Inspection Reports for Heritage Inn of Barnesville Health and Rehab
946 VETERANS PARKWAY, BARNESVILLE, GA, 30204
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 9, 2025, found no deficiencies during the revisit survey that verified correction of issues cited in April 2025. Earlier inspections showed a pattern of deficiencies related primarily to kitchen sanitation and medication management, with substantiated complaints involving medication errors and unsanitary kitchen conditions. Prior reports also noted issues with resident care communication, pain management, abuse investigations, and infection control, including a COVID-19 related survey in 2020 that cited lapses in protective measures. Complaint investigations were mostly unsubstantiated, though some substantiated complaints resulted in cited deficiencies, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies effectively, as indicated by the clean results in the latest inspection.
Deficiencies (last 8 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a July 2025 inspection.
Census over time
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Re-InspectionInspection Report
Annual Inspection| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed the findings during observation and interview on 4/9/2025 at 9:40 am, stating the white substance inside the oven was a cleaner and that dietary staff cleaned the kitchen on a rotating basis. |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| AA | Certified Medication Assistant | Named in medication error finding for not administering medications due to unavailability |
| BB | Licensed Practical Nurse | Described medication reorder process and confirmed medication error definition |
| Director of Nursing | Director of Nursing | Stated expectations for medication reorder and monitoring |
| Dietary Manager | Dietary Manager | Confirmed unsanitary kitchen findings during observation |
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Routine| Name | Title | Context |
|---|---|---|
| EE | Unit Manager | Interviewed regarding expectations for documenting and notifying refusals of dialysis |
| BB | Interim Director of Nursing | Confirmed lack of documentation for physician/family notification of refusals and falls |
| FF | Nurse Practitioner | Stated she was not notified of refusals of dialysis and described expected clinical orders |
| DOR | Director of Rehabilitation | Interviewed regarding therapy service dates and documentation inconsistencies |
| Administrator | Confirmed inconsistencies in resident records and stated plans to address accuracy in QAPI |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| EE | Unit Manager | Stated expectations for staff to notify NP, family, and dialysis clinic when resident refused dialysis |
| BB | Interim Director of Nursing | Confirmed lack of documentation of physician/family notification for resident refusing dialysis and primary contact notification for resident fall |
| FF | Nurse Practitioner | Stated she was not notified of resident refusing dialysis and would have given orders if notified |
| GG | Licensed Practical Nurse | Involved in incident where resident was called lazy by CNA during dressing assistance |
| HH | Certified Nursing Assistant | Called resident lazy and refused assistance leading to verbal abuse allegation |
| DD | MDS Coordinator | Confirmed failure to complete significant change MDS and inaccurate fall reporting on MDS |
| DOR | Director of Rehabilitation | Reviewed therapy services and discharge dates, unaware of beneficiary representative signing notice |
| Administrator | Facility Administrator | Responded to abuse complaint, acknowledged inconsistencies in medical records and MDS data, and planned QAPI action |
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Re-InspectionInspection Report
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Routine| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Observed providing care to resident #283 and reported resident's pain |
| CNA #3 | Certified Nursing Assistant | Observed providing care to resident #283 and reported resident's pain |
| LPN #8 | Licensed Practical Nurse, Charge Nurse | Responsible for pain assessment and medication administration for resident #283 |
| RCC | Resident Care Coordinator | Involved in communication about resident #283's pain management |
| NP | Nurse Practitioner | Assessed resident #283 and provided medical oversight |
| DON | Director of Nursing | Oversaw nursing care and pain management policies |
| WCC | Wound Care Coordinator | Provided wound care and pain management for resident #283 |
| ADON | Assistant Director of Nursing | Received abuse allegation report regarding resident #24 |
| Administrator | Facility Administrator | Informed of abuse allegation and responsible for reporting |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Assistant | Observed providing care to Resident #283 and interviewed regarding pain management |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding pain management process for Resident #283 |
| LPN #8 | Licensed Practical Nurse, Charge Nurse | Interviewed regarding pain management and physician notification for Resident #283 |
| Resident Care Coordinator (RCC) | Interviewed regarding pain management and resident preferences for Resident #283 | |
| Wound Care Coordinator (WCC) | Interviewed regarding pain management procedures for Resident #283 | |
| Director of Nursing (DON) | Interviewed regarding pain management expectations and abuse policy implementation | |
| Assistant Director of Nursing (ADON) | Reported abuse allegation from Resident #24 and described investigation | |
| Administrator | Interviewed regarding abuse allegations, reporting, and pain management policies | |
| Nurse Practitioner (NP) | Interviewed regarding assessment and management of Resident #283's pain | |
| Social Services Director (SSD) | Interviewed regarding notification requirements for Medicare Part A discharge |
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Re-InspectionInspection Report
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Renewal| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed performing catheter care without changing gloves appropriately |
| CNA BB | Certified Nursing Assistant | Assisted during catheter care observation |
| Director of Nursing | Director of Nursing | Interviewed regarding glove changing policies and expectations |
| LPN CC | Licensed Practical Nurse/Education Coordinator | Interviewed about in-service training on catheter and peri-care |
| LPN DD | Licensed Practical Nurse/Wound Nurse | Conducted in-service training and interviewed about catheter care education |
Inspection Report
Routine| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed performing catheter care without changing gloves appropriately |
| CNA BB | Certified Nursing Assistant | Assisted during catheter care observation |
| Director of Nursing | Director of Nursing | Interviewed regarding glove changing policies and in-service trainings |
| LPN Education Coordinator CC | Licensed Practical Nurse / Education Coordinator | Interviewed about in-service trainings and expectations for catheter care |
| LPN Wound Nurse DD | Licensed Practical Nurse / Wound Nurse | Conducted in-service on catheter care and peri-care; interviewed about training content |
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Life SafetyInspection Report
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Abbreviated Survey| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed not wearing gown when entering COVID-positive resident rooms; stated staff treated all residents as if COVID positive |
| CNA AA | Certified Nurse Assistant | Observed not wearing gown when entering COVID-positive resident rooms; stated gowns only worn for direct contact care |
| CNA BB | Certified Nurse Assistant | Stated staff treated all residents as if COVID positive; residents removed masks and mingled despite redirection |
| CNA CC | Certified Nurse Assistant | Observed not wearing gown when entering COVID-positive resident rooms; stated gowns only worn for personal care |
| DON | Director of Nursing | Acting as Infection Control Nurse; stated facility following CDC guidance; noted prior infection control nurse was terminated for poor performance |
| Administrator | Provided information about COVID unit designation and infection control practices |
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Life Safety| Name | Title | Context |
|---|---|---|
| Staff R | Confirmed findings during facility tour and interview |
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Abbreviated SurveyInspection Report
Abbreviated SurveyLoading inspection reports...



