Inspection Reports for Harborview Thomasville
930 SOUTH BROAD ST., THOMASVILLE, GA, 31792
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 26, 2025, cited multiple deficiencies including resident abuse incidents, medication errors, unsanitary kitchen conditions, and failure to maintain resident privacy. Earlier inspections showed a pattern of various issues such as failure to protect a resident at immediate jeopardy risk in November 2024, problems with employee health requirements, and deficiencies in managing residents’ personal funds and discharge notices. Complaint investigations included both substantiated and unsubstantiated findings, with the most notable substantiated case involving resident safety and self-harm risks in late 2024. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in resident safety, care plan adherence, and environmental cleanliness, with some corrections verified during follow-up visits but ongoing issues persisting into the latest survey.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
61 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Harborview Thomasville from June 24, 2025, through June 26, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
State Health deficiencies were cited during the survey indicating non-compliance with certain regulatory requirements.
Inspection Report
Routine
Census: 61
Deficiencies: 10
Date: Jun 26, 2025
Visit Reason
A standard survey was conducted at Harborview Thomasville from June 24, 2025, through June 26, 2025, including investigation of two complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00253641 and GA00253612 were investigated. GA00253641 was unsubstantiated and GA00253612 was substantiated without deficiency.
Findings
The survey revealed multiple deficiencies including failure to prevent abuse between residents, failure to report abuse to law enforcement, inadequate PASARR assessments, failure to follow care plans for assistance and bed positioning, unsafe environment hazards including unsecured housekeeping carts, medication administration errors, improper medication storage, unsanitary kitchen conditions, improper storage of resident care items, and failure to maintain resident privacy with adequate curtains.
Deficiencies (10)
Failure to ensure one resident was free from abuse, with incidents of hitting by another resident.
Failure to report abuse to law enforcement after resident-on-resident incidents.
Failure to ensure accurate PASARR Level I assessment and coordination of services for one resident.
Failure to follow care plans for assistance during meals and bed positioning for three residents.
Failure to ensure environment free of accident hazards including unsecured housekeeping carts and unsafe bed rails.
Medication administration errors with insulin pens, including failure to prime needles and hold pen after injection.
Failure to properly store medications and supplies, including expired items and opened biologicals.
Unsanitary kitchen conditions including expired food, dead insects, dirt, dust, unclean appliances, and exposed electrical breakers.
Failure to store resident personal care items properly to prevent cross-contamination.
Failure to maintain resident privacy by not providing privacy curtains or having non-functional or short curtains in multiple resident rooms.
Report Facts
Resident census: 61
Medication administration opportunities: 38
Medication administration errors: 2
Medication administration error rate: 5.26
PASARR Level I assessment sample: 6
PASARR Level I assessment failure: 1
Privacy curtain issues: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN GG | Licensed Practical Nurse | Named in medication administration error finding |
| DON | Director of Nursing | Named in abuse findings, medication storage, and privacy curtain findings |
| Administrator | Named in abuse findings and kitchen sanitation findings | |
| Dietary Manager | Named in kitchen sanitation findings | |
| Maintenance Director | Named in bed rail safety findings and privacy curtain findings | |
| CNA EE | Certified Nursing Assistant | Named in meal assistance findings |
| CNA FF | Certified Nursing Assistant | Named in meal assistance findings |
| MDS Coordinator | Named in PASARR assessment findings |
Inspection Report
Follow-Up
Census: 62
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 22, 2024 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on November 22, 2024. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the November 22, 2024 Complaint Survey were found to be corrected.
Report Facts
Census: 62
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 0
Date: Jan 16, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 22, 2024 Complaint Survey.
Complaint Details
This visit was a follow-up to a complaint survey conducted on November 22, 2024. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the November 22, 2024 Complaint Survey were found to be corrected.
Report Facts
Census: 62
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Nov 22, 2024
Visit Reason
A State Licensure survey was conducted at Harborview Thomasville from November 6, 2024 through November 22, 2024 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies related to employee health requirements, specifically the failure to ensure that three long-term employees received the required annual tuberculin skin test as mandated by state regulation.
Deficiencies (1)
Facility failed to ensure that three long-term employees received an annual tuberculin skin test as required by state regulation.
Report Facts
Sample employees reviewed: 10
Employees non-compliant: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Vice President of Clinical | Interviewed regarding revisions to Employee Tuberculosis Testing policy and compliance with state regulations | |
| Director of Nursing | Long-term employee found non-compliant with annual tuberculin skin test requirement | |
| Assistant Director of Nursing | Long-term employee found non-compliant with annual tuberculin skin test requirement | |
| Maintenance Director | Long-term employee found non-compliant with annual tuberculin skin test requirement |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 6
Date: Nov 22, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 11/6/2024 through 11/22/2024 investigating complaint intakes GA00252250 and GA00255395, which were substantiated with deficiencies.
Complaint Details
The investigation was triggered by complaint intakes GA00252250 and GA00255395, which were substantiated. Immediate Jeopardy was identified related to resident safety and care failures involving suicidal ideations and self-harm attempts.
Findings
The facility was found to be in Immediate Jeopardy due to failure to protect a resident (R2) with suicidal ideations who wrapped call light and bed remote cords around his neck multiple times, with inadequate psychiatric services, failure to remove choking hazards, failure to report incidents, and failure to implement appropriate care plans and supervision. The facility implemented corrective actions including staff education, resident audits, and policy reviews.
Deficiencies (6)
Failure to report that resident with suicidal ideations used call light cord and/or bed remote cord in an attempt to self-harm.
Failure to implement comprehensive care plan interventions to monitor safety of resident with suicidal ideations who wrapped cords around his neck.
Failure to ensure a safe environment free of choking hazards and adequate supervision for resident with history of suicide attempts and ideations.
Failure to provide necessary behavioral health services to resident with worsening behaviors and suicidal ideations.
Failure of Administrator and Director of Nursing to provide supervision and oversight to ensure resident safety and compliance with reporting and care requirements.
Failure to ensure call lights were within reach for two residents (R4 and R5).
Report Facts
Facility census: 59
Staff education completion: 85
Staff education completion: 86
Residents interviewed: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | Observed resident with call light cord wrapped around neck and called 911 |
| LPN FF | Licensed Practical Nurse | Observed resident wrapping cord around neck and called 911 |
| Director of Nursing | Director of Nursing | Responsible for monitoring resident mood and behaviors, staff education, and oversight |
| Administrator | Facility Administrator | Involved in decisions regarding resident safety interventions and staffing |
| Social Worker | Social Worker | Conducted resident interviews and audits related to suicidal ideations |
Inspection Report
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Thomasville, 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: 58
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
A revisit survey was conducted in conjunction with a complaint investigation to verify correction of deficiencies cited in the prior complaint survey of October 3, 2024.
Complaint Details
The visit was complaint-related and included a complaint investigation. Immediate jeopardy was identified during the complaint survey.
Findings
All deficiencies cited in the October 3, 2024 complaint survey were found to be corrected; however, immediate jeopardy was identified during the complaint survey.
Inspection Report
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Thomasville, 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: 58
Deficiencies: 0
Date: Nov 22, 2024
Visit Reason
A Revisit Survey was conducted on November 22, 2024 in conjunction with a complaint investigation to verify correction of deficiencies cited in the Complaint Survey of October 3, 2024.
Complaint Details
The visit was conducted in conjunction with a complaint investigation. Immediate jeopardy was identified during the complaint survey.
Findings
All deficiencies cited as a result of the Complaint Survey of October 3, 2024 were found to be corrected; however, Immediate jeopardy was identified during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 3, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00249788, which was substantiated with deficiencies cited.
Complaint Details
Complaint intake GA00249788 was substantiated with deficiencies cited.
Findings
The facility failed to maintain a clean and homelike environment in seven of 33 resident rooms, with issues including cracked wall molding, missing floor tiles, broken or missing toilet paper holders, missing ceiling tile pieces, holes in walls, black scuff marks on walls, and a dirty pillowcase. Observations were confirmed with the Maintenance Director and Housekeeping Supervisor.
Deficiencies (1)
Facility failed to maintain a clean and homelike environment in seven of 33 rooms, including cracked wall molding, missing floor tiles, broken or missing toilet paper holders, missing ceiling tile pieces, holes in walls, black scuff marks on walls, and a dirty pillowcase.
Report Facts
Rooms with deficiencies: 7
Total rooms: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed observations regarding room deficiencies | |
| Housekeeping Supervisor | Confirmed observations regarding room deficiencies | |
| Director of Nursing | DON | Provided information about bed linen and pillowcase standards |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as a State Licensure Survey from October 2, 2024 through October 3, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to maintain a clean and homelike environment in seven of 33 rooms, with issues including cracking wall molding, missing floor tiles, broken or missing toilet paper holders, missing ceiling tile pieces, holes in walls, black scuff marks on walls, and dirty pillowcases. Observations on both days revealed no changes in these deficiencies.
Deficiencies (1)
Facility failed to maintain a clean and homelike environment in seven of 33 rooms with issues such as cracking wall molding, missing floor tiles, broken or missing toilet paper holders, missing ceiling tile pieces, holes in walls, black scuff marks on walls, and dirty pillowcases.
Report Facts
Rooms with deficiencies: 7
Total rooms inspected: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed observations and described compliance rounds and reporting process | |
| Director of Nursing | DON | Explained that changing bed linen includes clean pillowcases |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Harborview Thomasville, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details about deficiencies or findings.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/25/2024 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 7/25/2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 7/25/2024 Complaint Survey were found to be corrected.
Report Facts
Census: 65
Inspection Report
Routine
Census: 63
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted as a State Licensure survey from July 22, 2024 through July 25, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found non-compliant in managing residents' personal funds, failing to pay final refunds within 30 days after discharge for two residents. Additionally, the facility failed to provide a 30-day written notice for a facility-initiated transfer or discharge for one resident.
Deficiencies (2)
The facility failed to ensure that two residents (R4, R8) were paid their final refund for account reconciliation within 30 days after discharge.
The facility failed to ensure that a facility-initiated transfer or discharge for one resident (R4) did not receive a 30-day notice discharge.
Report Facts
Facility census: 63
Refund amount for R4: 68.8
Refund amount for R8: 210
Monthly payment by responsible party for R4: 1550
Liability for R8: 2114
Monthly withheld amount for R8: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Regional Director of Operation | Interviewed regarding the lack of 30-day notice for discharge of R4 and decision not to accept R4 back | |
| Social Worker | Interviewed regarding corporate decision to not accept R4 back to the facility | |
| Receivable Account (AR) manager | Interviewed about payments and refunds related to residents R4 and R8 |
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 7/22/2024 to 7/25/2024 to investigate multiple complaints (GA00240732, GA00243031, GA00244675, GA00245112). Three complaints were unsubstantiated and one complaint was substantiated.
Complaint Details
The survey investigated complaints GA00240732, GA00243031, GA00244675, and GA00245112. Complaints GA00240732, GA00244675, and GA00245112 were unsubstantiated. Complaint GA00243031 was substantiated.
Findings
The facility failed to ensure timely payment of final refunds for two discharged residents and did not provide a 30-day discharge notice for one resident who was discharged after behavioral incidents. Deficiencies were cited related to accounting of personal funds and transfer/discharge notice requirements.
Deficiencies (2)
Facility failed to ensure two residents were paid their final refund for account reconciliation within 30 days after discharge.
Facility failed to ensure a facility-initiated transfer or discharge for one resident included a 30-day notice discharge.
Report Facts
Facility census: 63
Refund amount for Resident R4: 68.8
Refund amount for Resident R8: 210
Resident R4 discharge date: Jan 15, 2024
Resident R8 discharge date: Jan 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Regional Director of Operation | Interviewed regarding failure to issue 30-day discharge notice for Resident R4 | |
| Social Worker | Interviewed regarding decision to not accept Resident R4 back to facility | |
| Receivable Account (AR) manager | Interviewed regarding refunds and billing for Residents R4 and R8 |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
The inspection was conducted as a State Licensure survey from July 22, 2024 through July 25, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
Deficiencies were cited related to management of personal property/financial affairs, specifically delayed refunds to residents after discharge, and failure to provide a 30-day notice for a facility-initiated transfer or discharge for one resident. The facility did not ensure timely refunds for two residents and failed to provide proper discharge notice for one resident who was discharged after behavioral concerns.
Deficiencies (2)
The facility failed to ensure that two residents (R4, R8) were paid their final refund for account reconciliation within 30 days after discharge.
The facility failed to ensure that a facility-initiated transfer or discharge for one resident (R4) did not receive a 30-day notice discharge.
Report Facts
Facility census: 63
Refund amount for R4: 68.8
Refund amount for R8: 210
Monthly payment by responsible party for R4: 1550
Outstanding balance withheld from R8: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Regional Director of Operation | Interviewed regarding failure to issue 30-day notice for discharge of resident R4 | |
| Social Worker | Interviewed regarding decision to not accept resident R4 back to the facility | |
| Receivable Account (AR) manager | Interviewed regarding resident refunds and payments |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 2
Date: Jul 25, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 7/22/2024 to 7/25/2024 to investigate multiple complaints (GA00240732, GA00243031, GA00244675, GA00245112). Three complaints were unsubstantiated and one complaint (GA00243031) was substantiated.
Complaint Details
The investigation involved four complaints; three were unsubstantiated and one was substantiated (GA00243031). The substantiated complaint involved failure to timely refund residents' personal funds and failure to provide proper discharge notice.
Findings
The facility failed to ensure timely refund of residents' personal funds within 30 days after discharge for two residents, and failed to provide a 30-day notice of discharge for one resident who was discharged after behavioral incidents. Deficiencies were cited related to accounting of personal funds and transfer/discharge notice requirements.
Deficiencies (2)
Facility failed to ensure two residents were paid their final refund for account reconciliation within 30 days after discharge.
Facility failed to ensure a facility-initiated transfer or discharge for one resident included a 30-day notice discharge.
Report Facts
Facility census: 63
Refund amount for Resident R4: 68.8
Refund amount for Resident R8: 210
Resident R4 discharge date: Jan 15, 2024
Resident R8 discharge date: Jan 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receivable Account (AR) manager | Provided information about residents' refunds and payment issues | |
| Corporate Regional Director of Operation | Interviewed regarding discharge notice and decision not to accept resident back | |
| Social Worker | Interviewed regarding decision to not accept resident back after behavioral facility stay |
Inspection Report
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Harborview Thomasville, 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: 64
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the July 27, 2023 Recertification Survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
A State Licensure survey revisit was conducted to assess compliance with previously cited State Health deficiencies related to food storage and labeling practices.
Findings
The facility failed to ensure that food items in various storage areas were labeled and dated with expiration or use-by dates, and lacked a step-to-open trashcan by the handwashing sink, risking cross contamination. These deficiencies impacted 60 of 64 residents receiving oral diets.
Deficiencies (2)
Food items in pantry, walk-in cooler, reach-in refrigerator, reach-in freezer, and walk-in freezer were not labeled and dated to indicate expiration or use-by dates.
No step can trashcan by the handwashing sink, increasing risk of cross contamination.
Report Facts
Residents impacted: 60
Residents census: 64
Boxes of fudge rounds without use by/expiration date: 15
Boxes of oatmeal pies without use by/expiration date: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook AA | Cook | Interviewed regarding in-service training on labeling and use-by dates |
| Tray Aide BB | Tray Aide | Interviewed regarding knowledge of labeling requirements and trashcan usage |
| Dietary Manager | Dietary Manager | Confirmed observations of unlabeled food items and lack of expiration dates |
| Registered Dietitian | Registered Dietitian | Provided monitoring tool and guidance on labeling requirements |
| Director of Nursing | Director of Nursing | Received monitoring tool from Registered Dietitian |
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 2
Date: Sep 21, 2023
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a prior inspection.
Findings
The facility failed to ensure that food items in various storage areas were labeled and dated with expiration or use-by dates, and lacked a step-to-open trashcan by the handwashing sink, posing a risk of cross contamination. These deficiencies impacted 60 of 64 residents receiving oral diets.
Deficiencies (2)
Food items in pantry, walk-in cooler, reach-in refrigerator, reach-in freezer, and walk-in freezer were not labeled and dated to indicate expiration or use-by dates.
No step can trashcan by the handwashing sink; employees used a large trash can instead, increasing risk of cross contamination.
Report Facts
Residents impacted: 60
Census: 64
Boxes of fudge rounds without use by/expiration date: 15
Boxes of oatmeal pies without use by/expiration date: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook AA | Interviewed regarding in-service training on labeling and dating products | |
| Tray Aide BB | Interviewed confirming knowledge of labeling requirements and trashcan usage | |
| Dietary Manager (DM) | Confirmed observations of unlabeled food items and lack of step can trashcan; signed weekly monitoring tool | |
| Registered Dietitian (RD) | Provided monitoring tool and guidance on labeling requirements |
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Life Safety Code revisit.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 27, 2023
Visit Reason
A State Licensure survey was conducted at Harborview Thomasville from July 24, 2023 through July 27, 2023 to assess compliance with state health regulations and identify any deficiencies.
Findings
The inspection revealed multiple deficiencies including failure to follow infection control policies related to linen handling and laundry processes, inadequate nursing care regarding nail trimming for a resident, and improper food storage and labeling in the kitchen. Additionally, maintenance issues such as unclean dryer vents and kitchen fan dust were noted.
Deficiencies (3)
Failure to ensure infection control policies were followed for handling, storage, and processing of linens, cleaning of lint traps, and food along with personal items in the clean storage laundry.
Failure to ensure that a resident's nails were trimmed for one of 27 sampled residents, potentially impacting quality of life and functional status.
Failure to ensure that opened food items were properly dated and labeled in the cooler, freezer, and dry food pantry; failure to ensure the oven and fan were clean.
Report Facts
Residents served food from kitchen: 61
Sampled residents: 27
Residents in facility: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laundry Staff BB | Notified and confirmed issues with linen handling and laundry processes | |
| Housekeeping/Laundry Supervisor | Confirmed findings related to laundry and personal items storage; interviewed about dryer vent cleaning and staff education | |
| Director of Nursing | Director of Nursing | Interviewed regarding resident nail care practices and facility policies |
| Dietary Manager | Dietary Manager | Interviewed and observed regarding food storage and kitchen cleanliness |
| Maintenance Director | Maintenance Director | Interviewed and observed regarding cleaning of kitchen fan |
| Cook CC | Confirmed presence of unlabeled food items in kitchen | |
| Administrator | Administrator | Interviewed regarding expectations for food monitoring and kitchen walk-throughs |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 4
Date: Jul 27, 2023
Visit Reason
A standard survey was conducted from July 24 to July 27, 2023, including investigations of multiple complaint intake numbers which were found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00237445, GA00236393, GA00235203, GA00234994, and GA00232758 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate resident assessments related to PASRR, failure to ensure nail care for a resident, improper food labeling and cleanliness in the kitchen, and infection control lapses in laundry handling and storage.
Deficiencies (4)
Failed to ensure residents received accurate assessments reflecting their status related to Pre-Admission Screening and Resident Review (PASRR) for two residents.
Failed to ensure a resident's nails were trimmed, negatively impacting quality of life and functional status.
Failed to ensure opened food items were properly dated and labeled and failed to ensure the oven and fan were clean, potentially affecting 61 of 63 residents served food.
Failed to ensure infection control policies were followed for handling, storage, and processing of linens, cleaning of lint traps, and storage of food and personal items in the clean laundry area, potentially spreading infection.
Report Facts
Resident census: 63
Sampled residents: 27
Residents affected by food labeling deficiency: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) Director | Confirmed coding errors on resident assessments and planned corrections | |
| Director of Nursing (DON) | Provided expectations for accurate assessments and nail care procedures | |
| Dietary Manager (DM) | Confirmed food labeling deficiencies and kitchen cleanliness issues | |
| Maintenance Director (MD) | Confirmed cleaning needs for kitchen fan | |
| Laundry Staff BB | Described laundry procedures and acknowledged infection control lapses | |
| Housekeeping/Laundry Supervisor | Confirmed infection control deficiencies in laundry and cleaning procedures | |
| Administrator | Reported expectations for food monitoring and kitchen inspections |
Inspection Report
Life Safety
Census: 64
Capacity: 68
Deficiencies: 9
Date: Jul 26, 2023
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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including blocked exit discharge, damaged vertical openings, inadequate hazardous area protections, lack of fire alarm and sprinkler system maintenance, malfunctioning smoke doors, improper electrical installations, and unlabeled electrical circuits.
Deficiencies (9)
Exit discharge was blocked by a parked vehicle and not maintained free of obstructions on the South side of the facility.
Several ceiling tiles throughout the facility were missing, broken, or damaged, failing to maintain and protect vertical openings.
Laundry Room sheetrock walls were damaged and not capable of resisting smoke passage; door did not self-close and positively latch.
Fire alarm system inspection, testing, and maintenance had not been conducted since May 2022.
Sprinkler heads were loaded with lint and corroded in the Laundry Room and outside the Kitchen.
Smoke doors in the Large Dining Area did not close properly to resist passage of smoke.
Light fixtures in the Rehab room were not securely mounted to the ceiling.
Light fixtures were missing covers in the Corridor near Room S-11 and the Breakroom near the Nurse's Station.
Electrical circuits in all electrical panels throughout the facility were not labeled to identify the circuits they control.
Report Facts
Census: 64
Total Capacity: 68
Date of last fire alarm inspection: May 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 7/26/2023 |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Date: Dec 8, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint investigation (#GA00226465) to assess compliance with infection control regulations and COVID-19 preparedness.
Complaint Details
Complaint #GA00226465 was unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 65
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