Inspection Reports for Hill Haven Nursing Home
880 RIDGEWAY ROAD, COMMERCE, GA, 30529
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 15, 2025, found no deficiencies and confirmed correction of prior issues, with an unsubstantiated complaint investigation. Earlier inspections showed multiple deficiencies related mainly to failure to timely report and investigate allegations of abuse and injury, incomplete care plans for respiratory treatments, unsafe water temperatures, food storage problems, and lack of a water management program. Life safety surveys cited numerous issues with emergency preparedness, fire safety equipment, and maintenance of fire alarm and sprinkler systems. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved failure to report and investigate injuries, but no enforcement actions or fines were listed in the available reports. The facility appears to have addressed previous deficiencies, showing improvement in the most recent revisit surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
58 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the prior recertification/complaint survey concluded on February 20, 2025, and to investigate Complaint Intake Number GA00254556.
Complaint Details
Complaint Intake Number GA00254556 was investigated and found to be unsubstantiated without federal or state deficiencies cited.
Findings
The previously cited deficiencies were found to be corrected. The complaint investigation was unsubstantiated with no federal or state deficiencies cited.
Report Facts
Facility census: 58
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the recertification/complaint survey concluded on February 20, 2025, and to investigate Complaint Intake Number GA00254556.
Complaint Details
Complaint Intake Number GA00254556 was investigated and found to be unsubstantiated without federal deficiency cited.
Findings
The previously cited deficiencies were found to be corrected, and the complaint investigation was unsubstantiated with no federal deficiencies cited.
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the recertification/complaint survey concluded on February 20, 2025, and to investigate Complaint Intake Number GA00254556.
Complaint Details
Complaint Intake Number GA00254556 was investigated and found to be unsubstantiated without federal deficiency cited.
Findings
The previously cited deficiencies were found to be corrected, and the complaint investigation was unsubstantiated with no federal deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 14, 2025
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags from the Life Safety Code survey were noted to have been corrected during the revisit.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 6
Date: Feb 20, 2025
Visit Reason
The inspection was a State Licensure survey conducted at Hill Haven Nursing Home from February 18, 2025 through February 20, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to conduct required fingerprint background checks prior to employment for two employees, failure to timely report and thoroughly investigate an allegation of sexual abuse involving a resident, failure to develop comprehensive care plans for respiratory treatments for two residents, unsafe water temperatures in resident rooms, lack of an established water management plan, and improper labeling and storage of food items in the kitchen.
Deficiencies (6)
Failure to ensure fingerprint criminal background checks were conducted prior to employment for two employees.
Failure to timely report and thoroughly investigate an allegation of sexual abuse involving one resident.
Failure to develop comprehensive, person-centered care plans for nebulizer therapy and oxygen therapy for two residents receiving respiratory care.
Failure to keep residents free of accident hazards related to water temperatures above 110 degrees Fahrenheit in five resident rooms.
Failure to establish a water management program as part of the overall infection prevention and control program.
Failure to ensure food items stored in the main kitchen were labeled, dated, and properly stored.
Report Facts
Number of employees without fingerprint background check: 2
Number of residents sampled for sexual abuse allegation: 34
Number of residents with deficient care plans for respiratory care: 2
Number of resident rooms with water temperature hazards: 5
Facility census: 59
Number of residents affected by improper food storage: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA QQ | Certified Nursing Assistant | Named in deficiency for missing fingerprint criminal background check. |
| Dietary Aide SS | Dietary Aide | Named in deficiency for missing fingerprint criminal background check. |
| CNA MM | Certified Nursing Assistant | Named in sexual abuse allegation and investigation. |
| Human Resources Director | Responsible for background checks and employee files; interviewed regarding missing background checks and sexual abuse investigation. | |
| Administrator | Interviewed regarding missing background checks and sexual abuse reporting expectations. | |
| Director of Nursing | Involved in sexual abuse investigation and care plan deficiencies. | |
| Medical Director | Interviewed regarding sexual abuse incident and notification. | |
| Dietary Kitchen Manager | Interviewed regarding food labeling and storage deficiencies. | |
| Unit Nurse EE | Confirmed lack of care plan for nebulizer therapy. | |
| Maintenance Director | Conducted water temperature checks. |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 7
Date: Feb 20, 2025
Visit Reason
A recertification survey was conducted from February 18 through February 20, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the recertification survey, including allegations of sexual abuse involving one resident (R59). The facility failed to timely report the allegation and conduct a thorough investigation.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report and thoroughly investigate an allegation of sexual abuse, incomplete care plans for respiratory treatments, unsafe water temperatures in resident rooms, improper storage of respiratory equipment, unlabeled and improperly stored food items, and lack of a water management program.
Deficiencies (7)
Failure to ensure that an allegation of sexual abuse was reported to the State Agency and other officials within the required time frame for one resident.
Failure to ensure a thorough investigation was completed for sexual abuse allegations for one resident.
Failure to develop a comprehensive, person-centered care plan for nebulizer therapy and oxygen therapy for two residents receiving respiratory care.
Failure to keep residents free of accident hazards related to water temperatures above 110 degrees Fahrenheit in five resident rooms.
Failure to properly store the nebulizer mouthpiece when not in use for one resident receiving respiratory care.
Failure to ensure food items stored in the main kitchen were labeled, dated, and properly stored.
Failure to establish a water management program as part of the overall infection prevention and control program.
Report Facts
Residents present: 59
Complaint Intake Numbers: 13
Resident sample size: 34
Resident sample size: 8
Resident rooms with unsafe water temperature: 5
Residents affected by food storage deficiency: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Certified Nursing Assistant | Accused CNA involved in sexual abuse allegation with resident R59 |
| EE | Unit Nurse | Confirmed lack of care plan for nebulizer therapy for resident R10 |
| DD | Certified Nursing Assistant | Interviewed about proper storage of respiratory tubing and mouthpieces |
| DON | Director of Nursing | Involved in reporting, investigation, and interviews related to sexual abuse allegation and respiratory care deficiencies |
| HRD | Human Resource Director | Confirmed suspension of CNA MM and handling of employee files |
| Administrator | Provided expectations for abuse reporting and confirmed lack of water management plan | |
| DKM | Dietary Kitchen Manager | Interviewed about food labeling and storage practices in kitchen |
| MD | Medical Director | Interviewed regarding sexual abuse incident and water temperature checks |
Inspection Report
Life Safety
Census: 58
Capacity: 70
Deficiencies: 16
Date: Feb 19, 2025
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including fire safety, emergency plans, and facility maintenance.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included lack of documentation for emergency preparedness exercises, failure to update emergency plans annually, improperly maintained means of egress, non-functioning exit signs, hazardous storage conditions, fire alarm and sprinkler system maintenance issues, missing smoke detection in corridors, improperly maintained fire extinguishers, resident room door latch issues, electrical hazards, obstructed ventilation, incomplete fire drill documentation, and malfunctioning emergency lighting.
Deficiencies (16)
Emergency Preparedness Plan not in substantial compliance; no documentation of annual tabletop or full-scale exercises.
Emergency Preparedness Plan not reviewed and updated annually as required.
Multiple floor cover plates did not provide a level walking surface in Unit 1.
Numerous exit signs were not functioning throughout the facility.
Excessive combustible material stored in mechanical and electrical rooms; large hole in block wall in soiled linen room.
Fire alarm system smoke detector in common room failed test.
Dining rooms opening into corridor missing smoke detection in Unit 1.
Sprinkler system tamper switches not electronically supervised.
Wet sprinkler system yellow tagged; missing escutcheon plate in wet riser room; incomplete quarterly inspection documentation.
Outdoor fire extinguisher in smoking area not protected from damage.
Resident room 10 door would not latch properly when closed.
Multi-taps not secured from physical damage throughout facility.
Ventilation vent obstructed in mechanical room by kitchen, impairing fuel-fired equipment.
Fire drill documentation not provided.
Emergency light in medication room did not function properly.
Oxygen cylinders stored within five feet of combustible materials.
Report Facts
Certified beds: 70
Census: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the inspection |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Hill Haven Nursing Home following a survey completed on January 11, 2024.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Follow-Up
Census: 67
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the November 22, 2023, Complaint Investigation Survey.
Complaint Details
This visit was a follow-up to a complaint investigation survey conducted on November 22, 2023. All cited deficiencies were corrected.
Findings
All deficiencies cited in the prior complaint investigation survey were found to be corrected during this revisit survey.
Report Facts
Census: 67
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
A State Licensure survey was conducted at Hill Haven Nursing Home from November 14, 2023, through November 22, 2023, to assess compliance with state health regulations.
Findings
The facility failed to report an injury of unknown origin involving a resident with a closed fracture of the right distal femur within the required two-hour timeframe and did not investigate the allegation of injury of unknown origin, potentially risking other residents' safety.
Deficiencies (2)
Failure to report an injury of unknown origin to proper authorities within two hours for one resident with a closed fracture of the right distal femur.
Failure to investigate an allegation of injury of unknown origin for one resident.
Report Facts
Sample size: 21
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported no Facility Reported Incident (FRI) for Resident 12's fracture during interview |
| Administrator | Administrator | Reported no indication of injury reporting or investigation related to Resident 12's fracture during interview |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 2
Date: Nov 22, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intake numbers from November 14 through November 22, 2023, at Hills Haven Nursing Home.
Complaint Details
The complaint investigation found multiple complaint intake numbers unsubstantiated. Complaint Intake Numbers GA00238318 and GA00235907 were substantiated with no deficiencies cited. Complaint Intake Number GA00231422 was substantiated with regulatory deficiencies cited related to failure to report and investigate an injury of unknown origin for Resident R12.
Findings
The investigation found several complaints unsubstantiated, two substantiated with no deficiencies cited, and one substantiated with regulatory deficiencies cited. The facility failed to report an injury of unknown origin for one resident (R12) and failed to investigate the allegation of injury of unknown origin properly.
Deficiencies (2)
Failure to ensure an injury of unknown origin was reported to the proper authorities immediately, specifically a closed fracture of the right distal femur for Resident R12.
Failure to investigate an allegation of injury of unknown origin for Resident R12.
Report Facts
Sample size: 21
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 08/07/2023 and 08/13/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 07/31/2023 and 08/06/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 31, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 07/24/2023 and 07/30/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
A Follow-Up Desk Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
All previously cited survey tags have been corrected and all corrections were verified during the follow-up survey.
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Survey investigating complaints #GA00230796, #GA00230804, and #GA00230845 was conducted.
Complaint Details
Complaints #GA00230796, #GA00230804, and #GA00230845 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. Complaints were unsubstantiated and no regulatory violations were cited.
Report Facts
Complaints investigated: 3
Inspection Report
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Hill Haven Nursing Home, indicating a regulatory inspection was conducted.
Findings
The report contains only initial comments with no detailed deficiencies or findings provided.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Date: Dec 14, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/15/22 Recertification Survey.
Findings
All deficiencies cited in the previous Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 7, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected except for the failure to have a copy of the five year fire sprinkler system internal inspection documentation on site, which affects the probability of sprinkler system malfunction in case of fire.
Deficiencies (1)
Failed to have a copy of the five year fire sprinkler system internal inspection documentation on site.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed the absence of the five year fire sprinkler internal inspection documentation during the facility tour. |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 2
Date: Oct 15, 2022
Visit Reason
A State Licensure Survey was conducted from October 11, 2022 through October 15, 2022 to assess compliance with state regulations for Hill Haven Nursing Home.
Findings
The facility failed to employ a certified Dietary Manager and did not document temperatures for all foods on the steam table or dish machine temperatures, which could negatively impact food quality and cleanliness for all 60 residents.
Deficiencies (2)
Facility failed to have a certified Dietary Manager employed.
Facility failed to document temperatures of all foods on the steam table for all meals and failed to document dish machine temperatures.
Report Facts
Residents affected: 60
Temperature logs provided: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Not certified, registered for Nutrition Foodservice Professional Training course, completed SERV Safe Certification | |
| Administrator | Confirmed Dietary Manager was not certified and discussed need for certification | |
| Registered Dietician | Interim dietician onsite once a month, unaware of temperature documentation issues |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 6
Date: Oct 15, 2022
Visit Reason
A Recertification and Complaint survey was conducted at Hill Haven Nursing Home from October 11, 2022, through October 15, 2022, including investigation of Complaint Intake Number GA00226149.
Complaint Details
Complaint Intake Number GA00226149 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written transfer/discharge notices and bed hold policy notices to residents and representatives, inappropriate use and documentation of PRN psychotropic medications, lack of certified dietary manager, incomplete food temperature documentation, and incomplete staff training on abuse, neglect, and dementia.
Deficiencies (6)
Failure to provide written transfer/discharge notices and notify Ombudsman for four residents.
Failure to provide written notice of bed hold policy at time of transfer for four residents.
PRN antipsychotic medication used without appropriate indication and prescribed beyond 14 days for one resident.
Facility failed to employ a certified Dietary Manager.
Failure to document temperatures of all foods on steam table and dish machine temperatures.
Two Certified Nursing Assistants lacked documented training in dementia, abuse, and behavioral health prior to resident care.
Report Facts
Resident census: 60
PRN psychotropic medication order duration: 90
PRN psychotropic medication order limit: 14
Dietary Manager course registration date: Oct 11, 2022
Inspection Report
Life Safety
Census: 60
Capacity: 70
Deficiencies: 6
Date: Oct 12, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including fire safety and evacuation readiness.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and life safety codes. Deficiencies included failure to update emergency preparedness policies annually, obstructed egress corridors due to wheelchairs and lifts, lack of documentation for fire alarm sensitivity testing, missing five-year internal inspection/testing records for the sprinkler system, incomplete fire drill documentation, and a missing smoke/fire blanket in the designated smoking area.
Deficiencies (6)
Emergency Preparedness Program was not in substantial compliance; no documentation of annual update on policies and procedures.
Means of egress corridors obstructed by wheelchairs and lifts, affecting evacuation.
No documentation for fire alarm system sensitivity inspection/testing.
No documentation for five-year internal inspection/testing of fire sprinkler system.
Fire drills missing 7th month and third shift documentation for 4th, 5th, and 6th months.
Smoke/fire blanket missing from packaging in designated smoking area.
Report Facts
Census: 60
Total Capacity: 70
Missing fire drills documentation months: 1
Missing fire drills shifts: 3
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Aug 31, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaint #GA00215464.
Complaint Details
Complaint #GA00215464 was unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated with no regulatory violations cited. The facility was found to be in compliance with infection control regulations and had implemented recommended COVID-19 practices.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00209215.
Complaint Details
Complaint #GA00209215 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Nov 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations but had not implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 56
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.
Inspection Report
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Hill Haven Nursing Home, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies identified in the February 13, 2020 survey.
Findings
All deficiencies identified in the prior February 13, 2020 survey were found to be corrected during the July 21, 2020 revisit survey.
Inspection Report
Abbreviated Survey
Census: 61
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Survey Emergency Preparedness Survey was conducted to assess the facility's compliance with COVID-19 related regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, and in compliance with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2020
Visit Reason
A licensure survey was conducted from 2/10/2020 through 2/13/2020, including investigation of Complaint Intake Numbers GA00201921 and GA00201951 in conjunction with the standard survey.
Complaint Details
Complaint Intake Numbers GA00201921 and GA00201951 were investigated in conjunction with the licensure survey.
Findings
The facility failed to ensure all components of the nurse call system were fully functional in eight of 63 resident shared rooms, and lacked an effective monitoring system to identify call light issues. Multiple call light logs showed ongoing unresolved issues, and residents affected were not consistently provided secondary means to call for assistance.
Deficiencies (1)
The facility failed to ensure that all components of the nurse call system in eight of 63 resident shared rooms were fully functional and failed to have an effective monitoring system to identify call light issues.
Report Facts
Rooms with non-functional call lights: 8
Total resident rooms observed: 35
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #20 | Resident | Interviewed regarding non-functional call light and assistance. |
| Maintenance Director | Interviewed multiple times regarding call light system issues, electrician visits, and maintenance follow-up. | |
| Administrator | Interviewed regarding call light checks, QAPI plan, and provision of secondary call devices. | |
| Facility Owner | Interviewed regarding electrician visits, building lease issues, and plans for repair or replacement of call light system. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Feb 13, 2020
Visit Reason
A standard survey was conducted from 2/10/2020 through 2/13/2020, including investigation of Complaint Intake Numbers GA00201921 and GA00201951, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA00201921 and GA00201951 were investigated in conjunction with the standard survey.
Findings
The facility failed to ensure that all components of the nurse call system in eight of 63 resident shared rooms were fully functional and lacked an effective monitoring system to identify call light issues. Multiple call lights were not working over several months, and secondary means of alerting staff were inconsistently provided.
Deficiencies (1)
Failure to ensure all components of the nurse call system in eight of 63 resident shared rooms were fully functional and lack of effective monitoring system for call light issues.
Report Facts
Resident census: 62
Rooms with call light issues: 8
Rooms observed for call light function: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #20 | Resident | Interviewed regarding call light functionality and assistance |
| Maintenance Director | Interviewed about call light system maintenance and electrician visits | |
| Administrator | Interviewed about call light system monitoring, QAPI plan, and interim measures | |
| Facility Owner | Interviewed about electrician visits, building lease issues, and plans for repairs or replacement |
Inspection Report
Life Safety
Census: 61
Capacity: 70
Deficiencies: 1
Date: Feb 11, 2020
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to follow adopted smoking regulations, including lack of approved ashtrays and improper disposal of cigarette butts in combustible trash containers.
Deficiencies (1)
Failure to ensure adopted smoking regulations were followed, including no approved ashtray provided and cigarette butts discarded into a plastic waste container with combustible trash.
Report Facts
Census: 61
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 26, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00201260 and GA00196078.
Complaint Details
Complaints GA00201260 and GA00196078 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints GA00201260 and GA00196078 were found to be unsubstantiated with no deficiencies identified.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2019
Visit Reason
A complaint survey was conducted to investigate complaint # GA00192273 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint # GA00192273 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 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 deficiencies had been corrected.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Aug 23, 2018
Visit Reason
A standard survey was conducted from August 20, 2018 through August 23, 2018, including an investigation of Complaint Intake Number GA00188877 in conjunction with the standard survey.
Complaint Details
Complaint Intake Number GA00188877 was investigated in conjunction with the standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with the Healthcare Portion of the Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 65
Capacity: 70
Deficiencies: 4
Date: Aug 22, 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 life safety requirements, including improper locking mechanisms on egress doors, non-functioning emergency lighting, missing fire alarm strobes in certain restrooms, and inadequate smoking area fire safety equipment.
Deficiencies (4)
Main and secondary nurses stations had slide bolt locks on half doors used for entrance and exit, placing 10 residents at risk in the event of a fire.
Emergency lighting in the main entrance lobby was not working, placing 10 residents at risk in the event of a fire.
Fire alarm strobes were not installed in staff restrooms at the billing office and kitchen corridor, and in public restrooms at the main entrance lobby and dining area, placing 8 residents or staff at risk.
The facility failed to have a fire extinguisher, metal cigarette dispenser, fire blanket, and metal ash tray dump container at the staff smoking area at the emergency ambulance entrance, placing 10 residents and/or staff at risk.
Report Facts
Residents at risk: 10
Residents at risk: 10
Residents or staff at risk: 8
Residents and/or staff at risk: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to slide bolt locks, emergency lighting, fire alarm strobes, and smoking area safety equipment during the tour on 08/22/2018 |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 13, 2017
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 deficiencies had been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 0
Date: Aug 24, 2017
Visit Reason
A standard survey was conducted at Hill Haven Nursing Center from August 21, 2017 through August 24, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 67
Capacity: 70
Deficiencies: 9
Date: Aug 22, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper maintenance of the fire alarm system, fire sprinkler system, portable fire extinguishers, rated walls and ceilings, electrical systems, and emergency lighting. Specific issues included pull stations mounted at incorrect heights, missing smoke detectors, lack of sensitivity testing, painted sprinkler heads, missing escutcheons, missing outlet covers, use of prohibited space heaters, and absence of emergency lighting in medication rooms.
Deficiencies (9)
Pull stations mounted at incorrect height and not within 5 feet of egress doors; no smoke detector for fire alarm panel.
Failure to properly maintain fire alarm system initiation devices including smoke detectors located in air flow stream.
Failure to properly test smoke detectors; no sensitivity testing conducted in past 12 months.
Failure to properly maintain fire sprinkler system including painted heads, missing escutcheons, no head wrench, missing signage, light and wiring on sprinkler piping.
Failure to properly maintain portable fire extinguishers; several mounted too high.
Unprotected and improperly protected through penetrations in rated walls and ceilings in multiple locations.
Missing outlet cover in mechanical room 1.
Use of prohibited portable space heater in office area.
No emergency lighting provided in pharmacy and medication rooms.
Report Facts
Census: 67
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations | |
| Staff A | Provided facility records during review |
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