Inspection Reports for Healthcare at College Park, LLC
1765 TEMPLE AVENUE, COLLEGE PARK, GA, 30337
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 9, 2024, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related to resident care, including abuse and neglect, medication administration errors, care planning, and infection control, as well as multiple fire safety issues such as blocked exits, malfunctioning fire doors, and sprinkler system maintenance. Several complaint investigations were substantiated with deficiencies, particularly involving failure to report abuse and incidents timely, insufficient staffing for behavioral health needs, and unsafe discharge practices; fines or license actions were not listed in the available reports. The facility also had Immediate Jeopardy findings in 2022 related to neglect and unsafe discharge but took corrective actions that were verified in subsequent surveys. The trend indicates improvement over time, with the most recent surveys showing correction of prior deficiencies and no new issues cited.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
11.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
0 residents
Based on a October 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on August 12, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during the revisit survey conducted on October 8-9, 2024.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
A Revisit Survey was conducted on October 8-9, 2024 to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on August 12, 2024.
Findings
All deficiencies cited in the prior Standard/Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 1, 2024
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
Life Safety
Census: 67
Capacity: 100
Deficiencies: 8
Date: Aug 16, 2024
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including blocked exit pathways, improper emergency door hardware, inadequate separation of cooking equipment, fire alarm system trouble signals, loaded sprinkler heads, improperly closing patient room doors, penetrations in fire barriers, and poorly maintained fire and smoke doors.
Deficiencies (8)
Exit door in the laundry room was blocked by a chair, obstructing egress for 10 staff members.
Exit door in the kitchen had multiple non-approved locking devices affecting 10 kitchen staff.
Deep fryer was not separated by 16 inches from the stovetop in the kitchen, risking fire spread.
Fire alarm system showed a trouble signal, affecting 67 residents and hindering evacuation; repeat deficiency.
Sprinkler heads throughout multiple floors were covered with dust and lint, potentially compromising spray patterns for 67 residents and staff.
Patient room doors did not close properly, leaving gaps over 1/2 inch on multiple floors, affecting 20 residents and staff.
Penetrations and missing caulk above the ceiling at the fire barrier on the first floor near the entrance, risking smoke migration affecting 20 residents.
Fire and smoke doors on the first and second floors were missing parts, had loose hinges, smoke holes, and were not maintained, affecting 40 residents.
Report Facts
Residents affected: 67
Staff affected: 10
Residents affected: 20
Residents affected: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed multiple findings during the tour and observations on 8/16/2024 |
Inspection Report
Routine
Census: 65
Deficiencies: 11
Date: Aug 12, 2024
Visit Reason
A standard survey was conducted at Healthcare at College Park from 8/6/2024 through 8/12/2024, including complaint investigations of multiple complaint intake numbers.
Complaint Details
Multiple complaints were investigated in conjunction with the standard survey. Several complaints were found unsubstantiated, one was substantiated without deficiencies, and multiple were substantiated with deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to abuse and neglect, accuracy of assessments, PASARR screening, care planning, medication administration errors, ADL care, medication errors, medication storage, food sanitation, infection control, and antibiotic stewardship.
Deficiencies (11)
Failed to protect one resident from sexual abuse by another resident.
Failed to accurately assess one resident leading to potential risk for medical complications.
Failed to follow PASARR level II program recommendations for one resident.
Failed to develop a care plan consistent with resident's specific conditions and needs.
Failed to provide services meeting professional standards by not administering 5:00 pm medications to seven residents.
Failed to provide two hour check and change for one dependent resident.
Failed to ensure residents were free from significant medication errors related to missed medications.
Failed to secure a central supply storage room containing medications and medical supplies.
Failed to maintain clean and properly functioning ice machine; black residue observed and no cleaning documentation.
Failed to properly protect a resident on enhanced barrier precautions; staff did not use required personal protective equipment.
Failed to properly maintain an Antibiotic Stewardship Program, risking inappropriate antibiotic use and resistance.
Report Facts
Resident census: 65
Number of residents missing 5:00 pm medications: 7
Number of antibiotic starts in July 2024: 4
Number of infections in June 2024: 1
Number of antibiotic starts in June 2024: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Certified Medication Aide | Named in medication administration errors for missed 5:00 pm medications |
| DD | Licensed Practical Nurse Unit Manager | Interviewed regarding medication administration and care plans |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including abuse, assessments, PASARR, care plans, medication errors, infection control, and antibiotic stewardship |
| Administrator | Interviewed regarding abuse allegation and facility policies | |
| IP | Infection Preventionist | Interviewed regarding infection control and antibiotic stewardship |
| BB | Certified Nurse Aide | Interviewed regarding failure to use PPE for resident on enhanced barrier precautions |
| RR | Certified Nurse Aide | Interviewed regarding failure to use PPE for resident on enhanced barrier precautions |
| PP | Licensed Practical Nurse | Interviewed regarding unsecured central supply room |
| HH | Provider Extender | Interviewed regarding medication administration and adverse effects |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00248043, initiated on June 26, 2024, and concluded on July 2, 2024.
Complaint Details
Complaint #GA00248043 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint #GA00248043 was found to be unsubstantiated with no deficiencies cited during the survey.
Inspection Report
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Healthcare at College Park, LLC, related to a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the standard survey concluded on January 3, 2023.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 2
Date: Jan 5, 2023
Visit Reason
A State Licensure survey was conducted at Healthcare at College Park from January 3, 2023 through January 5, 2023 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies including failure to maintain confidentiality of water-damaged medical records exposed outside the facility, and failure to store food items off the floor and maintain cleanliness in the dry storage area of the kitchen.
Deficiencies (2)
The facility failed to maintain confidentiality of medical records that had been damaged by water and were exposed outside a storage building with protected health information visible.
The facility failed to store food items off the floor in the dry storage area and maintain a clean dry storage area, potentially affecting 66 residents.
Report Facts
Total census: 68
Residents potentially affected: 66
Height of record stacks: 5
Length of storage container: 17
Water depth in basement: 7
Weight of sugar bag: 25
Weight of canola oil box: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager | Provided information about flood damage and food storage practices |
| Director of Clinical Services | Director of Clinical Services | Commented on record confidentiality and food storage deficiencies |
| Administrator | Administrator | Provided details about record handling and food storage issues |
| Maintenance Director | Maintenance Director | Oversaw moving of records out of basement and described flooding |
| Corporate Maintenance Risk Manager | Corporate Maintenance Risk Manager | Instructed facility on handling of water-damaged records |
| Cook #1 | Cook | Provided information about food storage and cleaning duties |
Inspection Report
Routine
Census: 68
Deficiencies: 4
Date: Jan 5, 2023
Visit Reason
A standard survey was conducted at Healthcare at College Park from January 3, 2023 through January 5, 2023 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to timely transmit Minimum Data Set (MDS) assessments, failure to develop behavioral interventions for a resident exhibiting behavioral symptoms, improper food storage and cleanliness in the kitchen dry storage area, and failure to maintain confidentiality of damaged medical records stored outside with protected health information exposed.
Deficiencies (4)
Failed to ensure MDS assessments were transmitted within 14 days of completion for 5 of 19 residents reviewed.
Failed to ensure interventions were developed, care planned, and implemented to address behavioral symptoms for 1 of 4 sampled residents reviewed for psychotropic medications.
Failed to store food items off the floor and maintain a clean dry storage area in the kitchen, potentially affecting 66 residents.
Failed to maintain confidentiality of medical records that had been damaged and were stored outside with protected health information exposed.
Report Facts
Resident census: 68
Residents reviewed for MDS transmittal: 19
Residents with untimely MDS transmission: 5
Residents reviewed for psychotropic medication: 4
Residents with behavioral intervention deficiency: 1
Residents potentially affected by food storage deficiency: 66
Weight of sugar bag on floor: 25
Weight of canola oil box on floor: 35
Length of storage container: 17
Height of record stacks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #7 | Facility MDS Nurse | Indicated corporate RN MDS Coordinator was on family medical leave and MDS assessments were not transmitted timely |
| Director of Clinical Services | Expected timely submission of MDS assessments and care plan updates; confirmed care plan did not reflect resident behavioral issues | |
| Administrator | Unaware of untimely MDS transmissions; expected timely MDS submission and care plan updates | |
| Certified Dietary Manager | Reported food should be stored off floor; described flood and record storage situation | |
| Cook #1 | Stated nothing should be stored on floor; described cleaning duties | |
| Social Services staff member | Reported resident behavioral issues related to phone use | |
| Family Member #3 | Reported resident phone misuse and reasons for phone removal | |
| Registered Nurse #4 | Reported resident phone calling behaviors | |
| Certified Nursing Assistant #5 | Reported hearing resident phone behaviors | |
| Licensed Practical Nurse #6 | Reported hearing resident phone behaviors but did not document | |
| Maintenance Director | Oversaw moving water-damaged records out of basement | |
| Corporate Maintenance Risk Manager | Instructed facility to remove and secure water-damaged records; assessed situation on 01/03/2023 |
Inspection Report
Life Safety
Census: 68
Capacity: 100
Deficiencies: 5
Date: Jan 5, 2023
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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with several fire safety requirements including failure to properly maintain the hood suppression system and K-class extinguisher signage in the kitchen, fire alarm system trouble warnings, corridor doors not properly controlling smoke spread, smoke barrier penetrations allowing smoke passage, and electrical hazards such as a multiple outlet power supply on the floor in the director of nursing's office.
Deficiencies (5)
Hood suppression system and K-class fire extinguisher in the kitchen were not inspected and tagged properly; extinguisher mounted without signage.
Fire alarm control panel showed trouble warning light with 5 troubles listed on the system.
Several resident room doors failed to resist passage of smoke due to not closing, latching, or having gaps at the top.
Facility failed to keep potential smoke in a single compartment due to drilled penetration through a smoke wall.
Multiple outlet power supply (MOPS) located on the floor in the director of nursing's office, creating electrical shock hazard.
Report Facts
Census: 68
Total Capacity: 100
Smoke Compartments affected: 1
Troubles on fire alarm system: 5
Inspection Report
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Date: Dec 9, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 5, 2022 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on October 5, 2022; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the October 5, 2022 Complaint Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 1
Date: Oct 5, 2022
Visit Reason
A Licensure Survey was conducted from September 15, 2022 through October 5, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to ensure that one of six exit doors (the first-floor ramp exit door) was functioning properly, resulting in one resident eloping undetected. Maintenance records showed lack of monthly checks on door hardware, and observations confirmed the door did not close or lock as designed.
Deficiencies (1)
The facility failed to ensure that the first-floor ramp exit door was working properly, leading to one resident eloping undetected.
Report Facts
Number of exit doors: 6
Resident involved: 1
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 3
Date: Oct 5, 2022
Visit Reason
An abbreviated survey was conducted investigating complaint GA00227904, initiated on September 15, 2022 and concluded on October 5, 2022.
Complaint Details
The complaint investigation revealed failures in timely reporting of abuse and elopement incidents involving residents R#3, R#5, and R#9, and insufficient staffing contributing to resident R#2 eloping undetected.
Findings
The facility failed to report allegations of sexual abuse and resident elopement within required timeframes and failed to provide sufficient staff to meet behavioral health needs, resulting in resident elopement. Additionally, one exit door was not functioning properly, allowing a resident to elope undetected.
Deficiencies (3)
Failure to report allegations of sexual abuse and resident elopement to the State Survey Agency within required timeframes for three residents.
Failure to provide sufficient staff with appropriate competencies to meet behavioral health needs, resulting in one resident eloping undetected.
Failure to maintain mechanical equipment in safe operating condition; one exit door (first-floor ramp exit door) was not properly closing, allowing resident elopement.
Report Facts
Resident census: 64
Resident census on second floor: 32
Licensed Practical Nurse to resident ratio: 22
Certified Nursing Assistant to resident ratio: 15
Residents requiring behavioral services: 56
Open positions: 9
Open positions: 15
Open positions: 2
Open positions: 1
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
An abbreviated survey was conducted to investigate four complaints (#GA00224364, #GA00224798, #GA00224911, and #GA00225675) at the facility.
Complaint Details
Complaint #GA00224364 was substantiated without deficiencies cited. Complaints #GA00224798, #GA00224911, and #GA00225675 were unsubstantiated with no deficiencies cited.
Findings
Complaint #GA00224364 was substantiated without deficiencies cited. Complaints #GA00224798, #GA00224911, and #GA00225675 were unsubstantiated with no deficiencies cited.
Report Facts
Resident census: 65
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
A Revisit Survey was conducted from June 27, 2022 through June 29, 2022 to verify correction of deficiencies cited in the FIC and Complaint Survey of March 29, 2022.
Findings
All deficiencies cited as a result of the FIC and Complaint Survey of March 29, 2022 were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Jun 29, 2022
Visit Reason
A Revisit Survey was conducted from June 27, 2022 through June 29, 2022 to verify correction of deficiencies cited in the COVID-19 Focused Infection Control and Complaint Survey of March 29, 2022.
Findings
All deficiencies cited as a result of the COVID-19 Focused Infection Control and Complaint Survey of March 29, 2022 were found to be corrected.
Inspection Report
Licensure Survey
Deficiencies: 5
Date: Apr 14, 2022
Visit Reason
A Licensure Survey was conducted from February 15, 2022 through March 29, 2022 to assess compliance with state regulations and identify deficiencies.
Findings
The facility failed to notify the physician of a significant change in condition for one resident, failed to report allegations of abuse to the State Survey Agency, failed to ensure a safe and orderly discharge for one resident, failed to ensure appropriate follow-up for physician orders related to outside appointments, and failed to implement cognitive loss care plan interventions for one resident.
Deficiencies (5)
Failed to notify the physician of a significant change in condition for one resident related to physical, mental, and psychosocial status and need for medical treatment.
Failed to provide evidence that allegations of abuse were reported to the State Survey Agency for 4 staff to resident allegations.
Failed to ensure a safe and orderly discharge from the facility for one resident who was intoxicated, threatened staff, and was left outside the facility for over five hours without safe discharge arrangements.
Failed to ensure one resident received appropriate services related to physician orders for outside appointments, resulting in missed appointments and hospital admission.
Failed to implement cognitive loss care plan interventions including reducing extraneous environmental stimuli, approaching resident calmly, and interacting in a non-judgmental manner for one resident.
Report Facts
Residents sampled: 34
Residents reviewed for Safe/Orderly Transfer/Discharge: 17
Allegations of abuse: 14
Unreported abuse allegations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator CC | Administrator | Informed emergency operator about intoxicated resident; involved in discharge and incident on 1/26/22 |
| Licensed Practical Nurse OO | LPN | Nurse in charge of resident care on 1/26/22; did not notify physician or document resident's behavior |
| MDS Coordinator | Witnessed resident intoxicated on 1/26/22; responsible for initiating care plans | |
| DON DD | Director of Nursing | Confirmed physician was not notified; involved in discharge process |
| LPN MM | LPN | Observed resident outside on 1/26/22; did not notify physician |
| NP HH | Nurse Practitioner | Notified she was not informed of resident's intoxication and threatening behavior on 1/26/22 |
| Vice President | VP | Confirmed physician had not been notified of incident involving resident |
| Housekeeping Supervisor | HKS | Instructed to wheel resident outside on 1/26/22 |
| Police Officer NNN | Police Officer | Responded to emergency call; observed resident outside in poor condition; involved in resident transfer to hospital |
| Physician AA | Physician | Not aware of discontinuation of oncologist follow-up order |
| Interim Administrator | Interim Administrator | Confirmed follow-up orders were oversight and should have been followed |
| Staffing Coordinator | Staffing Coordinator | Reported resident missed oncologist appointment due to transportation issues |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 7
Date: Apr 14, 2022
Visit Reason
An Abbreviated Survey was conducted to verify the removal of Immediate Jeopardy (IJ) related to a complaint and prior deficiencies concerning resident neglect and unsafe discharge.
Complaint Details
The visit was triggered by a complaint investigation related to neglect and unsafe discharge of resident #4, who was found outside in cold weather without care and subsequently hospitalized with serious medical conditions.
Findings
The facility was found to have previously placed a resident (R#4) outside in cold weather without hydration, medication, food, or toileting, resulting in hospitalization with serious medical conditions. The facility failed to notify the physician of significant changes, protect the resident from neglect, ensure safe discharge, and implement cognitive care plan interventions. Immediate Jeopardy was removed after corrective actions including staff education, policy revisions, and management changes.
Deficiencies (7)
Failure to notify physician of significant change in condition for resident #4.
Failure to protect resident #4 from neglect by staff, including leaving resident outside in cold weather without care.
Failure to ensure safe and orderly discharge of resident #4, who was discharged AMA and left outside in unsafe conditions.
Failure to implement cognitive loss care plan interventions for resident #4.
Failure to provide treatment and care in accordance with professional standards, including missed follow-up appointments and lack of physician notification.
Failure to report allegations of abuse to the State Survey Agency within required timeframes.
Failure of facility administration to effectively oversee discharge process and resident safety.
Report Facts
Resident census: 66
Resident census: 70
Resident charts audited: 42
AMA discharges: 12
Residents interviewed: 31
Staff educated: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator CC | Administrator (previous) | Named in neglect and unsafe discharge findings; placed on administrative leave and terminated |
| Director of Nursing DD | Director of Nursing (previous) | Named in neglect and unsafe discharge findings; placed on administrative leave and terminated |
| Social Service Director EE | Social Service Director (previous) | Named in neglect and unsafe discharge findings; placed on administrative leave and terminated |
| Administrator RRR | Administrator (current) | Hired 2/22/22; involved in corrective action and education |
| Licensed Practical Nurse NN | LPN | Named in Immediate Jeopardy notification |
| Medical Director | Notified late of resident condition changes; involved in corrective action | |
| Nurse Practitioner HH | Nurse Practitioner | Physician order writer; not notified of resident condition changes |
| Licensed Practical Nurse OO | LPN | Nurse in charge of resident care during incident |
| MDS Coordinator | Responsible for care plan initiation; did not report resident condition changes | |
| Housekeeping Supervisor | Assisted resident outside per staff instruction | |
| Police Officer NNN | Responded to resident left outside; reported facility refusal to bring resident inside | |
| Vice President | Corporate official involved in post-incident actions |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 5
Date: Mar 29, 2022
Visit Reason
A Licensure Survey was conducted from February 15, 2022 through March 29, 2022 to assess compliance with state regulations and identify deficiencies.
Findings
The facility was found deficient in multiple areas including failure to notify the physician of a significant change in condition for one resident, failure to report allegations of abuse to the State Survey Agency, failure to ensure a safe and orderly discharge for one resident, failure to provide appropriate follow-up care for physician orders, and failure to implement cognitive loss care plan interventions.
Deficiencies (5)
Failure to notify the physician of a significant change in condition for one resident related to physical, mental, and psychosocial status.
Failure to report allegations of abuse to the State Survey Agency for 4 of 4 resident-to-resident allegations and failure to report investigation results within five working days.
Failure to ensure a safe and orderly discharge from the facility for one resident who was left outside in cold weather without proper care or discharge planning.
Failure to ensure one resident received appropriate services related to physician orders for outside appointments, resulting in missed appointments and subsequent hospitalization.
Failure to implement cognitive loss care plan interventions including reducing extraneous stimuli, approaching resident calmly, and interacting in a non-judgmental manner.
Report Facts
Residents sampled: 34
Residents reviewed for Safe/Orderly Transfer/Discharge: 17
Allegations of abuse not reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Administrator | Named in relation to failure to notify physician and discharge issues with resident R#4 |
| DD | Director of Nursing (DON) | Named in relation to failure to notify physician and discharge issues with resident R#4 |
| OO | Licensed Practical Nurse (LPN) | Nurse in charge of resident R#4's care on 1/26/22, did not notify physician or document behavior |
| HH | Nurse Practitioner (NP) | Notified that resident R#4 was intoxicated and would have ordered emergency room evaluation if informed |
| NNN | Police Officer | Responded to emergency call involving resident R#4 and reported facility refused to take resident back inside |
| AA | Physician | Not aware that oncologist follow-up order was discontinued for resident R#4 |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 7
Date: Mar 29, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints from 2/15/22 through 3/29/22.
Complaint Details
Complaints GA00217824, GA00220718, GA00221174, GA00221306, and GA00221637 were substantiated with deficiencies. Complaints GA00219507 and GA00221416 were unsubstantiated. Complaint GA00221801 was substantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with infection control regulations but had Immediate Jeopardy related to failure to notify physician of significant change, failure to protect a resident from neglect, failure to ensure safe and orderly discharge, failure to implement cognitive loss care plan interventions, and substandard quality of care related to missed follow-up appointments. Resident #4 was found intoxicated, threatened staff, was discharged AMA, left outside in cold weather without care, and later hospitalized with serious medical conditions.
Deficiencies (7)
Failure to notify physician of significant change in condition for Resident #4.
Failure to protect Resident #4 from neglect by staff, including leaving him outside in cold weather without hydration, medication, food, or toileting.
Failure to ensure safe and orderly discharge for Resident #4, including discharging without physician notification, no safe discharge arrangements, and refusal to allow resident back inside.
Failure to implement cognitive loss care plan interventions for Resident #4.
Substandard quality of care related to missed follow-up appointments with oncologist, gastroenterologist, and otolaryngology for Resident #4.
Failure to report allegations of abuse to State Survey Agency within required timeframes.
Failure of administration to effectively oversee facility operations including discharge process and resident safety.
Report Facts
Resident census: 70
Temperature: 30
Number of residents reviewed: 34
Number of substantiated complaints with deficiencies: 5
Number of substantiated complaints without deficiencies: 1
Number of unsubstantiated complaints: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator CC | Administrator | Named in findings related to neglect and failure to notify physician |
| Director of Nursing DD | Director of Nursing | Named in findings related to neglect and failure to notify physician |
| Licensed Practical Nurse NN | Licensed Practical Nurse | Named in Immediate Jeopardy notification |
| Administrator QQQ | Interim Administrator | Named in Immediate Jeopardy notification and interview |
| Administrator RRR | Administrator | Current Administrator hired 2/22/22 |
| Licensed Practical Nurse OO | Licensed Practical Nurse | Witnessed resident intoxication and neglect |
| Medical Director | Medical Director | Notified late of resident condition change |
| Nurse Practitioner HH | Nurse Practitioner | Not notified of resident condition change |
| Social Service Director SSD | Social Service Director | Named in neglect and discharge findings |
| Housekeeping Supervisor HKS | Housekeeping Supervisor | Assisted resident outside per SSD instruction |
| Police Officer NNN | Police Officer | Witnessed resident left outside in cold |
| Registered Nurse JJ | Registered Nurse | Informed resident was no longer allowed in facility |
| Vice President VP | Vice President | Corporate leadership interviewed about incident |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 10, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00220597.
Complaint Details
The complaint was substantiated with no deficiencies cited.
Findings
The complaint was substantiated but no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209527.
Complaint Details
Complaint GA00209527 was substantiated with no regulatory violation cited.
Findings
The complaint #GA00209527 was substantiated, but no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
A desk review was conducted on documentation supporting completion of the approved Plan of Correction (POC) by the Fire Safety Supervisor.
Findings
The approved Plan of Correction has been followed and all citations have been corrected as of the review date.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2020-03-05.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected. The facility was in substantial compliance as of 2020-04-13.
Report Facts
Previous survey date: Mar 5, 2020
Substantial compliance date: Apr 13, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandy Coffee | Named in citation text for Tag 0000 |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2020-03-05.
Findings
All deficiencies cited in the previous Recertification survey were found to be corrected, and the facility was in substantial compliance as of 2020-04-13.
Report Facts
Previous survey date: Mar 5, 2020
Substantial compliance date: Apr 13, 2020
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A revisit survey was conducted on July 29, 2020, in conjunction with Complaint Intake GA 00205264. The revisit was to verify correction of deficiencies cited in the 3/5/2020 Annual survey and to investigate the complaint.
Complaint Details
Complaint Intake GA 00205264 was investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the 3/5/2020 Annual survey were found to be corrected. The complaint investigation GA 00205264 was unsubstantiated with no deficiencies.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jul 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Renewal
Census: 80
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as a Licensure survey to assess compliance with pharmacy management and administration regulations.
Findings
The facility failed to establish a system of records for receipt and destruction of unused controlled medications, and the records of controlled medication destruction were not readily accessible for review. Interviews revealed missing documentation and improper key control for the medication destruction receptacle.
Deficiencies (1)
Failure to establish a system of records of receipt for destroying unused controlled medications and lack of readily accessible records of controlled medication destruction.
Report Facts
Facility census: 80
Date of reverse distributor pick up: Mar 3, 2020
Medication destruction frequency: 14
Retention period for inventory records: 2
Timeframe for sealed liner pick up: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Responsible for controlled and uncontrolled medication destruction; interviewed multiple times regarding medication destruction procedures and missing documentation | |
| Administrator | Holds key to medication collection receptacle; interviewed regarding medication destruction procedures and key control | |
| Owner of the pharmacy | Provided information on proper medication destruction procedures and key control during telephone interview |
Inspection Report
Routine
Census: 80
Deficiencies: 4
Date: Mar 5, 2020
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and federal requirements for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including maintaining a safe and clean environment, timely transmission of Minimum Data Set (MDS) assessments, proper pharmacy medication destruction procedures, and food safety practices including labeling, cleaning, and sanitation.
Deficiencies (4)
Failed to maintain a safe and clean wheelchair and clean enteral tube feeding pump poles and bases for residents.
Failed to ensure timely transmission of Minimum Data Set (MDS) assessments to CMS within 14 days for multiple residents.
Failed to establish and maintain a system of records for receipt and destruction of controlled medications; records were not readily accessible.
Failed to appropriately label and date sealed and opened food items, maintain clean microwave ovens, provide a trash bin with foot peddle and lid near hand wash sink, and allow kitchenware to air dry.
Report Facts
Residents sampled: 36
Residents census: 80
Residents affected by MDS transmission deficiency: 11
Residents affected by food safety deficiency: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified wheelchair armrest issue and cleaning responsibilities | |
| Central Supply/Medical Records Clerk | Responsible for ensuring patient care equipment cleanliness | |
| Director of Nursing (DON) | Confirmed equipment conditions, responsible for medication destruction, and cleaning oversight | |
| Administrator | Confirmed deficiencies and responsibilities for corrective actions | |
| Corporate Minimum Data Set (MDS) Coordinator | Assisted with MDS transmissions and oversight | |
| Regional MDS Coordinator | Reviewed validation reports and transmission issues | |
| Pharmacy Owner | Provided interview on medication destruction procedures | |
| Food Service Director (FSD) | Observed food safety and sanitation issues | |
| Housekeeping/Laundry Supervisor | Discussed cleaning responsibilities and schedules |
Inspection Report
Life Safety
Census: 78
Capacity: 100
Deficiencies: 3
Date: Mar 3, 2020
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety and related regulations at Healthcare at College Park.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with sprinkler system maintenance, resident room doors not resisting smoke passage, and corridor smoke doors failing to close properly, placing residents at risk in the event of fire.
Deficiencies (3)
Failure to maintain automatic sprinkler and standpipe systems at optimum readiness, including a painted sprinkler head not replaced and loaded sprinkler heads in the laundry area.
Resident room door (#112) would not close to latch, failing to resist passage of smoke.
Corridor smoke door leading into dining room off main corridor would not close to latch when released from magnetic hold-open device.
Report Facts
Residents at risk due to sprinkler system deficiency: 40
Residents at risk due to resident room door deficiency: 4
Residents at risk due to corridor smoke door deficiency: 50
Census: 78
Total licensed capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the inspection |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 3, 2019
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
Re-Inspection
Census: 78
Deficiencies: 0
Date: Jul 1, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Standard Survey of 5/17/19.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 80
Capacity: 100
Deficiencies: 6
Date: May 14, 2019
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including missing fire alarm notification devices, fire alarm system trouble signals, lack of smoke detector sensitivity testing, and multiple doors failing to properly resist smoke passage. Additionally, electrical safety hazards were observed with power supplies located on the floor.
Deficiencies (6)
No fire alarm notification device (Horn/Strobe unit) in the conference room.
Fire alarm control panel showed a 'Trouble' light indicating a smoke detector was not functioning.
Required smoke detector sensitivity testing had not been performed.
Several resident room doors (#101, 102, 107, 115, 205, & 209) did not close completely or securely to resist smoke passage.
Smoke doors mid-hallway on second floor and fire door from main hallway into dining room did not close properly to resist smoke.
Multiple Outlet Power Supplies (MOPS) were located on the floor in the business office, administrator's office, and rehab gym, posing shock hazards.
Report Facts
Census: 80
Total Capacity: 100
Staff and visitors at risk: 5
Residents at risk: 50
Staff and/or residents at risk: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews | |
| Maintenance Director | Advised about smoke detector issue on fire alarm control panel |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaint GA00192074 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00192074 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 4, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00191784 and GA00191816 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey investigated complaints #GA00191784 and GA00191816 and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Aug 30, 2018
Visit Reason
A revisit survey was conducted in conjunction with investigation of Complaint GA00190346 to verify correction of previously cited deficiencies.
Complaint Details
Investigation of Complaint GA00190346 found the facility to be in substantial compliance with regulations.
Findings
All deficiencies cited in the prior Abbreviated/Partial Extended Survey were found to be corrected, and the facility was found to be in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Aug 30, 2018
Visit Reason
A revisit survey was conducted in conjunction with investigation of Complaint GA00190346 to verify correction of previously cited deficiencies.
Complaint Details
Investigation of Complaint GA00190346 found the facility to be in substantial compliance with regulations.
Findings
All deficiencies cited in the prior Abbreviated/Partial Extended Survey were found to be corrected, and the facility was found to be in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 16, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00189114 and GA00189650, initiated on July 11, 2018 and concluded on July 16, 2018.
Complaint Details
Complaint GA00189114 was partially substantiated with a deficiency. Complaint GA00189650 was substantiated with a deficiency.
Findings
The facility failed to ensure that an allegation of physical abuse involving Resident #3 was immediately reported to the Administrator and State Agency. The Social Service Director (SSD) received an email about the abuse but did not report it timely, and the Administrator and Director of Nursing were unaware of the allegation until surveyor inquiry.
Deficiencies (1)
Failure to report an allegation of physical abuse immediately to the Administrator and State Agency as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Social Service Director (SSD) | Failed to report allegation of physical abuse of Resident #3 to Administrator and State Agency. |
| Administrator | Administrator | Notified late about the abuse allegation after surveyor inquiry. |
| Director of Nursing | Director of Nursing (DON) | Notified late about the abuse allegation after surveyor inquiry. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 15, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00184997, with a re-entry visit initiated for further investigation.
Complaint Details
Complaint GA00184997 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated after the investigation concluded on July 16, 2018.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: May 15, 2018
Visit Reason
A revisit survey was conducted on May 14-15, 2018 to verify correction of deficiencies cited in the March 23, 2018 Standard Survey.
Findings
All deficiencies cited as a result of the March 23, 2018 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 9, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 12, 2018
Visit Reason
A complaint survey was conducted on 4/12/18 - 4/13/18 to investigate complaints #GA00187072, #GA00187334, and #GA00187545 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to three complaints identified by their numbers. No deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Life Safety
Census: 81
Capacity: 100
Deficiencies: 6
Date: Mar 21, 2018
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 NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in fire alarm system readiness, sprinkler system maintenance, corridor door smoke resistance, smoke barrier integrity, smoke barrier doors, and utility safety. Multiple issues were confirmed during observation and staff interviews.
Deficiencies (6)
Fire alarm system had trouble signals from a pull station in the kitchen and a circuit card in the control panel, indicating failure to keep the fire alarm system in optimum readiness.
Sprinkler system deficiencies including loaded sprinkler heads in the laundry and an improperly adjusted sprinkler head in the upstairs dining hall.
Resident room door (#120 upstairs) had a large gap at the top, failing to resist smoke passage from the room to the corridor.
A 2" x 2" unsealed area above a ceiling tile near an electrical box upstairs near room #210 and nurses station allowed smoke passage between compartments.
Upstairs smoke barrier doors did not close correctly during fire alarm system test, failing to resist smoke passage.
Facility failed to maintain removal of multi-outlet power strips in office areas, posing a fire hazard.
Report Facts
Staff and residents at risk: 50
Staff at risk: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple fire safety deficiencies during facility tour and fire alarm system test on 03/21/2018. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 23, 2018
Visit Reason
A complaint survey was conducted to investigate complaint GA 00185282 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA 00185282 was investigated and found to have no deficiencies.
Findings
No deficiency was cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
An abbreviated/partial survey was conducted on December 5, 2017 to investigate complaint GA#00182176.
Complaint Details
Complaint GA#00182176 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 6, 2017
Visit Reason
A follow-up to a complaint survey conducted on August 21, 2017, to verify correction of previous deficiencies.
Complaint Details
The visit was a follow-up to a complaint survey from August 21, 2017. The deficiencies identified in the complaint survey were corrected.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 29, 2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176102 during a complaint survey on 6/16/17 - 6/17/17.
Complaint Details
Complaint #GA00176102 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 14, 2017
Visit Reason
A follow-up visit was conducted on 6/14/17 to verify correction of deficiencies identified during the recertification survey on 4/18/17.
Findings
The deficiency identified in the prior recertification survey had been corrected as of the follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 6, 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
Deficiencies: 0
Date: May 19, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00175288.
Complaint Details
The complaint was substantiated with no deficiencies.
Findings
The complaint was substantiated but no deficiencies were found during the survey.
Inspection Report
Life Safety
Census: 78
Capacity: 100
Deficiencies: 4
Date: Apr 18, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with fire safety and related National Fire Protection Association (NFPA) standards at Healthcare at College Park, LLC.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in sprinkler system maintenance, corridor door latching and smoke resistance, smoke barrier construction, and electrical hazards in staff areas. These issues could place residents and staff at risk in the event of fire.
Deficiencies (4)
Failure to ensure complete fire protection compliance of the sprinkler system; a loaded sprinkler head was found in a restroom on the second floor near room 209.
Failure to ensure corridor doors could latch positively and limit smoke infiltration; doors to resident rooms 105 and 102 had latching and smoke passage issues.
Failure to ensure smoke/fire barriers limited or resisted passage of smoke; a small penetration about 1" x 6" in the fire wall above a door and ceiling tiles could allow smoke spread.
Failure to prevent potential electrical hazards in staff areas; multi-outlet power strips not mounted off the floor and a voided space in the electrical panel box in the kitchen.
Report Facts
Residents at risk: 50
Staff at risk: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
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