Inspection Reports for High Shoals Health and Rehabilitation
3450 NEW HIGH SHOALS RD, GA, 30621
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Life Safety
Deficiencies: 0
May 19, 2025
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected at the time of the revisit.
Inspection Report
Deficiencies: 0
May 14, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for High Shoals Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 80
Deficiencies: 0
May 14, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the recertification survey concluded on March 27, 2025.
Findings
All deficiencies cited during the March 27, 2025 recertification survey were found corrected during the revisit survey on May 14, 2025.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 2
Mar 27, 2025
Visit Reason
A recertification survey was conducted from March 25, 2025 through March 27, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to document missed medication doses, inaccurate transcription of medication parameters, and failure to cover clean laundry during transport, increasing infection risk.
Complaint Details
Complaint Intake Numbers GA00253403, GA00252180, GA00252440, GA00253190, GA00248054, GA00253891, and GA00250701 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document an explanation for a missed dose of enoxaparin for Resident R386 and failed to follow prescribed blood pressure parameters and ensure accurate transcription of antihypertensive medication for Resident R17 during medication administration. | SS= D |
| Failed to cover clean laundry when transporting on one of five halls, increasing risk of infection transmission. | SS= D |
Report Facts
Residents sampled: 39
Resident census: 81
Missed medication dose date: 1
Medication administration dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Medication Assistant | Administered lisinopril despite incorrect blood pressure parameters |
| AA | Licensed Practical Nurse | Signed medication administration record for missed enoxaparin dose without documentation |
| RCC | Resident Care Coordinator | Acknowledged incorrect transcription of lisinopril blood pressure parameters |
| DON | Director of Nursing | Interviewed regarding missed medication documentation and expectations |
| EE | Pharmacist | Provided pharmacy records and explained medication risks |
| ES | Environmental Supervisor | Oversaw laundry operations and described laundry transport practices |
| DD | Laundry Aide | Described laundry covering practices during transport |
| Administrator | Confirmed facility standards for covering clean laundry during transport |
Inspection Report
Original Licensing
Deficiencies: 1
Mar 27, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at High Shoals Health and Rehabilitation from March 25, 2025 through March 27, 2025 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to cover clean laundry when transporting it in one out of five halls, which had the potential to increase the risk of infection transmission among residents. Observations and interviews confirmed that clean laundry was not covered in hallways, contrary to the facility's standard practice.
Deficiencies (1)
| Description |
|---|
| Facility failed to cover clean laundry when transporting to prevent the spread of infection on one out of five halls. |
Report Facts
Number of halls with uncovered laundry: 1
Number of halls observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Laundry Aide | Interviewed regarding laundry transport practices. |
| Environmental Supervisor | Interviewed regarding laundry transport practices. | |
| Administrator | Administrator | Interviewed regarding laundry transport standards and oversight. |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 3
Mar 27, 2025
Visit Reason
A recertification survey was conducted from March 25, 2025 through March 27, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to document missed medication doses, inaccurate transcription of medication parameters, and failure to cover clean laundry during transport, increasing infection risk.
Complaint Details
Complaint Intake Numbers GA00253403, GA00252180, GA00252440, GA00253190, GA00248054, GA00253891, and GA00250701 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to document an explanation for a missed dose of enoxaparin for Resident R386. | SS= D |
| Failed to follow prescribed blood pressure parameters and ensure accurate transcription of antihypertensive medication for Resident R17 during medication administration. | SS= D |
| Failed to cover clean laundry when transporting on one of five halls, increasing risk of infection transmission. | SS= D |
Report Facts
Residents sampled: 39
Medication doses missed: 1
Medication administration dates with blood pressure readings: 5
Medication deliveries: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Medication Assistant (CMA) | Administered lisinopril despite incorrect blood pressure parameters |
| AA | Licensed Practical Nurse (LPN) | Signed medication administration record for enoxaparin with missing documentation for missed dose |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding missed medication documentation and nursing practice |
| Resident Care Coordinator (RCC) | Resident Care Coordinator | Confirmed incorrect transcription of medication parameters |
| EE | Pharmacist | Provided information on medication deliveries and consequences of missed doses |
| DD | Laundry Aide | Interviewed about laundry transport practices |
| Environmental Supervisor (ES) | Environmental Supervisor | Interviewed about laundry covering practices |
| Administrator | Administrator | Interviewed about laundry transport standards |
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 27, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at High Shoals Health and Rehabilitation from March 25, 2025 through March 27, 2025 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to cover clean laundry when transporting it in one out of five hallways, which had the potential to increase the risk of infection transmission among residents. Observations and interviews confirmed that clean laundry was not covered in hallways, contrary to the facility's stated standard practice.
Deficiencies (1)
| Description |
|---|
| The facility failed to cover clean laundry when transporting to prevent the spread of infection on one out of five halls. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Laundry Aide | Interviewed regarding laundry transport practices and covering clean laundry. |
| Environmental Supervisor | Interviewed regarding laundry transport practices and covering clean laundry. | |
| Administrator | Interviewed regarding expectations for covering clean laundry during transport. |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 3
Mar 27, 2025
Visit Reason
A recertification survey was conducted from March 25, 2025 through March 27, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to document missed medication doses, inaccurate transcription of medication parameters, and failure to cover clean laundry during transport, increasing infection risk.
Complaint Details
Complaint Intake Numbers GA00253403, GA00252180, GA00252440, GA00253190, GA00248054, GA00253891, and GA00250701 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to document an explanation for a missed dose of enoxaparin for Resident R386. | SS= D |
| Failed to follow prescribed blood pressure parameters and ensure accurate transcription of antihypertensive medication for Resident R17 during medication administration. | SS= D |
| Failed to cover clean laundry when transporting on one of five halls, increasing risk of infection transmission. | SS= D |
Report Facts
Residents sampled: 39
Medication doses missed: 1
Medication administration dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Medication Assistant (CMA) | Administered lisinopril despite incorrect blood pressure parameters |
| AA | Licensed Practical Nurse (LPN) | Signed medication administration record for missed enoxaparin dose without documentation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding missed medication documentation and facility expectations |
| Resident Care Coordinator (RCC) | Resident Care Coordinator | Acknowledged incorrect transcription of lisinopril blood pressure parameters |
| EE | Pharmacist | Provided information on medication delivery and consequences of missed doses |
| Environmental Supervisor (ES) | Environmental Supervisor | Interviewed about laundry transport practices |
| Laundry Aide (LA) DD | Laundry Aide | Described laundry covering practices during transport |
| Administrator | Administrator | Confirmed facility standards for covering clean laundry during transport |
Inspection Report
Life Safety
Census: 80
Capacity: 100
Deficiencies: 7
Mar 25, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including failure to maintain self-closing doors, hazardous area enclosures, sprinkler system maintenance, corridor door latching, smoke barrier penetrations, and generator safety equipment.
Severity Breakdown
D: 5
E: 1
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Storage room in physical therapy did not have a self-closing device on the door. | D |
| Combustible material stored in the electrical room, a hazardous area. | D |
| Sprinkler system deficiencies including loaded heads in kitchen and multiple sprinkler heads and escutcheon plates dropped from ceiling in unit 3 corridor and clock room. | D |
| Corridor door in unit 3 would not latch in the closed position properly. | E |
| Penetrations not properly sealed in maintenance room and missing components of ceiling grid in unit 3. | D |
| Issue with generator's automatic transfer switch (ATS) affecting entire facility. | F |
| Generator did not have emergency light in the generator area. | D |
Report Facts
Census: 80
Total Capacity: 100
Deficiency Severity D Count: 5
Deficiency Severity E Count: 1
Deficiency Severity F Count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and record review |
Inspection Report
Original Licensing
Deficiencies: 1
Mar 25, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at High Shoals Health and Rehabilitation from March 25, 2025 through March 27, 2025 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to cover clean laundry when transporting it in one out of five halls, which could increase the risk of infection transmission among residents. Observations and interviews confirmed that clean laundry was uncovered in hallways despite the facility's standard practice requiring it to be covered during transport.
Deficiencies (1)
| Description |
|---|
| The facility failed to cover clean laundry when transporting to prevent the spread of infection on one out of five halls. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Laundry Aide | Interviewed regarding laundry transport practices. |
| Environmental Supervisor | Interviewed regarding laundry transport practices. | |
| Administrator | Interviewed regarding laundry transport practices and facility standards. |
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 0
Jun 5, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Findings
Four complaints were unsubstantiated and one complaint was substantiated. No deficiencies were cited related to any of the complaints.
Complaint Details
Complaints GA00246681, GA00244974, GA00244685, and GA00243197 were unsubstantiated. Complaint GA00245257 was substantiated. No deficiencies were cited related to these complaints.
Report Facts
Complaints investigated: 5
Facility census: 74
Inspection Report
Deficiencies: 0
Jan 16, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for High Shoals Health and Rehabilitation, 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: 78
Deficiencies: 0
Jan 16, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 16, 2023 Recertification Survey.
Findings
All deficiencies cited in the November 16, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 73
Capacity: 100
Deficiencies: 0
Nov 27, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code standards.
Inspection Report
Original Licensing
Deficiencies: 3
Nov 16, 2023
Visit Reason
The inspection was conducted as a State Licensure survey at High Shoals Health and Rehabilitation from November 13, 2023, through November 16, 2023, to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to provide written transfer notices containing all required information to five residents transferred emergently to hospitals, and failed to provide written notice of the facility's bed-hold policy to these residents and/or their representatives. Additionally, the facility failed to ensure meaningful activities were offered to three residents with dependent activity needs, potentially decreasing their quality of life.
Deficiencies (3)
| Description |
|---|
| Failure to provide written transfer notice with all required information to five residents transferred emergently to hospitals. |
| Failure to provide written notice of the facility's bed-hold policy to five residents and/or their representatives upon hospital transfer. |
| Failure to ensure meaningful activities were offered to three residents with dependent activity needs. |
Report Facts
Residents reviewed for emergent hospital transfers: 5
Residents reviewed for dependent activities: 5
Residents failed to receive written transfer notice: 5
Residents failed to receive bed-hold policy notice: 5
Residents failed to receive meaningful activities: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated that transfer notices were scanned into the chart but not given to residents or families. |
| Health Information Manager | Health Information Manager | Stated residents and representatives were not given written information during transfers or about bed-hold policy. |
| Activity Director | Activity Director | Provided attendance records and confirmed lack of meaningful activities for dependent residents. |
| Administrator | Administrator | Stated expectation that activities be provided for all residents and that the Activity Director engage dependent residents. |
Inspection Report
Routine
Census: 74
Deficiencies: 6
Nov 16, 2023
Visit Reason
A standard survey was conducted from November 13 through November 16, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for High Shoals Health and Rehabilitation.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report and investigate alleged abuse, failure to provide proper written transfer and bed-hold notices to residents and representatives, lack of meaningful activities for dependent residents, and lack of behavioral health training for direct care staff.
Complaint Details
Complaint Intake Numbers GA00240592, GA00240125, GA00237886, GA00237715, GA00233750, and GA00232592 were investigated. Four complaints were unsubstantiated. One complaint was substantiated with no deficiencies. One complaint was substantiated with deficiencies.
Severity Breakdown
Level D: 2
Level F: 2
Level E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to report an allegation of abuse immediately, but no later than two hours, for one resident. | Level D |
| Failure to conduct a thorough investigation following an allegation of abuse for one resident. | Level D |
| Failure to provide written transfer notices containing all required information to five residents transferred emergently to hospital. | Level F |
| Failure to provide notice of bed hold policy before or upon transfer to hospital for five residents. | Level F |
| Failure to ensure meaningful activities were offered for three residents with cognitive impairments and dependent activity needs. | Level E |
| Failure to ensure behavioral health training was provided to four CNAs and one LPN caring for residents with mental health diagnoses. | Level E |
Report Facts
Complaint Intake Numbers Investigated: 6
Residents reviewed for transfer notice deficiencies: 5
Residents reviewed for bed hold notice deficiencies: 5
Residents reviewed for activity deficiencies: 3
Direct care staff reviewed lacking behavioral health training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Named in abuse allegation reporting and documentation |
| Resident Care Coordinator | Involved in abuse allegation reporting | |
| Director of Nursing | Director of Nursing | Involved in abuse allegation reporting and investigation |
| Administrator | Administrator | Involved in abuse allegation reporting and expectations |
| Activity Director | Activity Director | Provided activity attendance records and interview about resident participation |
| Health Information Manager | Health Information Manager | Interviewed about transfer notice and bed hold policy provision |
| Emergency Room Patient Affairs Coordinator 2 | Reported resident abuse allegation at hospital | |
| Human Resources Representative | Interviewed about staff training records |
Inspection Report
Deficiencies: 0
Jan 17, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for High Shoals Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Jan 17, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 13, 2022 Recertification Survey.
Findings
All deficiencies cited in the prior November 13, 2022 Recertification Survey were found to be corrected during this revisit survey.
Report Facts
Census: 65
Inspection Report
Life Safety
Census: 60
Capacity: 100
Deficiencies: 0
Nov 15, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Certified Beds: 100
Census: 60
Inspection Report
Renewal
Deficiencies: 1
Nov 13, 2022
Visit Reason
The inspection was a Licensure Survey conducted from November 4, 2022 through November 6, 2021, to assess compliance with licensure requirements.
Findings
The facility failed to develop a person-centered care plan for one resident (R#261) regarding refusal of care and medications. Documentation and interviews confirmed that the resident's refusal was not properly care planned despite multiple refusals recorded.
Deficiencies (1)
| Description |
|---|
| Failure to develop a person-centered care plan for resident R#261 for refusal of care and medications. |
Report Facts
Sample size: 20
Medication refusals: 11
Medication refusals: 4
Medication refusals: 7
Medication refusals: 3
Medication refusals: 3
Medication refusals: 3
Medication refusals: 3
Medication refusals: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding documentation and communication of resident refusal of care and medications |
| Minimum Data Set (MDS) Coordinator | Interviewed about development of comprehensive care plans and medication refusal documentation |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Nov 13, 2022
Visit Reason
A standard survey was conducted from November 11 through November 13, 2022, including investigation of Complaint Intake Number GA00227450, to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide showers according to resident preferences for two residents, and failure to develop a person-centered care plan for one resident related to refusal of care and medications.
Complaint Details
Complaint Intake Number GA00227450 was investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure two residents were provided showers according to their preferences. | SS= D |
| Failure to develop a person-centered care plan for one resident for refusal of care and medications. | SS= D |
Report Facts
Resident census: 61
Sample size: 20
Sample size: 20
Medication refusal counts: 11
Medication refusal counts: 4
Medication refusal counts: 7
Medication refusal counts: 3
Medication refusal counts: 3
Medication refusal counts: 3
Medication refusal counts: 3
Medication refusal counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Responsible for monitoring bathing forms and filing completed bath sheets |
| CC | Certified Nursing Assistant (CNA) | Provided baths and showers and completed bath forms |
| AA | Licensed Practical Nurse (LPN) | Documented resident refusals of care or medications and communicated with physician and Nurse Practitioner |
| DON | Director of Nursing | Oversaw bathing/showering procedures and responsibilities |
| Minimum Data Set (MDS) Coordinator | Developed comprehensive care plans; confirmed lack of care plan for medication refusal |
Inspection Report
Deficiencies: 0
Oct 17, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for High Shoals Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Oct 17, 2022
Visit Reason
A revisit was conducted at High Shoals Health and Rehabilitation to verify correction of deficiencies cited during the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 10/9/22.
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 6
Aug 25, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints, including GA00213948 which was substantiated with deficiencies cited.
Findings
The facility was found to be in compliance with COVID-19 infection control regulations but failed to meet food safety requirements. Deficiencies included improper sealing, labeling, and dating of food items; unsanitary kitchen conditions such as condensation dripping onto food and dirty floors; and improper food handling practices including failure to change gloves and wash hands appropriately during meal preparation.
Complaint Details
The survey investigated complaints GA00213948, GA00217719, GA00221443, GA00222578, and GA00226458. Complaint GA00213948 was substantiated with deficiencies cited. Complaints GA00217719 and GA00222578 were substantiated without deficiencies. Complaints GA00226458 and GA00221443 were unsubstantiated.
Deficiencies (6)
| Description |
|---|
| Failed to properly seal, label, and date food items in refrigerator and dry storage. |
| Condensation and dripping water from ceiling vents onto pots, pans, and food preparation areas. |
| Water leaking from a filtration cartridge connected to the dish machine into a pan of standing water on the floor. |
| Dirty floors under movable appliances and storage shelves; tacky work surfaces in the kitchen. |
| Dietary personnel did not change gloves after touching non-food surfaces and before handling ready-to-eat foods; failed to wash hands with soap and water when changing gloves. |
| Use of alcohol-based hand sanitizer instead of washing hands with soap and water in food service setting. |
Report Facts
Sample size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook D | Observed improperly handling food and gloves during meal preparation | |
| Dietary Aide E | Dietary Aide | Observed placing prepared plates on trays |
| Dietary Aide F | Dietary Aide | Observed using alcohol-based hand sanitizer instead of washing hands |
| RN C | Registered Nurse | Acknowledged improper use of hand sanitizer in food service setting |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 3
Aug 23, 2022
Visit Reason
The inspection was conducted as a complaint survey from August 23, 2022 through August 25, 2022 to investigate reported deficiencies at the facility.
Findings
The facility failed to maintain sanitary conditions in the kitchen, including improper sealing, labeling, and dating of food items, condensation and water leaks contaminating food and equipment, dirty floors and work surfaces, and improper food handling practices by dietary personnel, such as not changing gloves appropriately and not washing hands when required.
Complaint Details
The visit was complaint-related, conducted from August 23 to August 25, 2022. The complaint was substantiated by findings of unsanitary kitchen conditions and improper food handling practices.
Deficiencies (3)
| Description |
|---|
| Failed to properly seal, label, and date food items in refrigerator and dry storage area. |
| Failed to maintain sanitary conditions in kitchen related to condensation, dripping water, dirty floors, and dirty work surfaces. |
| Failed to prepare and serve food in a sanitary manner, including dietary personnel not changing gloves after touching non-food surfaces and not washing hands when gloves were changed. |
Report Facts
Census: 62
Sample size: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook D | Cook | Observed improperly handling food and gloves during meal preparation. |
| DA E | Dietary Aide | Observed placing prepared plates on trays without using insulated dome lids. |
| DA F | Dietary Aide | Observed using alcohol-based hand sanitizer instead of washing hands with soap and water. |
| RN C | Registered Nurse | Acknowledged that alcohol-based hand sanitizer may not substitute for hand washing in food service. |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Aug 11, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00201420, #GA00205357, and #GA00201903.
Findings
Complaint #GA00201420 was substantiated with no deficiencies cited. Complaints #GA00205357 and #GA00201903 were unsubstantiated with no deficiencies cited.
Complaint Details
Complaint #GA00201420 was substantiated with no deficiencies cited. Complaints #GA00205357 and #GA00201903 were unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Jul 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Nov 27, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 9/25/19 Complaint Survey.
Findings
All deficiencies cited as a result of the 9/25/19 Complaint Survey were found to be corrected.
Report Facts
Census: 90
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Sep 23, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/25/19 Recertification Survey.
Findings
All deficiencies cited in the previous 7/25/19 Recertification Survey were found to be corrected during this revisit survey.
Report Facts
Census: 93
Inspection Report
Follow-Up
Deficiencies: 0
Sep 9, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 89
Capacity: 100
Deficiencies: 2
Jul 22, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to fully protect the building with the fire sprinkler system, specifically a closet in the Doctor's Office was not sprinklered, and failure to properly maintain the sprinkler system as two sprinkler heads in the kitchen were loaded with grease.
Severity Breakdown
E: 1
F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Closet in the Doctor's Office at the Nurse's Station is not protected by the fire sprinkler system. | E |
| Two fire sprinkler heads are loaded with grease in the Kitchen near the Hood, indicating failure to properly maintain the sprinkler system. | F |
Report Facts
Census: 89
Total Capacity: 100
Number of sprinkler heads loaded with grease: 2
Number of residents at risk due to sprinkler system deficiency: 25
Number of residents at risk due to maintenance deficiency: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 18, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was initiated and concluded to investigate GA00194663.
Findings
The investigation was unsubstantiated with no deficiencies found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 7, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00193799.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00193799 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 20, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00192795.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint GA00192795 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2018
Visit Reason
A complaint survey was conducted from 10/10/18 to 10/11/18 to investigate complaints GA 00191271 and GA 00191361 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted to investigate complaints GA 00191271 and GA 00191361; no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 13, 2018
Visit Reason
A follow-up to the complaint survey conducted on July 25, 2018, to verify correction of deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 5, 2018.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 4
Jul 25, 2018
Visit Reason
A complaint survey was conducted from 7/23/18 through 7/25/18 to investigate multiple complaints regarding compliance with Federal and State Long Term Care Requirements.
Findings
The facility failed to notify responsible parties and physicians timely about significant changes and medication issues for residents, failed to provide a medication as ordered for one resident, and failed to ensure a timely admission nutritional assessment for a resident at nutritional risk.
Complaint Details
The complaint survey investigated complaints GA00189134, GA00189684, GA00189846, and GA00189999 related to notification failures, medication administration issues, and nutritional assessment delays.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify the Responsible Party of a urinary tract infection diagnosis and antibiotic order in a timely manner for one resident. | SS= D |
| Failure to notify a Physician of abnormal lab results and medication unavailability for three days for one resident. | SS= D |
| Failure to provide a medication (Hydrocortisone) as ordered for one resident after hospital discharge. | SS= D |
| Failure to ensure a timely admission nutritional assessment by a Registered Dietician for one resident at nutritional risk. | SS= D |
Report Facts
Census: 95
Medication missed doses: 3
Fluid intake recommendation: 2200
Sodium lab results: 175
Sodium lab results: 155
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Discovered missing Hydrocortisone medication and administered leftover medication without notifying pharmacy or physician. |
| LPN JJ | Licensed Practical Nurse | Did not administer Hydrocortisone on 7/21/18 and 7/22/18 and did not notify physician of missing medication. |
| Director of Nurses | Director of Nursing | Aware of notification failures and medication issues; responsible for making list of new admissions for dietician. |
| Medical Director | Physician | Managed care of resident #3; expected notification of missed medications and lab results. |
| Resident Care Coordinator II | Resident Care Coordinator | Aware of antibiotic order notification failure to family for resident #2. |
| Administrator | Facility Administrator | Expected nursing staff to notify physicians and families timely about medication orders, lab results, and missed medications. |
| Director of Pharmacy | Pharmacy Director | Confirmed medication delivery issues and lack of notification for emergency medication needs. |
| Regional Registered Dietician | Registered Dietician | Interviewed about timing of nutritional assessments and facility practices. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 25, 2018
Visit Reason
The inspection was conducted due to complaints regarding failure to notify responsible parties and physicians timely about residents' health changes, and failure to provide ordered medications.
Findings
The facility failed to notify a resident's responsible party of a urinary tract infection diagnosis and antibiotic order in a timely manner. The facility also failed to notify a physician of abnormal lab results and missed medication administration for another resident. Additionally, the facility failed to provide a medication as ordered for a resident after hospital discharge.
Complaint Details
The investigation was complaint-driven, focusing on notification failures and medication administration issues. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Failure to notify Responsible Party of diagnosis of Urinary Tract Infection and antibiotic order for resident #2 in a timely manner. |
| Failure to notify Physician of abnormal lab results and missed medication administration for resident #3. |
| Failure to provide Hydrocortisone medication as ordered for resident #3 after hospital discharge. |
Report Facts
Sample size: 5
Medication missed doses: 3
Fluid intake ordered: 2200
Medication dosage: 100
Medication dosage: 5
Sodium level: 175
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Discovered missing Hydrocortisone medication for resident #3 and administered leftover medication without notifying pharmacy or physician |
| LPN JJ | Licensed Practical Nurse | Did not administer Hydrocortisone on 7/21/18 and 7/22/18 and did not notify physician of missing medication |
| Director of Nurses | Director of Nursing | Interviewed regarding failure to notify family and nurses about antibiotic order and lab results |
| Medical Director | Physician | Managed care of resident #3 and expected notification of missed medications and lab results |
| Resident Care Coordinator II | Resident Care Coordinator | Aware of antibiotic order not communicated timely to family and lab results notification issues |
| Director of Pharmacy | Pharmacy Director | Provided information on medication delivery and pharmacy notification processes |
| Administrator | Facility Administrator | Confirmed expectations for nursing staff to notify physicians and families and pharmacy to deliver medications promptly |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 25, 2018
Visit Reason
A follow-up to the Recertification survey of May 3, 2018 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected, and the facility was in substantial compliance as of June 6, 2018.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 19, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 2
May 3, 2018
Visit Reason
A standard annual survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to develop and implement a comprehensive care plan for a resident with left upper extremity contracture and failure to provide appropriate treatment and services, including splinting, to prevent further decrease in range of motion for the resident's contracted left hand.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop a care plan for a resident with left upper extremity contracture. | SS= D |
| Failure to provide a splint/device to a resident's contracted left hand to prevent further functional decline and lack of documentation regarding refusal or discontinuation of the splint. | SS= D |
Report Facts
Resident census: 92
Sample size: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assisted resident with hand assessment and provided information about splint use |
| LPN BB | MDS Coordinator | Responsible for completing initial comprehensive care plans and interviewed regarding care plan deficiencies |
| CNA CC | Certified Nursing Assistant | Consistently assigned to resident, provided information about splint use and care |
| RN DD | Registered Nurse, Unit Manager | Interviewed regarding documentation of splint use and refusals |
| RN EE | Corporate Nurse | Participated in meeting regarding lack of documentation and splint discontinuation |
| TS FF | Therapy Staff | Provided information about therapy notes and splint application |
Inspection Report
Routine
Deficiencies: 1
May 3, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically regarding the provision of a splint/device to Resident #40 to prevent further functional decline of her left contracted hand.
Findings
The facility failed to provide Resident #40 with a splint or evidence that the splint was discontinued due to refusal to wear it. Documentation was lacking regarding the splint's discontinuation, and staff were unable to provide evidence of refusal or current therapy related to the splint. Resident #40's left hand was severely contracted without protective splinting, and no policy on assistive devices was provided.
Deficiencies (1)
| Description |
|---|
| Failure to provide Resident #40 with a splint/device to her left contracted hand to prevent further functional decline and lack of documentation regarding refusal or discontinuation of the splint. |
Report Facts
Sample size: 40
Assessment Reference Date: Feb 19, 2018
Assessment Reference Date: Dec 26, 2017
Therapy service date: May 2, 2017
Admission date: Feb 24, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assessed Resident #40's hand and reported lack of awareness of splint or recommendations |
| CNA CC | Certified Nursing Assistant | Consistently assigned to Resident #40, recalled splint use and training but unaware of splint's current status |
| TS FF | Therapy Staff | Provided information on therapy notes and current therapy evaluation status for Resident #40 |
| RN DD | Registered Nurse, Unit Manager | Interviewed regarding restorative notes and documentation of refusal to wear splint |
| RN EE | Corporate Nurse | Met with Administrator regarding lack of documentation on splint refusal and discontinuation |
Inspection Report
Life Safety
Census: 95
Capacity: 100
Deficiencies: 5
May 2, 2018
Visit Reason
The inspection was conducted to assess compliance with Life Safety Code requirements and emergency preparedness regulations at High Shoals Health and Rehabilitation.
Findings
The facility was found not in substantial compliance with emergency preparedness and Life Safety Code requirements, including deficiencies in the emergency preparedness plan, handrails, smoke detectors, fire sprinkler system, and rated walls. These deficiencies could place residents at risk in the event of an emergency.
Severity Breakdown
F: 4
D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan was not site specific, did not address all hazards, and did not meet Appendix Z requirements. | F |
| Facility failed to properly maintain handrails; handrails did not return correctly and guardrails were damaged or missing on loading dock. | D |
| Facility failed to properly maintain smoke detectors; detectors in two IT rooms were in the airflow stream of HVAC supplies. | F |
| Facility failed to properly maintain fire sprinkler system; no identification plate on fire sprinkler riser. | F |
| Facility failed to properly maintain rated walls; unprotected through penetrations in rated wall above corridor smoke doors in Unit 1. | F |
Report Facts
Residents at risk due to emergency preparedness plan deficiency: 95
Residents at risk due to handrail deficiency: 64
Residents at risk due to smoke detector deficiency: 64
Residents at risk due to fire sprinkler system deficiency: 64
Residents at risk due to rated wall deficiency: 95
Census: 95
Total licensed capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A confirmed emergency preparedness plan findings | ||
| Staff M confirmed multiple Life Safety Code deficiencies during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186877 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00186877 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2017
Visit Reason
An unannounced complaint survey was conducted to investigate Complaint intake number #GA00181215.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint intake number #GA00181215 was investigated and found unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 11, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 2
Jul 31, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at High Shoals Health and Rehabilitation.
Findings
The survey found that most previously cited deficiencies were corrected except for issues related to improperly protected openings in the grease duct and deficiencies in the sprinkler system maintenance and testing, including a missing escutcheon plate and loaded sprinkler heads.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Improperly protected opening in the grease duct due to removed electrical wire leaving unprotected holes. | E |
| Sprinkler system deficiencies including use of a plumbing escutcheon plate as replacement instead of a listed plate and presence of something on the sprinkler head in the walk-in cooler. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the tour of the facility on 7/31/17. |
Inspection Report
Follow-Up
Deficiencies: 0
Jul 26, 2017
Visit Reason
A follow up survey was conducted to verify that all deficiencies cited during the Standard Survey of 6/8/17 had been corrected.
Findings
The follow up survey determined that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 90
Capacity: 100
Deficiencies: 10
Jun 6, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements including improperly maintained egress doors, improperly wired kitchen hood fan, incorrectly installed fire alarm system, incomplete sprinkler system coverage and maintenance, improperly maintained corridor doors, unsealed rated walls and ceilings, electrical system deficiencies, incomplete fire evacuation plan, and generator maintenance issues.
Severity Breakdown
E: 5
D: 3
F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Egress doors at the end of Unit 4 were not opening freely. | E |
| Kitchen cooking hood up draft fan wiring runs through grease duct and is not properly wired. | E |
| Fire alarm system visual notification devices not mounted at correct height. | D |
| Fire sprinkler system does not fully protect the facility; women's shower and fire sprinkler riser room not protected. | E |
| Fire sprinkler system maintenance and testing deficient; no 5 year inspection, missing escutcheon plate, and obstruction on sprinkler head. | E |
| Sleeping room door (room 123) does not seal properly. | F |
| Unprotected and improperly protected penetrations in corridor smoke walls and rated ceilings throughout facility. | D |
| Electrical system deficiencies including missing junction box covers and flexible cords running through suspended ceilings. | D |
| Facility fire plan incomplete; missing element to call 911 for all alarms. | F |
| Generator maintenance deficient; documented run times for weekly and monthly load tests could not be verified due to malfunctioning hour meter. | F |
Report Facts
Census: 90
Total Capacity: 100
Deficiencies cited: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member involved in observations and interviews confirming deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 10, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint No. GA00173656.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint No. GA00173656 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 6, 2017
Visit Reason
A partial extended survey was conducted in response to complaint GA168307.
Findings
No deficiencies were cited and the complaint was unsubstantiated.
Complaint Details
Complaint GA168307 was investigated and found to be unsubstantiated.
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