Inspection Reports for Lenbrook

This document is a Statement of Deficiencies and Plan of Correction for the facility Lenbrook, indicating regulatory oversight and corrective actions following an inspection.

The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.

A health revisit survey was conducted at Lenbrook-LTC on March 5, 2025 to verify correction of deficiencies cited in the Recertification survey and Complaint Investigation survey that concluded on January 19, 2025.

All deficiencies cited as a result of the Recertification survey in conjunction with a Complaint Investigation survey were found to be corrected.

The inspection was conducted as a State Licensure survey at Lenbrook-LTC from January 17, 2025 through January 19, 2025 to determine compliance with the State Long Term Care Requirements.

The facility was found deficient in pharmacy management for failing to implement a 14-day stop date on psychotropic medications for two residents, and in medical and nursing care for failing to ensure one resident's call light was accessible, posing safety risks.

A standard annual survey was conducted at Lenbrook LTC from January 17, 2025, through January 19, 2025, to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccessible call lights for residents, failure to prevent infection spread due to improper handling of respiratory equipment, and lack of required stop dates on psychotropic medication orders.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.

The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Plan was found in compliance with 42 CFR &483.73.

An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00251057.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint Intake Number GA00251057 was investigated and found to be unsubstantiated with no regulatory violations cited.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).

A State Licensure survey was conducted from 8/15/2023 through 8/17/2023 to determine compliance with State Long Term Care Requirements.

No deficiencies were cited during the survey.

A standard survey was conducted at Lenbrook from August 15, 2023 through August 17, 2023 to assess compliance with Medicare/Medicaid regulations.

The standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.

A standard survey was conducted at Lenbrook from March 22, 2022 through March 24, 2022 to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.

The inspection was conducted as a licensure survey from March 22, 2022 through March 24, 2022.

No deficiencies were identified during the licensure survey.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition.

The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.

A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal infection control regulations and emergency preparedness requirements related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices to prevent COVID-19.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00202380.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00202380 was investigated and found to be unsubstantiated.

The visit was conducted to assess the facility's infection control practices related to COVID-19 and to investigate complaint GA00204318.

No regulatory violations were cited and the allegation was not substantiated following observations and interviews during the COVID-19 Focused Infection Control Survey.

Complaint GA00204318 was investigated and found to be not substantiated.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 23-24, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.

A follow-up to the Complaint survey of August 27, 2019, was conducted to verify correction of previous deficiencies.

The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 18, 2019.

The visit was a follow-up to a complaint survey conducted on August 27, 2019. All deficiencies identified previously were corrected.

An Abbreviated/Partial Extended Survey was initiated to investigate allegations of abuse at the facility.

The facility failed to report an allegation of abuse involving one resident to the State Survey Office in a timely manner. Additionally, the facility did not have a registered nurse designated as Director of Nursing from 3/8/19 through 8/12/19, which posed potential risk to residents.

The visit was complaint-related, investigating allegations of abuse involving resident #5. The allegation was substantiated as the facility failed to report the abuse allegation to the State Survey Office as required.

The inspection was conducted to assess compliance with nursing service requirements, specifically regarding the designation of a Registered Nurse as Director of Nurses (DON) following the resignation of the previous DON.

The facility failed to ensure a Registered Nurse was designated as the Director of Nurses from 3/8/19 through 8/12/19. Interviews revealed confusion and lack of official notification regarding the DON position, with the Assistant Director of Nurses not officially appointed as DON and the Administrator temporarily assuming the role without proper designation.

A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint was unsubstantiated with no deficiencies cited.

A Follow-Up Survey was conducted to verify that all previously cited deficiencies had been corrected.

The surveyor noted that all previously cited tags have been corrected.

A standard survey was conducted at LenBrook from November 5, 2018 through November 8, 2018 to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.

The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.

The facility was found not in substantial compliance with fire safety requirements, including improper installation of smoke detectors, lack of documentation for smoke detector sensitivity testing, missing sprinkler head in a hallway alcove, absence of a remote annunciator for the emergency generator, and failure to conduct an annual load bank test on the generator.

A standard survey was conducted at Lenbrook from November 20, 2017 through November 22, 2017 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.

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.

Lenbrook was found in substantial compliance with the Life Safety Code requirements at 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 Edition.