
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, found that all deficiencies cited during the April 22, 2025 complaint survey were corrected. Earlier inspections showed a pattern of deficiencies primarily related to failure to follow care plans for resident assistance, inadequate staffing and supervision, and food safety and medication management issues. Complaint investigations included a substantiated case in April 2025 involving a resident fall due to insufficient staffing and care plan noncompliance, while most other complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements recently, as prior deficiencies were addressed in follow-up surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
86 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
A revisit survey was conducted on June 3, 2025, to verify correction of deficiencies cited during the April 22, 2025 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on April 22, 2025. The deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited as a result of the April 22, 2025 Complaint Survey were found to be corrected during the revisit survey.
Report Facts
Census: 86
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 22, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from April 16 to April 22, 2025, investigating complaint number GA00254620 regarding care and supervision issues that resulted in a resident fall and injury.
Complaint Details
Complaint number GA00254620 was substantiated with deficiencies. Actual harm occurred on April 12, 2025, when CNA BB provided care alone to Resident R1, who fell out of bed sustaining a left femoral neck fracture and left frontal scalp hematoma.
Findings
The facility failed to ensure the care plan was followed for two-person assistance toileting for Resident R1, resulting in a fall on April 12, 2025, causing a left femoral neck fracture and left frontal scalp hematoma. The investigation found inadequate staffing and supervision during care, with CNA BB providing care alone despite the resident's need for two-person assistance.
Deficiencies (2)
Failure to follow the care plan requiring two-person assistance for toileting, resulting in resident fall and injury.
Failure to provide adequate supervision and staffing to prevent accidents during resident care.
Report Facts
Deficiencies cited: 2
Fall Risk Evaluation score: 5
Laceration size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Provided care alone resulting in resident fall and injury |
| RN MDS Coordinator | Registered Nurse MDS Coordinator | Reported care plan requirements and confirmed need for two-person assistance |
| CNA EE | Certified Nursing Assistant | Reported working with R1 with assistance of another CNA and discomfort providing care alone |
| CNA FF | Certified Nursing Assistant | Reported training CNA BB that R1 required two-person assist |
| LPN GG | Licensed Practical Nurse | Reported R1 required two people for ADLs and posture maintenance |
| Director of Nursing | Director of Nursing | Reported CNA BB should have waited for assistance and nurse could have helped |
| Administrator | Administrator | Reported uncertainty why CNA BB did not have assistance and described resident's fall risk |
Inspection Report
Annual Inspection
Census: 3
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
A licensure survey was conducted at Harborview Satilla from April 16, 2025 to April 22, 2025 to assess compliance with regulatory requirements.
Findings
The facility failed to ensure the care plan was followed for two-person assistance toileting for one resident, resulting in a fall that caused a left femoral neck fracture and left frontal scalp hematoma. The care plan required two-person assistance for multiple activities due to the resident's significant impairments.
Deficiencies (1)
Failure to follow care plan for two-person assistance toileting resulting in resident fall and injury.
Report Facts
Residents present: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Named in the finding related to providing care alone resulting in resident fall |
| MDS Coordinator | Registered Nurse | Interviewed regarding care plan and staffing requirements |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Harborview Satilla, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide specific details of deficiencies or findings within the visible content.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the recertification/complaint survey concluded on January 9, 2025.
Findings
All deficiencies cited in the prior recertification/complaint survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 27, 2025
Visit Reason
A Life Safety Code revisit survey was conducted at Harborview Satilla and Harborview Pierce County buildings to verify correction of previously cited survey tags.
Findings
The survey found that all previously cited survey tags had been corrected at both Harborview Satilla and Harborview Pierce County buildings.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 9, 2025
Visit Reason
A State Licensure survey was conducted at Harborview Satilla from January 7 through January 9, 2025, to determine compliance with State Long Term Care Requirements and State Health regulations.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of transfer/discharge and bed hold policy to resident representatives, failure to document rationale for extending PRN antianxiety medication orders beyond 14 days, unsecured over-the-counter medication at bedside, failure to implement care plans for residents including use of scoop mattress and proper nail care, and failure to properly date and discard expired food items in the kitchen.
Deficiencies (6)
Facility failed to provide written notice of transfer/discharge to resident or representative for one resident (R2) hospitalized twice without written notice.
Facility failed to provide written notice of bed hold policy to resident representative for one resident (R2) hospitalized twice without written notice.
Facility failed to indicate need to extend PRN antianxiety medication orders beyond 14 days and failed to document rationale for extension for one resident (R18).
Facility failed to ensure over-the-counter medication (cough drops) were not stored at bedside for one resident (R151), allowing potential unauthorized access.
Facility failed to implement care plan for two residents (R22 and R12): R22 was not provided a scoop mattress as care planned; R12 had long, discolored fingernails embedded into palm with foul odor, indicating failure to provide proper nail care.
Facility failed to discard expired food and failed to label and date opened food items in walk-in cooler, refrigerator, and dry storage, potentially affecting 86 residents receiving oral diet.
Report Facts
Residents reviewed for hospitalization: 4
Residents in sample size: 55
Residents affected by food safety deficiency: 86
Residents total: 89
BIMS score: 2
BIMS score: 3
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding transfer/discharge notification and bed hold policy procedures. |
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding transfer/discharge notification and bed hold policy procedures. |
| Business Office Manager (BOM) | Interviewed regarding notification procedures for transfer/discharge and bed hold policy. | |
| Administrator | Interviewed regarding notification procedures and survey assistance. | |
| DON | Director of Nursing | Interviewed regarding medication orders, care plan implementation, and staff expectations. |
| Primary Physician | Interviewed regarding rationale for PRN medication order. | |
| LPN CC | Licensed Practical Nurse | Interviewed regarding unauthorized medication at bedside. |
| Dietary Manager (DM) | Interviewed regarding food labeling and expiration practices. | |
| MDS Coordinator | Interviewed regarding care plan expectations for nail care. |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 8
Date: Jan 9, 2025
Visit Reason
A standard annual survey was conducted at the dual facility of Harborview Satilla and Harborview Pierce from January 7 through January 9, 2025, including investigation of three complaints at Facility B which were unsubstantiated.
Complaint Details
Complaints GA00242903, GA00243567, and GA00249863 were investigated at Facility B in conjunction with the standard survey and were unsubstantiated.
Findings
The survey revealed multiple deficiencies including failure to secure over-the-counter medications, failure to provide transfer/discharge notices and bed hold notices, failure to implement care plans for residents, improper nail care, incorrect oxygen administration, failure to document rationale for psychotropic medication extensions, and failure to properly date mark food items in the kitchen.
Deficiencies (8)
Facility B failed to ensure over-the-counter medication were not stored at the bedside for one resident (R151).
Facility A failed to provide notice of transfer/discharge to resident or representative for one resident (R2).
Facility A failed to provide notice of bed hold for one resident (R2).
Facility A failed to implement care plan for two residents (R22 and R12), including failure to provide scoop mattress and proper nail care.
Facility A failed to perform nail care for one totally dependent resident (R12) with left-hand contracture.
Facility B failed to ensure oxygen administered by nasal cannula was set at prescribed rate for one resident (R30).
Facility B failed to document rationale for extending PRN antianxiety medication beyond 14 days for one resident (R18).
Facility A failed to discard food in walk-in cooler by use by date and failed to label and date opened food items in walk-in refrigerator and dry storage area.
Report Facts
Residents present: 86
Residents sampled: 55
Residents sampled: 42
Residents sampled: 4
Residents receiving oral diet: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed resident could not have cough drops at bedside without physician order |
| AA | Licensed Practical Nurse (LPN) | Described transfer notification process and confirmed no written notice given |
| BB | Licensed Practical Nurse (LPN) | Described transfer notification process and confirmed no written notice given |
| FF | Licensed Practical Nurse (LPN) | Observed oxygen set incorrectly and confirmed order |
| GG | Licensed Practical Nurse (LPN) | Confirmed oxygen order and nurse responsibility for oxygen rate |
| Dietary Manager | Responsible for food labeling and discard, confirmed expired and unlabeled food items found | |
| DON | Director of Nursing | Provided multiple interviews confirming deficiencies and expectations for care |
| Administrator | Provided interviews regarding staff expectations and deficiencies |
Inspection Report
Life Safety
Census: 75
Capacity: 78
Deficiencies: 6
Date: Jan 8, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with self-closing doors in exit passageways, cooking equipment safety, fire extinguisher placarding, fire alarm system breaker identification, sprinkler system maintenance, sprinkler piping obstructions, smoke barrier construction, and fire wall penetrations.
Deficiencies (6)
Doors in exit passageways did not have self-closing devices installed.
Cooking equipment lacked automatic shutoff upon activation of the kitchen hood suppression system.
Improper placarding for the Class K portable fire extinguisher in the kitchen.
Fire alarm system dedicated breaker was not red in color and lacked proper locking device.
External loads such as wire and conduit were placed on sprinkler piping.
Penetrations through a rated fire wall in the mechanical room were not properly sealed.
Report Facts
Census: 75
Total Capacity: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tours on 1/8/2025 and 1/9/2025 |
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaints GA00247697, GA00241726, GA00238025, GA00237948 were substantiated. Complaints GA00251024, GA00250681, GA00250086, GA00244200, GA00244122, GA00240969, GA00239274, GA00237002, GA00235843, and GA00235345 were unsubstantiated.
Findings
Several complaints were substantiated, while others were unsubstantiated. No regulatory violations were cited during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
A focused infection control survey was conducted at Harborview Satilla on August 28, 2023, by CertiSurv on behalf of the Georgia Department of Community Health.
Findings
The survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 23, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Harborview Satilla, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: May 23, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 14, 2023 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on February 14, 2023. All deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected during this revisit survey.
Report Facts
Census: 87
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 1
Date: Apr 6, 2023
Visit Reason
A Revisit Licensure Survey was conducted from April 4, 2023 through April 6, 2023 to assess compliance following previous deficiencies.
Findings
The facility failed to have adequate staff to prepare meals for breakfast and lunch, affecting 81 of 87 residents on an oral diet. Staffing shortages led to inadequate meal preparation, including reliance on purchased biscuits from a local restaurant and use of paper plates due to insufficient staff to wash dishes.
Deficiencies (1)
The facility failed to have adequate staff to carry out the functions of preparing meals for breakfast and lunch for residents, potentially affecting 81 of 87 residents on an oral diet.
Report Facts
Residents affected: 81
Total residents: 87
Residents on puree diet: 12
Residents on chopped diet: 13
Residents on ground diet: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide AA | Dietary Aide | Reported staffing shortages and notified Administrator of missing Morning Cook |
| Administrator | Administrator | Acknowledged staffing shortages and coordinated meal preparation and food procurement |
| Evening Cook | Evening Cook | Called in to assist due to Morning Cook absence and reported staffing levels |
| Dietary Manager BB | Dietary Manager | Came to assist facility after being notified of staffing needs |
| Registered Dietitian (RD) | Registered Dietitian | Approved revised menu and commented on staffing shortages affecting meal service |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Date: Apr 6, 2023
Visit Reason
A Revisit Survey was conducted from April 4 through April 6, 2023, due to a complaint survey to assess the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
The deficiencies resulted from the facility's noncompliance related to the complaint survey. The facility was not in substantial compliance with Medicare/Medicaid regulations.
Findings
The facility failed to have adequate staff to prepare meals for breakfast and lunch, resulting in inadequate meal options and delayed meal service. Additionally, the facility failed to maintain safe food temperatures during meal service, with some food items served below required temperatures.
Deficiencies (2)
Failed to have adequate staff to carry out meal preparation functions for breakfast and lunch, affecting 81 of 87 residents on an oral diet.
Failed to maintain food temperatures in safe range on the tray line during meal service delivery, potentially affecting 71 of 78 residents receiving an oral diet.
Report Facts
Residents on oral diet affected: 81
Residents on oral diet affected: 71
Census: 87
Residents on puree diet: 12
Residents on chopped diet: 13
Residents on ground diet: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide AA | Dietary Aide | Reported Morning Cook absence and began cooking oatmeal |
| Dietary Manager BB | Dietary Manager | Arrived to assist facility, reported food temperature issues and staffing shortages |
| Administrator | Administrator | Notified of staffing and food temperature issues, coordinated meal alternatives and thermometer replacement |
| Evening Cook | Cook | Called in due to Morning Cook absence, reported staffing shortages and meal preparation challenges |
| Registered Dietitian | Registered Dietitian | Approved menu changes and acknowledged staffing and meal service issues |
Inspection Report
Annual Inspection
Capacity: 81
Deficiencies: 6
Date: Feb 14, 2023
Visit Reason
The inspection was a State Licensure survey conducted from January 31, 2023 through February 14, 2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including insufficient nursing staff leading to inadequate care for residents' Activities of Daily Living (ADLs) such as showers and changing briefs and linens. The dietary department lacked a qualified dietary manager and adequate staffing, resulting in inadequate meal service and food safety issues. Additionally, the facility failed to maintain proper food temperatures, enforce kitchen hygiene standards, and maintain sanitary ice storage. These deficiencies affected the quality of care and safety for residents.
Deficiencies (6)
Insufficient nursing staff to provide adequate care and respond to residents' individual needs, resulting in missed showers and inadequate changing of briefs and bed linens.
Dietary department lacked a designated dietary manager with appropriate certification or qualifications.
Inadequate staffing in dietary services on Christmas Day, resulting in improper meal preparation and service.
Failure to provide nursing care according to residents' needs and care plans, specifically related to ADLs for six residents.
Failure to maintain food temperatures on the serving line and failure to ensure all kitchen staff wore hairnets during meal preparation.
Failure to maintain sanitary ice bin with a gap causing ice to melt and potential contamination.
Report Facts
Residents affected: 75
Residents affected: 6
Residents: 81
Staffing ratios: 1.81
Staffing ratios: 2
Residents per CNA: 18
Food temperatures: 125
Food temperatures: 118
Food temperatures: 120
Food temperatures: 115
Food temperatures: 100
Food temperatures: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in relation to shower care and staffing shortages |
| DON | Director of Nursing | Interviewed regarding staffing shortages and care deficiencies |
| Administrator | Facility Administrator | Interviewed regarding staffing crisis and quality of care issues |
| Cook MM | Cook | Observed during meal preparation and food temperature taking |
| LPN FF | Licensed Practical Nurse | Interviewed regarding missed showers and staffing |
| Housekeeper QQ | Housekeeper | Interviewed about assisting in kitchen meal tray preparation |
| Floor Tech RR | Floor Technician | Interviewed about meal tray preparation and delivery |
| Environmental & Laundry SS | Environmental & Laundry Staff | Interviewed about meal tray preparation |
| Maintenance Director | Maintenance Director | Interviewed about ice bin repair |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 14, 2023
Visit Reason
An abbreviated survey was conducted to investigate multiple complaints regarding resident care, staffing shortages, and facility operations.
Complaint Details
The survey was initiated on January 31, 2023, and concluded on February 14, 2023, investigating multiple complaints which were all substantiated with deficiencies.
Findings
The facility was found to have substantiated deficiencies including failure to provide consistent wound care and Activities of Daily Living (ADL) assistance such as showers and hygiene for multiple residents due to staffing shortages. Additional deficiencies included medication administration errors, inadequate wound treatment documentation, insufficient staffing levels, lack of a certified dietary manager, food safety violations, and unclean air conditioning vents in resident rooms.
Deficiencies (9)
Failed to provide wound care to residents on a consistent basis according to their person-centered care plan and/or ADL showers for seven residents.
Failed to provide ADL care including showers and changing of briefs and bed linens for six residents related to insufficient staff.
Failed to ensure residents dependent on staff for ADLs received showers for two residents.
Failed to ensure insulin was accurately reconciled and administered within prescribed parameters for one resident, resulting in hypoglycemia and hospitalization.
Failed to ensure residents with pressure ulcers received consistent wound treatments as prescribed, with multiple missing treatment dates for three residents.
Failed to adequately staff the facility to meet residents' individual care needs, resulting in inadequate ADL assistance and inconsistent showering and linen changes.
Failed to have a certified dietary manager to provide oversight and daily functions of dietary services.
Failed to maintain food temperatures on serving line, ensure all kitchen staff wore hairnets, and maintain sanitary ice bins.
Failed to ensure air conditioning vents in five resident rooms were clean, with visible dust, debris, and unclean filters.
Report Facts
Missing wound treatment dates: 44
Staffing ratio: 1.85
Staffing ratio: 1.95
Staffing ratio: 1.95
Staffing ratio: 1.81
Staffing ratio: 1.98
Residents on oral diet: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TT | Registered Nurse | Administered insulin earlier than prescribed contributing to hypoglycemia. |
| DD | Licensed Practical Nurse | Administered insulin and responded to hypoglycemia event. |
| AA | Certified Nursing Assistant | Reported staffing shortages and inability to provide showers. |
| MM | Cook | Worked alone on Christmas day and served alternate meals. |
| BB | Housekeeping Supervisor | Responsible for cleaning schedules and quality control of room cleanliness. |
| GG | Maintenance Director | Responsible for cleaning air conditioning units and acknowledged need for better system. |
Inspection Report
Annual Inspection
Capacity: 81
Deficiencies: 5
Date: Feb 14, 2023
Visit Reason
The inspection was a State Licensure survey conducted from January 31, 2023 through February 14, 2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including insufficient nursing staff leading to inadequate resident care such as missed showers and changing of briefs and linens, lack of a qualified dietary manager, inadequate dietary staffing and meal preparation issues, and failure to maintain proper food safety and hygiene standards in the kitchen.
Deficiencies (5)
Insufficient nursing staff to provide adequate care and respond to residents' individual needs, resulting in missed showers and changing of briefs and bed linens.
Dietary department lacked a designated qualified dietary manager to provide daily functions and oversight.
Inadequate staffing to carry out dietary functions on Christmas Day, resulting in improper meal service.
Failure to provide adequate Activities of Daily Living (ADL) care including showers and changing briefs for six of seven residents reviewed.
Failure to maintain food temperatures on the serving line and ensure all kitchen staff wore hairnets; ice bin was unsanitary with a gap causing ice to melt.
Report Facts
Residents on oral diet: 75
Total licensed capacity: 81
Staffing averages: 1.85
Staffing averages: 1.95
Staffing averages: 1.95
Staffing averages: 1.81
Staffing averages: 1.98
Staffing averages: 1.91
Residents per CNA: 18
Residents per CNA: 16
Residents per CNA: 10
Residents per CNA: 17
Residents per CNA: 14
Food temperatures: 125
Food temperatures: 118
Food temperatures: 120
Food temperatures: 115
Food temperatures: 100
Food temperatures: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in staffing and shower care deficiencies; assigned 18 residents on 2/1/2023 |
| CNA HH | Certified Nursing Assistant | Named in staffing deficiencies; assigned 16 residents on 2/1/2023 |
| CNA II | Certified Nursing Assistant | Named in staffing deficiencies; assigned 10 residents on 2/1/2023 |
| CNA JJ | Certified Nursing Assistant | Named in staffing deficiencies; assigned 17 residents on 2/1/2023 |
| CNA KK | Certified Nursing Assistant | Named in staffing deficiencies; assigned 14 residents on 2/1/2023 |
| DON | Director of Nursing | Interviewed regarding staffing shortages and shower care deficiencies |
| Administrator | Facility Administrator | Interviewed regarding staffing crisis and dietary management issues |
| Cook MM | Cook | Observed preparing meals and taking food temperatures |
| LPN FF | Licensed Practical Nurse | Interviewed about missed showers and staffing shortages |
Inspection Report
Abbreviated Survey
Deficiencies: 9
Date: Feb 14, 2023
Visit Reason
An abbreviated survey was conducted to investigate multiple substantiated complaints regarding care and services at the facility.
Complaint Details
The survey was initiated to investigate multiple complaints (GA00226818, GA00229501, GA00229540, GA00230822, GA00231254, GA00231747, GA00231757, GA00231793, GA00231814, GA00231954) all of which were substantiated with deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide consistent wound care and ADL assistance such as showers and hygiene, inadequate staffing impacting resident care, medication administration errors leading to hypoglycemia, failure to provide ordered wound treatments, inadequate dietary staffing and food service management, food safety violations, and environmental cleanliness issues including unclean air conditioning vents.
Deficiencies (9)
Failed to provide wound care to residents on a consistent basis according to their person-centered care plan and/or ADL showers for seven residents.
Failed to provide ADL care including showers and changing of briefs and bed linens for six residents due to insufficient staff.
Failed to ensure that two residents dependent on staff for ADLs received showers.
Failed to ensure insulin was accurately reconciled and administered within prescribed parameters for one resident, resulting in hypoglycemia and hospitalization.
Failed to ensure three residents with pressure ulcers received consistent wound treatments as prescribed.
Failed to adequately staff the facility to meet resident care needs, resulting in inadequate ADL assistance and inconsistent showers and linen changes.
Failed to ensure adequate dietary staffing and qualified dietary manager, impacting food service operations.
Failed to maintain food temperatures on serving line, ensure kitchen staff wore hairnets, and maintain sanitary ice bin.
Failed to ensure air conditioning vents in five resident rooms were clean, compromising a safe, sanitary, and comfortable environment.
Report Facts
Missing wound treatment dates: 44
Staffing ratio: 1.85
Staffing ratio: 1.95
Staffing ratio: 1.95
Staffing ratio: 1.81
Staffing ratio: 1.98
Staffing ratio: 1.91
Food temperatures: 125
Food temperatures: 118
Food temperatures: 120
Food temperatures: 115
Food temperatures: 100
Food temperatures: 115
Blood sugar: 36
Blood sugar: 44
Blood sugar: 159
Blood sugar: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Unit Manager | Administered insulin to Resident #15 and described medication reconciliation process. |
| CNA AA | Certified Nursing Assistant | Reported staffing shortages and inability to provide showers; assigned 18 residents on day of interview. |
| Cook MM | Cook | Reported working alone on Christmas day and serving hamburgers and hotdogs instead of planned meals. |
| Administrator | Acknowledged staffing crisis, dietary manager vacancy, and food service deficiencies. | |
| Director of Nursing | DON | Acknowledged staffing crisis, inability to provide showers, and wound care oversight responsibilities. |
| LPN FF | Licensed Practical Nurse | Administered glucagon to Resident #15 during hypoglycemic episode. |
| Maintenance Director GG | Maintenance Director | Described air conditioning unit cleaning process and acknowledged need for better system. |
| Housekeeping Supervisor BB | Housekeeping Supervisor | Described cleaning schedules and quality control for resident rooms and air conditioning vents. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility Harborview Satilla, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report lists deficiencies identified during the inspection, but no specific deficiencies or severity levels are detailed on the provided page.
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 11, 2022 Recertification Survey.
Findings
All deficiencies cited as a result of the August 11, 2022 Recertification Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 11, 2022
Visit Reason
A Licensure Survey was conducted from 8/9/22 through 8/11/22 to assess compliance with licensure requirements at Harborview Satilla.
Findings
The facility failed to ensure that PRN orders for psychotropic drugs documented the rationale for the extended duration of the PRN order for one resident (R#132). Specifically, an Ativan order was extended for 12 months without documented rationale, contrary to facility policy requiring documentation for extensions beyond 14 days.
Deficiencies (1)
Failure to document rationale for extended duration of PRN psychotropic medication order for one resident.
Report Facts
Medication doses administered: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Entered the original Ativan order in the electronic record on 6/6/22. |
| DON | Director of Nursing | Verified lack of documented rationale for medication extension and provided multiple interview statements. |
| RN CC | Registered Nurse | Participated in interview regarding medication order discontinuation and reordering. |
| LPN DD | Licensed Practical Nurse | Administered PRN Ativan to resident and provided interview about medication use. |
Inspection Report
Routine
Census: 158
Deficiencies: 3
Date: Aug 11, 2022
Visit Reason
A standard survey was conducted at Harborview Satilla and Harborview Pierce from 8/9/22 through 8/11/22, including investigation of multiple complaints which were unsubstantiated.
Complaint Details
Complaints GA00221942, GA00226269, and GA00221941 were investigated and found to be unsubstantiated.
Findings
The survey revealed deficiencies in respiratory care related to CPAP equipment storage and maintenance, psychotropic medication PRN order documentation, and food storage practices including expired and unlabeled food items.
Deficiencies (3)
Facility failed to ensure CPAP respiratory supplies were properly stored and reservoir emptied when not in use for one resident.
Facility failed to ensure PRN orders for psychotropic drugs documented rationale for extended duration beyond 14 days for one resident.
Facility failed to ensure food items in dry storage were labeled, dated, and discarded by expiration date, with expired and unlabeled items observed.
Report Facts
Resident census: 158
Residents receiving respiratory treatments: 19
Residents reviewed for medication management: 5
Doses of Ativan administered: 18
Residents potentially affected by food storage deficiency: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Interviewed regarding CPAP use and medication administration |
| BB | Registered Nurse (RN) | Interviewed regarding CPAP mask storage and psychotropic medication orders |
| CC | Registered Nurse (RN) | Interviewed regarding medication order discontinuation and clarification |
| DON | Director of Nursing | Interviewed regarding medication orders and administration |
| Dietary Manager | Interviewed regarding food storage and expiration dates | |
| Tray Aide | Interviewed regarding food storage practices |
Inspection Report
Life Safety
Census: 89
Capacity: 96
Deficiencies: 3
Date: Aug 11, 2022
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 fire safety requirements, including failure to maintain sprinkler heads free of dust and debris, improper maintenance of smoke barrier walls with unsealed penetrations, and failure to properly identify oxygen storage rooms with required signage.
Deficiencies (3)
Failed to ensure sprinkler heads are free of dust and debris, potentially affecting all staff and residents if sprinklers fail during a fire.
Failed to ensure smoke barrier walls are properly maintained; conduit and wiring penetrations were not fire stopped in smoke barriers affecting four of eight smoke compartments.
Failed to ensure room containing oxygen storage was properly identified with required signage, affecting four of eight smoke compartments.
Report Facts
Certified beds: 96
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00217762, #GA00219062, and #GA00219841.
Complaint Details
Complaints #GA00217762, #GA00219062, and #GA00219841 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 5, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212926.
Complaint Details
Complaint #GA00205723 was unsubstantiated with no regulatory violations.
Findings
Complaint #GA00205723 was found to be unsubstantiated with no regulatory violations identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 25, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211015.
Complaint Details
Complaint #GA00211015 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00207397, GA00208933, and GA00209740.
Complaint Details
Complaints GA00207397, GA00208933, and GA00209740 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaints investigated were unsubstantiated with no regulatory violations found.
Inspection Report
Routine
Census: 79
Deficiencies: 0
Date: Nov 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's 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 CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Total census: 79
Inspection Report
Re-Inspection
Census: 80
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 10, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 1
Date: Sep 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control regulations due to failure to ensure staff wore appropriate facemasks (N95 or equivalent) while providing care, specifically a Licensed Practical Nurse (LPN) was observed wearing a cloth facemask instead of the required N95 mask in resident care areas. The facility had two coronavirus outbreaks and signage requiring N95 masks was posted, but staff education and enforcement were inadequate.
Deficiencies (1)
Licensed Practical Nurse (LPN) failed to wear a N95 or equivalent facemask while administering medications in resident care areas.
Report Facts
Total residents present: 83
Residents on Honeysuckle Avenue unit: 10
Residents on Wisteria Blvd unit: 13
Residents on Azalea Road unit: 19
Residents on Dogwood Trail unit: 10
Residents on Rose Lane unit: 11
Residents on Sunflower Lane unit: 19
Residents diagnosed with COVID-19 on Azalea Road unit: 13
Residents with COVID-19 on Azalea unit: 15
Residents with COVID-19 or under investigation on Dogwood Trail unit: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed not wearing required N95 mask; interviewed about mask usage and education |
| Infection Preventionist | Interviewed regarding infection control expectations and staff education | |
| Director of Nursing | Director of Nursing | Interviewed regarding supervision and expectations for PPE use |
| Administrator | Administrator | Interviewed regarding overall responsibility and staff compliance with infection control policies |
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.83 for emergency preparedness and 42 CFR 483.80 for infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00207061 and #GA00204667.
Complaint Details
Complaints #GA00207061 and #GA00204667 were investigated and found to be unsubstantiated.
Findings
The complaints #GA00207061 and #GA00204667 were found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted at Harborview Satilla on July 21, 2020 to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
Both Harborview Satilla and Harborview Pierce facilities were found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations related to COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2019
Visit Reason
The inspection was conducted to investigate complaints #GA00198603 and #GA00197506 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Investigation of complaints #GA00198603 and #GA00197506 found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 12/12/2019 through 12/17/2019.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 29, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00196071.
Complaint Details
Complaint GA00196071 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Date: Apr 23, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2019-02-21.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 18, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00195335 and GA00195367 from 3/14/19 to 3/18/19.
Complaint Details
Complaints GA00195335 and GA00195367 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Inspection Report
Life Safety
Census: 90
Capacity: 96
Deficiencies: 1
Date: Feb 19, 2019
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements related to fire safety.
Findings
The facility was found not in substantial compliance due to failure to properly inspect and document fire doors within the past 12 months, which could place residents at risk in the event of a fire.
Deficiencies (1)
Facility failed to ensure that fire doors were properly inspected and documented within the past 12 months.
Report Facts
Residents at risk: 90
Certified beds: 96
Census: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire door inspection deficiencies |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 2, 2019
Visit Reason
An abbreviated / Partial Extended Survey was conducted to investigate complaint GA00193310.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2018
Visit Reason
A complaint survey was conducted on 10/22/2018 and 10/23/2018 to investigate complaints #GA 00191650 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA 00191650 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 18, 2018
Visit Reason
An abbreviated/Partial Extended survey was conducted to investigate complaint GA00191148.
Complaint Details
Complaint GA00191148 was investigated and found to be unsubstantiated.
Findings
The complaint investigated during the survey was found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 27, 2018
Visit Reason
The inspection was conducted to investigate complaints #GA00190195 and #GA00190199 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint survey conducted to investigate complaints #GA00190195 and #GA00190199; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey conducted from 7/26/18 through 7/27/18.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 18, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00189153.
Complaint Details
Complaint GA00189153 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2018
Visit Reason
An unannounced complaint investigation was conducted on 5/23/18 in response to complaints (GA00188504).
Complaint Details
Complaint GA00188504 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was completed on 5/23/18, the Ombudsman was notified, the complainant could not be reached for further information, and the complaint was found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 8, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00188169.
Complaint Details
Complaint GA00188169 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Census: 162
Deficiencies: 0
Date: Apr 6, 2018
Visit Reason
A revisit survey was conducted on April 5-6, 2018 to verify correction of deficiencies cited in the standard survey conducted on February 15, 2018.
Findings
All deficiencies cited as a result of the February 15, 2018 standard survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 93
Capacity: 96
Deficiencies: 0
Date: Feb 12, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and the NFPA 101 Life Safety Code 2012 edition.
Findings
Both Harborview Satilla and Harborview Pierce were found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.70(a) and the related NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 29, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA #00182411.
Complaint Details
The complaint was substantiated but no deficiencies were cited.
Findings
The complaint was substantiated and no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 4, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181517.
Complaint Details
Complaint #GA00181517 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 2, 2017
Visit Reason
A follow-up survey was conducted on 6/2/17 to the recertification survey to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior recertification survey had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 25, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175014 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00175014 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 19, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00173945.
Complaint Details
The complaint was substantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.
Inspection Report
Routine
Census: 162
Deficiencies: 3
Date: Apr 6, 2017
Visit Reason
A standard survey was conducted from April 3, 2017 through April 6, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to failures in food procurement, storage, preparation, and serving sanitary standards. Issues included unlabeled and undated food items, expired items in refrigerators and pantries, lack of temperature logs for freezers, and improper storage practices in both Facility A and Facility B.
Deficiencies (3)
Failure to label and date food items and use items before expiration in reach-in coolers and refrigerators.
Failure to maintain freezer temperature logs in resident pantries.
Failure to properly store and secure open food items to prevent cross contamination.
Report Facts
Resident census: 162
Tube feeders: 9
Expiration dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor BB | Dietary Supervisor | Interviewed regarding labeling and discarding of expired food items |
| Director of Nursing | Director of Nursing | Interviewed regarding responsibility for pantry checks and food item monitoring |
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding monitoring of nutritional supplements and temperature guidelines |
| Dietary Manager DM | Dietary Manager | Interviewed regarding expectations for labeling and securing food items |
| Administrator | Administrator | Interviewed regarding policy for monitoring refrigerators and freezers |
Inspection Report
Life Safety
Census: 159
Capacity: 174
Deficiencies: 0
Date: Apr 4, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Report Facts
Census: 89
Certified beds: 96
Census: 70
Certified beds: 78
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