Deficiencies per Year
16
12
8
4
0
Severe
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
May 12, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center following a survey completed on 05/12/2025.
Findings
No specific deficiencies or findings are detailed in the document; the form appears to be a blank or placeholder plan of correction statement.
Inspection Report
Re-Inspection
Deficiencies: 0
May 7, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 8, 2025 Standard Survey and to investigate multiple complaint intake numbers.
Findings
All deficiencies from the January 8, 2025 Standard Survey were found to be corrected. The complaint investigation found several complaints unsubstantiated and others substantiated with no deficiencies.
Complaint Details
Complaints GA00254320, GA002544626, GA00254700, GA00254701, and GA00254726 were unsubstantiated. Complaints GA00254319, GA00254420, and GA00254735 were substantiated with no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
May 7, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 8, 2025 Standard Survey and to investigate multiple complaint intake numbers.
Findings
All deficiencies cited in the January 8, 2025 Standard Survey were found to be corrected. The complaint investigation found several complaints unsubstantiated and others substantiated with no deficiencies.
Complaint Details
Complaints GA00254320, GA002544626, GA00254700, GA00254701, and GA00254726 were unsubstantiated. Complaints GA00254319, GA00254420, and GA00254735 were substantiated with no deficiencies.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 2
Mar 3, 2025
Visit Reason
A revisit survey was conducted on 3/3/2025 to investigate complaint intake numbers GA00253584 and GA00253618 and to assess compliance with Medicare/Medicaid regulations following a prior standard survey with complaints dated 1/8/2025.
Findings
The facility was found not in substantial compliance due to failure to properly administer inhaled respiratory medications by not ensuring residents rinse their mouth after treatment, and failure to complete required skill competencies related to inhalants for all licensed nursing staff.
Complaint Details
Complaint Intake Numbers GA00253584 and GA00253618 were investigated in conjunction with this revisit survey and were substantiated with no deficiencies.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure that the Registered Nurse properly administered inhaled medications by having the resident rinse their mouth after receiving inhaled respiratory medication. | SS= D |
| Failure to complete skill competencies related to inhalants for all licensed nursing staff as part of the plan of correction. | SS= D |
Report Facts
Resident receiving inhaled respiratory medication: 1
Licensed nursing staff without inhalant skill competency: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN EE | Registered Nurse | Named in medication administration deficiency for failing to have resident rinse mouth after inhaled medication. |
| Director of Nurses | Director of Nursing | Interviewed regarding expectations for rinsing after inhalants and training of RN EE. |
| LPN QQ | Licensed Practical Nurse | Interviewed and revealed lack of skills competency on inhalants. |
| LPN OO | Licensed Practical Nurse | Interviewed and revealed lack of skills competency on inhalants. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 3, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center following a survey completed on March 3, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Mar 3, 2025
Visit Reason
A revisit survey was conducted at Life Care Center in Fitzgerald from 2/25/2025 to 3/3/2025 to verify correction of deficiencies cited in the December 19, 2024 complaint survey.
Findings
All deficiencies cited as a result of the December 19, 2024 complaint survey were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted to verify correction of deficiencies from a complaint survey dated December 19, 2024.
Report Facts
Facility census: 83
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 3, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00253584 and GA00253618.
Findings
Both complaints GA00253584 and GA00253618 were substantiated, but no deficiencies were cited during the survey.
Complaint Details
Complaints GA00253584 and GA00253618 were substantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 28, 2025
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 by the surveyor.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 4
Jan 8, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare facility regulations, including resident rights, infection control, care planning, physical plant standards, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure a resident's right to smoke, inadequate infection control practices such as hand hygiene and catheter bag management, failure to follow care plans related to oxygen therapy and behaviors, and physical plant issues including unclean ice machine and staff not wearing hairnets in the kitchen.
Deficiencies (4)
| Description |
|---|
| Facility failed to ensure one of 13 residents (R17) was able to exercise their right to smoke. |
| Facility failed to ensure infection control practices were followed for two residents (R435 and R7), including hand hygiene during medication administration and proper securing of indwelling catheter drainage bag. |
| Facility failed to ensure care plans were followed for three residents (R24, R7, and R54) related to oxygen therapy, catheter positioning, and behaviors. |
| Facility failed to maintain ice machine in a clean and sanitary condition and failed to ensure staff wore appropriate head covering in the food service area. |
Report Facts
Residents affected by smoking rights deficiency: 1
Residents affected by infection control deficiency: 2
Residents affected by care plan noncompliance: 3
Residents receiving oral diet: 82
Total residents receiving oral diet: 85
Oxygen flow rate discrepancy: 1
Oxygen flow rate discrepancy: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Observed not performing hand hygiene during medication administration and confirmed catheter bag laying on floor. |
| LPN NN | Licensed Practical Nurse | Observed handling medication with bare hands and not performing hand hygiene between glove use. |
| Interim Director of Nursing | Interim Director of Nursing | Made judgment call to restrict resident R17 from smoking without physician order or updated care plan. |
| Nurse Practitioner | Nurse Practitioner | Stated nurse should educate resident R17 about smoking risks but still allow choice. |
| Director of Nursing | Director of Nursing | Confirmed hand hygiene requirements, catheter bag care plan needs, and care plan updates for behaviors. |
| LPN FF | Licensed Practical Nurse | Confirmed oxygen concentrator was set incorrectly for resident R24. |
| Unit Manager Regina Turpen | Unit Manager | Confirmed nurses are responsible for following physician orders and care plans. |
| LPN KK | Licensed Practical Nurse | Revealed resident R54 adjusted oxygen flow rate higher than ordered despite education. |
| MDS Coordinator | MDS Coordinator | Revealed behaviors of resident R54 should have been care planned. |
| Dietary Manager | Dietary Manager | Reported ice machine cleaning procedures and staff in-service on hairnet use. |
| Dishwasher AA | Dishwasher | Observed not wearing hairnet in kitchen. |
| Dishwasher BB | Dishwasher | Observed not wearing hairnet in kitchen. |
| Cook CC | Cook | Reported ice machine cleaning schedule and hairnet policy. |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 7
Jan 8, 2025
Visit Reason
A recertification survey was conducted from January 5 through January 8, 2025, including investigation of three complaint intake numbers which were unsubstantiated with no deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to resident rights, care plan adherence, medication administration, oxygen therapy, infection control, and sanitation practices.
Complaint Details
Complaint Intake Numbers GA00253275, GA00253286, and GA00253382 were investigated and found unsubstantiated with no deficiencies.
Severity Breakdown
D: 5
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure one resident (R17) was able to exercise their right to smoke as per facility policy. | D |
| Failed to ensure care plans were followed for three residents (R24, R7, R54) related to oxygen therapy, catheter positioning, and behaviors. | D |
| Failed to properly administer respiratory inhalant medication by not having resident rinse mouth after inhaler use. | D |
| Failed to ensure oxygen therapy was administered according to physician orders (R24 receiving oxygen at 3L instead of 2L). | D |
| Failed to maintain ice machine in a clean and sanitary condition and failed to ensure staff wore hairnets in food service area. | F |
| Failed to ensure infection control practices including hand hygiene during medication administration and proper catheter bag handling for two residents (R435 and R7). | D |
| Failed to establish and sustain a comprehensive infection prevention training program for all staff, with lack of documented in-service education and staff confusion about Enhanced Barrier Precautions. | F |
Report Facts
Residents present: 85
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 3
Residents affected: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Named in infection control deficiency related to hand hygiene and catheter bag handling |
| LPN NN | Licensed Practical Nurse | Named in infection control deficiency related to hand hygiene during medication administration |
| LPN FF | Licensed Practical Nurse | Named in oxygen therapy and infection control deficiencies |
| RN EE | Registered Nurse | Named in medication administration deficiency related to inhaler use |
| Interim Director of Nursing | Director of Nursing | Named in resident rights deficiency related to smoking policy |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including care plan adherence, infection control, and training |
| Dietary Manager | Dietary Manager | Named in ice machine sanitation and food service hairnet deficiencies |
| Cook CC | Cook | Named in food service hairnet deficiency |
| Dishwasher AA | Dishwasher | Named in food service hairnet deficiency |
| Dishwasher BB | Dishwasher | Named in food service hairnet deficiency |
Inspection Report
Life Safety
Census: 85
Capacity: 167
Deficiencies: 1
Jan 6, 2025
Visit Reason
The visit was conducted as a Life Safety Code Survey 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 due to failure in proper inspection, testing, and maintenance of the fire alarm system. Trouble signals were observed on the fire alarm control panel during the survey.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure proper inspection, testing, and maintenance of the fire alarm system as required by NFPA 70, NFPA 72, and related codes. | SS=F |
Report Facts
Census: 85
Total Capacity: 167
Inspection Report
Annual Inspection
Deficiencies: 3
Dec 19, 2024
Visit Reason
The inspection was conducted as a State Licensure survey at Life Care Center from November 19, 2024 through December 19, 2024, to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas related to resident supervision and care planning. Specifically, the facility failed to notify the physician and responsible party of a resident's elopement, failed to revise the resident's care plan following the elopement, and failed to adequately supervise the resident to prevent elopement, including securing an exit door. These deficiencies placed the resident at risk of unmet needs, avoidable injury, and diminished quality of life.
Deficiencies (3)
| Description |
|---|
| Failure to ensure physician and responsible party were notified of a resident's elopement. |
| Failure to revise and update the resident's care plan following an elopement. |
| Failure to adequately supervise the resident to prevent elopement and failure to secure a door leading outside. |
Report Facts
Sample size: 24
BIMS score: 3
Date of elopement: Oct 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Found resident outside facility and returned resident to secure unit; did not notify responsible party or physician |
| CNA FF | Certified Nursing Assistant | Reported resident eloped on 10/17/2024 and was on smoke break when informed of elopement |
| LPN GG | Licensed Practical Nurse | Working on secure unit when resident was returned; unaware of notification to responsible party or physician |
| Maintenance Director | Completed maintenance request regarding door security and changed keypad code after elopement | |
| MDS Coordinator | Unaware of resident elopement, which led to care plan not being updated | |
| DON BB | Director of Nursing | Notified CNA FF of resident elopement |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Dec 19, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from November 19, 2024, through December 19, 2024, to investigate multiple complaint intake numbers, of which one was substantiated.
Findings
The facility failed to notify the physician and responsible party of a resident's elopement, failed to revise the resident's care plan after the elopement, and failed to adequately supervise the resident and secure a door leading outside, placing the resident at risk of unmet needs, injury, and diminished quality of life.
Complaint Details
Complaint Intake Number GA00252769 was substantiated with deficiencies cited; other complaint intake numbers were unsubstantiated with no deficiencies.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure physician and responsible party were notified of a resident's elopement. | SS= D |
| Failed to revise and update the care plan following a resident's elopement. | SS= D |
| Failed to adequately supervise a resident to prevent elopement and failed to secure a door leading outside. | SS= D |
Report Facts
Complaint Intake Numbers investigated: 5
Resident sample size: 24
BIMS score: 3
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Found resident R1 outside the facility and returned him to the secure unit |
| FF | Certified Nursing Assistant (CNA) | Reported resident R1 eloped on 10/17/2024 and was on smoke break |
| GG | Licensed Practical Nurse (LPN) | Was working on the secure unit when resident R1 was returned and did not notify responsible party or physician |
| BB | Director of Nursing (DON) | Notified by LPN EE about resident R1 outside the facility |
| Maintenance Director | Completed maintenance request and checked door security after resident elopement | |
| MDS Coordinator | Unaware of resident R1's elopement when it occurred, so care plan was not updated |
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Feb 27, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00243364, GA00242500, GA00242967, GA00242967, GA00243206, and GA00234364.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. No deficiencies were cited related to complaints GA00243364, GA00242500, and GA00242967. Complaints GA00242967 and GA00243206 were substantiated, while complaint GA00234364 was unsubstantiated.
Complaint Details
Complaints GA00242967 and GA00243206 were substantiated. Complaint GA00234364 was unsubstantiated.
Report Facts
Complaint numbers investigated: 6
Inspection Report
Deficiencies: 0
Jan 17, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
No specific deficiencies or findings are detailed in the report; only initial comments are noted.
Inspection Report
Follow-Up
Census: 88
Deficiencies: 0
Jan 17, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the November 29, 2023 Standard Survey with Complaints.
Findings
All deficiencies cited in the prior November 29, 2023 survey were found to be corrected during this revisit survey.
Report Facts
Census: 88
Inspection Report
Follow-Up
Deficiencies: 0
Jan 16, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags and Life Safety Code deficiencies have been corrected as of the follow-up survey date.
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 29, 2023
Visit Reason
The inspection was a State Licensure survey conducted at Life Care Center Fitzgerald from November 26 through November 29, 2023, to determine compliance with the State Long Term Care Requirements.
Findings
Deficiencies were cited related to pharmacy management and administration, including failure to transcribe medication orders correctly for one resident. Additional deficiencies included failure to implement or follow care plans for residents with post-traumatic stress syndrome and failure to follow occupational therapy restorative referral recommendations for passive range of motion and splint application. Documentation and adherence to restorative programs were also deficient.
Deficiencies (3)
| Description |
|---|
| Facility failed to transcribe a medication as ordered by the provider for one resident, resulting in incorrect medication administration. |
| Facility failed to implement a care plan for one resident diagnosed with post-traumatic stress syndrome and failed to follow the care plan for another resident. |
| Facility failed to follow an Occupational Therapy restorative referral recommendation for passive range of motion and orthotic application for one resident, including lack of physician's order defining the restorative program and frequency. |
Report Facts
Sample size: 33
Medication doses: 10
Dates with no documentation: 21
Restorative aide work days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Confirmed resident received Haldol 10 mg tablets twice daily. |
| BB | Licensed Practical Nurse (LPN), MDS Coordinator | Verified lack of care plan for PTSD diagnosis and responsible for care plans. |
| AA | Restorative Aide (RA) | Denied performing range of motion exercises prior to splint application and stated restorative services are not done on weekends. |
| BB | Restorative Nurse (RN) | Stated 15 minutes required for PROM treatments and verified restorative aide work schedule. |
| CC | Certified Occupational Therapy Assistant (COTA) | Provided information on occupational therapy services and discharge to restorative nursing. |
| DON | Director of Nursing | Verified medication administration issues, expectations for care plans, and restorative services staffing and training. |
| KK | Pharmacy Technician | Confirmed medication changes for resident R29. |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 5
Nov 29, 2023
Visit Reason
A standard survey was conducted from November 26 through November 29, 2023, including investigation of Complaint Intake Number GA00237040, which was found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to update and file advance directives for one resident, failure to develop and implement comprehensive care plans for two residents, failure to provide timely toenail care for two residents, failure to follow restorative therapy recommendations for one resident, and failure to transcribe medication orders correctly for one resident.
Complaint Details
Complaint Intake Number GA00237040 was investigated in conjunction with the standard survey and was found unsubstantiated.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure one resident's advance directives and code status were correctly entered and filed. | D |
| Failed to develop and implement a care plan for post-traumatic stress syndrome and failed to follow care plan for another resident. | D |
| Failed to ensure timely toenail care for two residents, resulting in long, thick, discolored toenails. | D |
| Failed to follow occupational therapy restorative referral for passive range of motion and splint application for one resident; also lacked physician order defining restorative program and frequency. | D |
| Failed to transcribe medication order correctly for one resident, resulting in administration of incorrect dose of Haloperidol. | D |
Report Facts
Residents sampled: 33
Residents with toenail care issues: 2
Days with missing documentation: 21
Medication dose change date: Jun 28, 2023
Facility census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Provided information about resident code status list and medication cart observation |
| BB | Licensed Practical Nurse / Restorative Nurse | Provided information about restorative care and care plans |
| SSD | Social Service Director | Discussed advance directives, podiatry scheduling, and resident care issues |
| DON | Director of Nursing | Provided information about care plans, restorative services, and medication tracking |
| MM | Certified Nursing Assistant | Discussed nail care responsibilities |
| HH | Certified Nursing Assistant | Discussed nail care responsibilities |
| FF | Licensed Practical Nurse | Discussed podiatry scheduling and resident care |
| AA | Restorative Aide | Described restorative care practices and documentation |
| CC | Certified Occupational Therapy Assistant | Provided information about occupational therapy services and splint use |
| NN | Podiatrist | Provided podiatry care and described resident foot condition |
| OO | Podiatrist | Previously provided podiatry services to the facility |
| KK | Pharmacy Technician | Provided information about medication order changes |
Inspection Report
Life Safety
Census: 89
Capacity: 167
Deficiencies: 4
Nov 28, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included failure to maintain a compliant Emergency Preparedness Program, propped open self-closing doors in hazardous areas, missing escutcheon ring on a sprinkler head, and combustible decorations attached to a resident room door.
Severity Breakdown
F: 1
D: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Emergency Preparedness Program was not in substantial compliance with 42 CFR § 483.73; multiple components missing and staff unfamiliar with the program. | F |
| Hazardous areas (Kitchen Storage Area and Copy Room) had self-closing doors propped open, failing to ensure proper enclosure. | D |
| Improper installation of fire sprinkler system components; missing escutcheon ring on a sprinkler head in the Activities Room. | D |
| Combustible decorations attached to resident room #15 West door, violating combustible decoration requirements. | D |
Report Facts
Certified beds: 167
Census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings and corrected citations during the survey |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 2, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00238378 and GA00238574.
Findings
No deficiencies were cited related to the complaints investigated during this survey.
Complaint Details
The survey was complaint-related, investigating complaint numbers GA00238378 and GA00238574. No deficiencies were found related to these complaints.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Aug 22, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00237729, GA00238013, and GA00238244.
Findings
Complaints #GA00237729 and #GA00238013 were unsubstantiated with no deficiencies cited. Complaint #GA00238244 was substantiated with no deficiency cited.
Complaint Details
Complaints #GA00237729 and #GA00238013 were unsubstantiated. Complaint #GA00238244 was substantiated but no deficiency was cited.
Report Facts
Complaints investigated: 3
Inspection Report
Follow-Up
Deficiencies: 0
Jul 7, 2023
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the 5/18/23 Recertification Survey and to investigate complaints GA00235704 and GA00236396.
Findings
All deficiencies from the prior recertification survey were found to be corrected. The complaint investigations were determined to be unsubstantiated.
Complaint Details
Complaints GA00235704 and GA00236396 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 7, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00235704 and GA00236396.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
The survey investigated complaints GA00235704 and GA00236396 which were found to be unsubstantiated.
Inspection Report
Life Safety
Deficiencies: 0
Jul 5, 2023
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags from prior inspections were noted to have been corrected during this revisit.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
May 18, 2023
Visit Reason
A standard survey was conducted from May 16, 2023 through May 18, 2023, including investigation of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to properly change and store respiratory supplies for a resident receiving respiratory care, and failure to provide continuous one-to-one monitoring for a resident with a history of physically aggressive behavior.
Complaint Details
The investigation included Complaint Intake Numbers GA00234745, GA00230869, GA00234440, and GA00230459. The complaint investigation revealed noncompliance related to respiratory care and behavior management monitoring.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure respiratory supplies were properly changed and stored for one resident receiving respiratory care, increasing risk of respiratory infections. | SS= D |
| Failure to provide continuous one-to-one monitoring for one resident with a history of physically aggressive behavior as ordered by the physician. | SS= D |
Report Facts
Resident census: 81
Oxygen order: 2
Nebulizer medication dose: 2.5
Dates missing one-to-one supervision: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Interviewed regarding respiratory tubing maintenance and resident transport to Emergency Department |
| LPN BB | Licensed Practical Nurse Unit Manager | Interviewed regarding responsibility for changing respiratory tubing and nebulizer mask storage |
| DON | Director of Nursing | Interviewed regarding expectations for respiratory supply maintenance and monitoring log issues |
| NP | Nurse Practitioner | Interviewed regarding resident's COPD history and medication orders |
| LPN YY | Licensed Practical Nurse | Interviewed regarding one-to-one monitoring for resident #44 |
Inspection Report
Life Safety
Census: 80
Capacity: 167
Deficiencies: 4
May 16, 2023
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements, including improper locking of gates in the West Smoke Area, improper installation of the fire alarm system power supply, failure to maintain flame spread ratings of privacy curtains in Room South 7, and improper storage of oxygen cylinders in Oxygen Room North.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure proper locking of gates in the West Smoke Area; a combination lock was used instead of a keyed lock. | D |
| Failed to ensure proper installation of the fire alarm system power supply; fire alarm circuit breaker was not properly identified, not locked in the 'on' position, and not marked red. | D |
| Failed to maintain flame spread ratings of privacy curtains in Room South 7; curtains lacked NFPA 701 compliance tags and documentation of flame-retardant treatment. | D |
| Failed to ensure proper storage of oxygen cylinders in Oxygen Room North; empty and full cylinders were stored together without labeling. | D |
Report Facts
Census: 80
Total Capacity: 167
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and corrected citations during survey |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Nov 17, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from November 14 to November 17, 2022 at the Life Care Center to investigate four complaint numbers related to compliance with Federal and State Long Term Care Requirements.
Findings
Three complaint investigations were unsubstantiated, one was substantiated with no deficiency cited, and no deficiencies were identified during the survey.
Complaint Details
Complaint Numbers GA00228152, GA00228610, GA00229321 were unsubstantiated; GA00229601 was substantiated with no deficiency cited.
Report Facts
Complaint Numbers Investigated: 4
Inspection Report
Re-Inspection
Census: 85
Deficiencies: 0
Nov 17, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on June 29, 2022.
Findings
All deficiencies cited as a result of the complaint survey on June 29, 2022 were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey on June 29, 2022. All deficiencies from that complaint survey were corrected.
Report Facts
Census: 85
Inspection Report
Monitoring
Deficiencies: 0
Nov 17, 2022
Visit Reason
A Federal Monitoring Resource Support Survey was conducted with the Georgia State Agency from 11/14-17/22.
Findings
The report documents the completion of a Federal Monitoring Resource Support Survey conducted jointly with the Georgia State Agency over the specified dates.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 15, 2022
Visit Reason
An abbreviated survey was conducted to investigate multiple complaints identified by their tracking numbers.
Findings
The complaints were substantiated; however, no deficiencies were cited during the survey.
Complaint Details
The survey investigated complaints #GA00225572, GA00226849, GA00226947, GA00227584, and GA00227802, all of which were substantiated.
Inspection Report
Routine
Census: 40
Deficiencies: 6
Jul 19, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with healthcare facility regulations, including grievance procedures, medical and dental care, hygiene, environmental sanitation, infection control, and vaccination protocols.
Findings
The facility was found deficient in multiple areas including failure to promptly resolve resident grievances, inadequate dental and nursing care, poor hygiene practices, environmental sanitation issues with flies present, improper infection control practices including PPE use and medication handling, and failure to ensure residents were offered influenza and pneumococcal vaccines.
Severity Breakdown
Level D: 3
Level E: 2
Level F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to make prompt efforts to resolve dental service grievances and maintain grievance records. | Level D |
| Failure to ensure timely dental services for residents requiring urgent dental care. | Level D |
| Failure to provide adequate nursing care including facial hair removal, proper wound care, and toileting assistance. | Level D |
| Failure to maintain an environment free from flies in resident areas. | Level E |
| Failure to ensure sanitary use and maintenance of shared resident equipment and proper PPE use during care and medication administration. | Level F |
| Failure to ensure residents were offered and/or received influenza and pneumococcal vaccines as required. | Level E |
Report Facts
Sample size: 40
Pest control service dates: 7
Flies observed: 8
Wound measurements: 6
Wound measurements: 2
Wound measurements: 5.7
Wound measurements: 5.8
Wound measurements: 5.4
Wound measurements: 13
Wound measurements: 4
Wound measurements: 0
Incontinence days: 7
Incontinence days: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CCCC | Certified Nursing Aide (CNA) | Provided oral care to Resident #8 and observed during wound care |
| BBBB | Regional Nursing Consultant | Delegated to follow-up with grievances |
| GGGG | Revenue Cycle Manager | Interviewed regarding dental program enrollment and grievances |
| BBBB | Interim Director of Nursing (DON) | Confirmed mask wearing policy and PPE requirements |
| ZZ | Licensed Practical Nurse (LPN) | Observed washing underwear in sink and drying in microwave |
| OOOO | Licensed Practical Nurse (LPN) | Involved in medication administration and disposal incident |
| AAAA | Licensed Practical Nurse (LPN) | Involved in medication administration and disposal incident |
Inspection Report
Abbreviated Survey
Census: 99
Deficiencies: 15
Jul 19, 2022
Visit Reason
An abbreviated survey was conducted to verify the removal of Immediate Jeopardy identified during a prior extended survey related to abuse, neglect, and involuntary seclusion at Life Care Center.
Findings
The facility was found to have systemic failures in maintaining an abuse-free environment including verbal, mental, sexual, and physical abuse involving staff to resident and resident to resident incidents. Immediate Jeopardy was removed after corrective actions, but the facility remained out of compliance with ongoing systemic issues. Additional deficiencies were found in grievance resolution, care planning, medication administration, infection control, dental services, record keeping, and quality assurance.
Severity Breakdown
Level L: 1
Level D: 6
Level E: 2
Level F: 3
: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Repeated systemic failure to maintain an abuse free environment including verbal, mental, sexual, and physical abuse involving staff to resident and resident to resident incidents. | Level L to F (various scope/severity levels noted) |
| Failure to make prompt efforts to resolve grievances and maintain grievance records. | D |
| Failure to ensure residents were free from involuntary seclusion with use of locks on resident doors. | D |
| Failure to implement abuse/neglect policies including reporting, investigation, and protection. | D |
| Failure to report alleged violations of abuse in a timely manner. | E |
| Failure to thoroughly investigate allegations of verbal abuse and implement corrective actions. | D |
| Failure to revise care plans to include physical altercations and implement interventions. | D |
| Failure to provide necessary ADL care including facial hair removal and perineal care. | D |
| Failure to ensure timely and appropriate dental services for residents. | — |
| Failure of administration to provide effective oversight to maintain an abuse free environment. | F |
| Failure to maintain complete and accurate resident medical records. | — |
| Failure to implement effective Quality Assurance Performance Improvement (QAPI) activities related to abuse prevention and other deficiencies. | F |
| Failure to maintain infection prevention and control including sanitary medication administration, wound care, PPE use, and COVID-19 outbreak testing. | F |
| Failure to ensure residents were offered and/or received influenza and pneumococcal immunizations. | — |
| Failure to maintain a safe, functional, sanitary, and comfortable environment free from dried spills and pest infestation. | E |
Report Facts
Resident census: 99
Staff in-service counts: 117
Resident sample size: 40
Facility capacity: 128
Facility capacity: 99
Number of residents with updated care plans: 34
Number of residents in facility: 99
Number of staff: 90
Number of residents on COVID unit: 7
Number of staff recovering from COVID-19: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator BBB | Facility Administrator / Abuse Coordinator | Named in Immediate Jeopardy findings and abuse oversight |
| Assistant Director of Nursing DDD | Assistant Director of Nursing | Named in Immediate Jeopardy findings and abuse oversight |
| CNA YY | Named in physical abuse incident with resident #1 and terminated | |
| LPN GG | Licensed Practical Nurse | Named in physical abuse incident with resident #1 and terminated |
| LPN AA | Licensed Practical Nurse | Named in verbal abuse allegations and terminated |
| CNA UU | Named in verbal abuse allegations and terminated | |
| LPN VV | Agency Licensed Practical Nurse | Named in mental abuse allegations and terminated |
| LPN ZZ | Licensed Practical Nurse | Named in verbal abuse allegations and infection control violations |
| Regional Vice President of Operations | Provided education and oversight during corrective action | |
| Regional Nurse Consultant | Provided education and oversight during corrective action | |
| Director of Nursing ZZZ | Director of Nursing | Named in abuse oversight and education |
| LPN OOOO | Licensed Practical Nurse | Named in medication administration violation |
| LPN AAAA | Licensed Practical Nurse | Named in medication administration violation |
| LPN CCC | Agency Licensed Practical Nurse | Named in infection control violation |
| LPN ZZ | Licensed Practical Nurse | Named in infection control violation and abuse allegations |
| Interim Director of Nursing BBBB | Interim Director of Nursing | Named in record keeping and infection control |
| Nurse Practitioner HHHH | Nurse Practitioner | Named in record keeping and hospital transfer |
| Administrator BB | Former Facility Administrator | Named in Immediate Jeopardy and terminated |
| CNA UU | Named in verbal abuse allegations and terminated |
Inspection Report
Deficiencies: 1
Jul 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/11/2022 and 07/17/2022, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Census: 99
Deficiencies: 13
Jun 29, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints from April 19, 2022 through June 29, 2022.
Findings
The facility was found not in compliance with infection control regulations and had substantiated complaints involving abuse, neglect, verbal and physical abuse by staff and residents, failure to report and investigate abuse allegations timely, failure to maintain an abuse free environment, failure to revise care plans, and failure to provide timely dental and medical care. Additional findings included failure to maintain complete medical records, failure to provide timely influenza and pneumococcal vaccinations, failure to maintain sanitary conditions, and failure to follow COVID-19 infection control protocols.
Complaint Details
Multiple complaints were investigated including allegations of abuse (verbal, physical, sexual), neglect, failure to provide dental care, and infection control violations. All complaints were substantiated with deficiencies.
Severity Breakdown
Level L: 3
Level K: 1
Level J: 2
Level F: 4
Level E: 3
Level D: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Repeated systemic failure to maintain an abuse free environment including involuntary seclusion, verbal, mental, sexual and physical abuse involving staff to resident and resident to resident incidents. | Level L |
| Failure to make prompt efforts to resolve grievances related to dental services and resident complaints. | Level D |
| Failure to ensure residents were free from abuse, neglect, and exploitation including verbal, mental, physical, sexual abuse and involuntary seclusion. | Level L |
| Failure to report and investigate staff to resident and resident to resident abuse allegations timely and to suspend staff pending investigation. | Level K |
| Failure to revise care plans to include physical altercations and implement interventions to prevent recurrence. | Level J |
| Failure to maintain a comprehensive facility assessment including resident population and facility resources. | Level F |
| Failure to maintain complete and accurate clinical records for multiple residents. | Level D |
| Failure to provide medications within prescribed times and failure to obtain vital signs as ordered. | Level J |
| Failure to provide appropriate oral care and perineal care and failure to follow infection control practices including PPE use. | Level F |
| Failure to ensure residents were offered and/or received influenza and pneumococcal vaccines timely. | Level E |
| Failure to conduct COVID-19 outbreak testing timely and in accordance with guidelines. | Level F |
| Failure to maintain an environment free from dried spills around gastrostomy tube pumps for two residents. | Level D |
| Failure to maintain an environment free from flies on multiple halls and resident rooms. | Level E |
Report Facts
Facility census: 99
Deficiencies cited: 40
Management changes: 7
Management changes: 6
Pest control visits: 8
Staff tested: 1
Staff total: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator BB | Facility Administrator | Instructed maintenance to install locks on resident room and bathroom doors; was suspended and terminated for abuse management failures |
| LPN GG | Licensed Practical Nurse | Physically abused resident R#1; suspended and terminated |
| LPN HH | Licensed Practical Nurse | Related to LPN GG; involved in abuse incident |
| LPN AA | Licensed Practical Nurse | Verbally abused residents R#6 and R#12; suspended and terminated |
| CNA UU | Certified Nursing Assistant | Verbally abused resident R"B"; terminated |
| CNA II | Certified Nursing Assistant | Witnessed LPN GG physically abuse resident R#1 |
| LPN VV | Agency Licensed Practical Nurse | Posted videos of residents on social media; suspended and placed on do not use list |
| Regional Vice President CC | Corporate Regional Vice President | Led abuse investigations and reported staff to law enforcement |
| Senior Vice President FF | Corporate Senior Vice President | Led abuse investigations and reported staff to law enforcement |
| LPN OOOO | Licensed Practical Nurse | Discarded resident medications in trash; medication administration issues |
| LPN AAAA | Licensed Practical Nurse | Administered medications discarded by LPN OOOO |
| LPN ZZ | Licensed Practical Nurse | Verbally abused residents; washed underwear in sink and dried in microwave; not suspended timely |
| LPN CCC | Agency Licensed Practical Nurse | Observed not wearing mask in resident care area |
| LPN III | Licensed Practical Nurse | Wound care nurse failed to measure wound depth and contaminated wound dressing |
| CNA CCCC | Certified Nursing Assistant | Failed to clean soiled bedside table during perineal care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00218475 and #GA00219184.
Findings
The complaints #GA00218475 and #GA00219184 were found to be unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00218475 and #GA00219184 were investigated and found unsubstantiated with no regulatory violations cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 7, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Life Care Center following a survey completed on 10/07/2021.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey. Specific deficiencies and severity levels are not detailed in the provided page.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Oct 7, 2021
Visit Reason
A revisit survey was conducted on 10/7/2021 to verify correction of deficiencies cited during the 8/19/2021 Recertification Survey.
Findings
All deficiencies cited as a result of the 8/19/2021 Recertification Survey were found to be corrected as of 10/3/2021.
Inspection Report
Renewal
Census: 92
Deficiencies: 0
Aug 19, 2021
Visit Reason
A licensure survey was conducted at Life Care Center from August 17, 2021 through August 19, 2021 to assess compliance for renewal of the facility's license.
Findings
The survey revealed that the facility was in substantial compliance with regulatory requirements.
Inspection Report
Routine
Census: 92
Deficiencies: 6
Aug 17, 2021
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to multiple environmental deficiencies including leaking air conditioning ducts causing water damage and wet floors, stained ceiling tiles, dust accumulation, black substance behind toilets, missing and chipped paint in bathrooms, and missing floor tiles.
Severity Breakdown
E: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Leaking air conditioning ducts causing water dripping onto floors and nurse stations. | E |
| Stained ceiling tiles with water marks and dark discoloration. | E |
| Black substance behind toilet in shared bathroom. | E |
| Missing and chipped paint on bathroom doors and walls. | E |
| Missing tiles on floor in shared bathroom. | E |
| Dust accumulation in ceiling vents. | E |
Report Facts
Resident census: 92
Number of air conditioning units: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Certified Nursing Assistant | Provided information about bathroom usage on West Wing C Hall |
| Maintenance Assistant | Reported awareness of leaking air conditioning ducts and maintenance efforts | |
| Maintenance Director | Confirmed findings and stated need for replacement of air conditioning units | |
| Administrator | Acknowledged facility repair needs and remodeling focus | |
| Assistant Director of Nurses | Reported knowledge of air conditioning duct leaks | |
| Housekeeping Supervisor | Reported awareness of air conditioning duct leaks for over one year |
Inspection Report
Life Safety
Census: 92
Capacity: 167
Deficiencies: 0
Aug 17, 2021
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 Life Safety Code requirements and the Emergency Preparedness Program was substantially compliant with 42 CFR § 483.73.
Report Facts
Certified beds: 167
Census: 92
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 22, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (#GA00213883, #GA00214063, #GA00214397, #GA00214763, #GA00214878, and #GA00214977).
Findings
All complaints investigated during the survey were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00213883, #GA00214063, #GA00214397, #GA00214763, #GA00214878, and #GA00214977 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 26, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00210956.
Findings
The complaint #GA00210956 was unsubstantiated and no deficiencies were identified during the survey.
Complaint Details
Complaint #GA00210956 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 4, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00209754.
Findings
The complaint #GA00209754 was unsubstantiated with no regulatory violations found during the survey.
Complaint Details
Complaint #GA00209754 was investigated and found to be unsubstantiated with no regulatory violations.
Inspection Report
Routine
Census: 100
Deficiencies: 0
Nov 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and recommended practices for COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Nov 10, 2020
Visit Reason
A Desk Review for the COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on November 10, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 23, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00207745, GA0027816, and GA0028355.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00207745, GA0027816, and GA0028355 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 100
Deficiencies: 0
Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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 related to infection control regulations.
Report Facts
Total census: 100
Inspection Report
Abbreviated Survey
Census: 103
Deficiencies: 4
Aug 21, 2020
Visit Reason
A COVID-19 Focused Infection Control survey was conducted to assess the facility's compliance with infection prevention and control requirements related to COVID-19.
Findings
The facility failed to update infection prevention and control policies regarding eye protection, failed to ensure proper use of PPE by staff in most nursing units, lacked proper signage for transmission-based precautions for one resident, and failed to store ice scoops and clean hydration carts properly, placing residents at risk for infection.
Severity Breakdown
F: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to update infection prevention and control policies addressing use of eye protection when providing care to residents. | F |
| Failure to ensure proper use of personal protective equipment (PPE) by staff in four of five nursing units, specifically failure to wear eye protection. | F |
| Failure to post signage for transmission-based precautions outside one resident's room on isolation. | F |
| Failure to store two of five ice scoops in a sanitary manner and failure to ensure all hydration carts were cleaned and disinfected daily. | F |
Report Facts
Residents positive with COVID-19: 4
Residents in non-COVID unit: 99
Nursing units with PPE issues: 4
Ice scoops improperly stored: 2
Hydration carts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Stated goggles or face shields were optional and did not think facility had face shields; observed not wearing eye protection. |
| Licensed Practical Nurse #1 | LPN | Observed moving in and out of resident rooms and nursing station without eye protection. |
| Licensed Practical Nurse #2 | LPN | Observed moving in and out of resident rooms without eye protection. |
| Director of Nursing | DON and Infection Control Preventionist | Unaware of CDC guideline on eye protection; stated eye protection required only in COVID unit. |
| Dietary Manager | Dietary Manager | Reported CNAs supposed to bring hydration carts to kitchen for cleaning; no written policy on cleaning schedule. |
| Dietary Aid | Dietary Aid | Stated had not cleaned hydration carts since hire date. |
| Certified Nursing Assistant #2 | CNA | Not aware of responsibility to take hydration cart to kitchen for cleaning. |
Inspection Report
Routine
Census: 117
Deficiencies: 0
Jul 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on July 14-15, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Mar 12, 2020
Visit Reason
An abbreviated / Partial Extended Survey was conducted to investigate GA00202738 and GA00202799.
Findings
Both investigations GA00202738 and GA00202799 were unsubstantiated with no deficiencies found.
Inspection Report
Deficiencies: 0
Mar 11, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Life Care Center in Fitzgerald, GA, related to a regulatory inspection completed on 03/11/2020.
Findings
The report contains initial comments and a summary statement of deficiencies but does not provide specific details or findings within the provided page.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Mar 11, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/2/2020 Complaint Survey.
Findings
All deficiencies cited as a result of the 1/2/2020 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 1/2/2020; all cited deficiencies were corrected.
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 1
Jan 2, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple allegations (GA#00199107, GA#00200949, and GA#00201334) related to accident hazards and other concerns.
Findings
The facility failed to maintain comfortable temperature levels within six of 102 resident rooms on three of four units, four of five shower rooms, and one of five dining rooms. Temperatures were frequently observed in the 50s and 60s Fahrenheit, below the acceptable range of 71 to 81 degrees Fahrenheit. Residents and staff confirmed discomfort due to cold temperatures, and maintenance logs showed inconsistent temperature monitoring and unresolved thermostat issues.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure temperatures were maintained within a comfortable range in resident rooms, shower rooms, and dining rooms. |
Report Facts
Resident rooms with temperature issues: 6
Shower rooms with temperature issues: 4
Dining rooms with temperature issues: 1
Facility census: 112
Temperature range: 71
Temperature range: 81
Observed temperatures: 57.4
Observed temperatures: 69.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Reported temperature inconsistencies on East Hall and maintenance notification procedures |
| Housekeeper BB | Housekeeper | Reported noticing cold temperatures on lower part of East Hall |
| CNA DD | Certified Nursing Assistant | Reported cold temperatures on lower East Hall and use of heater in shower |
| Head of Maintenance | Provided temperature readings, confirmed thermostat issues, and maintenance log practices |
Inspection Report
Renewal
Deficiencies: 0
Jan 2, 2020
Visit Reason
The inspection was conducted as a licensure survey to determine compliance with State Long Term Care Requirements.
Findings
No State Health Deficiencies were cited during the licensure survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 1, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a prior complaint survey conducted on 2019-05-08.
Findings
All deficiencies cited as a result of the complaint survey conducted on 2019-05-08 were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey; all prior deficiencies were corrected.
Report Facts
Survey dates: May 8, 2019
Survey dates: Jul 1, 2019
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 26, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00197627.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.
Complaint Details
The complaint was substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 7, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00194377.
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 GA00194377 was investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 10, 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 deficiencies had been corrected during this follow-up visit.
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 13, 2018
Visit Reason
A Revisit Survey was conducted at Life Care Center on 12/13/18 in conjunction with a complaint investigation (Complaint Intake Number GA00193110).
Findings
All deficiencies cited as a result of the standard survey on 9/13/18 were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies found.
Complaint Details
Complaint Intake Number GA00193110 was investigated and found unsubstantiated with no deficiencies.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Dec 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 9/13/18 recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 107
Deficiencies: 0
Dec 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/23/18 complaint survey.
Findings
All deficiencies cited as a result of the 10/23/18 complaint survey were found to be corrected.
Inspection Report
Re-Inspection
Deficiencies: 9
Nov 19, 2018
Visit Reason
A Life Safety Code (LSC) Revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility failed to properly maintain multiple life safety and fire safety features including exits, door locking systems, exit signage, interior finishes, fire alarm system, corridor doors, smoke/fire barriers, electrical systems, and staff fire drill training. These deficiencies could place residents and staff at risk in the event of fire.
Severity Breakdown
D: 1
F: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to properly maintain 1 exit; exit ramp lacked approved guardrails and handrails. | D |
| Failed to properly maintain door locking systems; staff unable to open wood exit gate in smoking recreation area. | F |
| Failed to properly maintain exit lighting and signs; exit lights not working in battery backup mode. | F |
| Failed to properly maintain interior wall and ceiling finishes; damaged paneling not meeting Class C rating in multiple areas. | F |
| Failed to properly maintain fire alarm system; panel in trouble, strobes improperly mounted. | F |
| Failed to properly maintain corridor doors; door to Room W-22 will not close and latch properly. | F |
| Failed to properly maintain 8 of 8 smoke/fire barriers; barriers inaccessible and improperly sealed wiring conduits. | F |
| Failed to properly maintain electrical systems; missing junction box cover, unlabeled breakers, improper use of adapters. | F |
| Failed to properly train staff in fire drill procedures; multiple drills showed staff scored 25% or less with no documented inservice training. | F |
Report Facts
Fire drill score: 25
Number of smoke/fire barriers not properly maintained: 8
Number of staff unable to open exit gate: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff M accompanied the surveyor during the tour and confirmed multiple findings. |
Inspection Report
Life Safety
Census: 106
Capacity: 167
Deficiencies: 16
Sep 11, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including means of egress, door locking systems, emergency lighting, exit signage, hazardous area enclosures, cooking facilities maintenance, interior finishes, fire alarm system maintenance, sprinkler system installation and maintenance, portable fire extinguisher maintenance, corridor door functionality, smoke barrier maintenance, electrical system safety, fire drill training, and oxygen cylinder storage.
Severity Breakdown
SS= D: 4
SS= E: 1
SS= F: 10
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to provide approved guard rails at exits; exit at landing/ramp to recreation/smoking area lacked guardrails and handrails. | SS= D |
| Failed to properly maintain door locking systems; multiple doors had slide bolts and staff unaware of door codes. | SS= F |
| Failed to properly maintain emergency lighting; multiple emergency lights not operable or not tested monthly. | SS= F |
| Failed to properly test and maintain exit lighting; no monthly testing documented and several exit signs not working. | SS= F |
| Failed to properly maintain doors to hazardous areas; doors would not close and latch, combustible storage in crawl space not fire separated. | SS= F |
| Failed to properly maintain kitchen hood exhaust system; hood cleaning not properly documented and grease buildup observed. | SS= F |
| Failed to properly maintain interior wall and ceiling finishes; damaged paneling and spray foam not meeting Class C rating. | SS= F |
| Failed to properly maintain fire alarm system; panel in trouble, strobes improperly mounted. | SS= F |
| Failed to properly maintain sprinkler system; no sprinkler protection in Room E-1 restroom. | SS= D |
| Failed to properly maintain sprinkler system; no hydraulic data plates, sprinkler piping supporting external loads. | SS= F |
| Failed to properly maintain portable fire extinguishers; extinguishers not mounted and not inspected monthly. | SS= E |
| Failed to properly maintain corridor doors; doors not closing and latching, some doors not smoke tight. | SS= F |
| Failed to properly maintain smoke/fire barriers; no access for inspection and penetrations not properly sealed. | SS= F |
| Failed to properly maintain electrical systems; multiple electrical safety violations including unapproved adapters, missing covers, and unsecured outlets. | SS= F |
| Failed to properly train staff in fire drill procedures; multiple fire drills showed staff scored 25% or less and no documented inservice training. | SS= F |
| Failed to properly store oxygen cylinders; storage room not properly labeled with required caution sign. | SS= D |
Report Facts
Residents at risk due to guardrail deficiency: 40
Census: 106
Total licensed capacity: 167
Fire drill staff score: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during facility tour and interviews. |
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Aug 6, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the abbreviated survey on July 11, 2018.
Findings
All deficiencies cited in the previous abbreviated survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 23, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00189897 from 7/10/18 to 7/23/18.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was partially substantiated but no deficiencies were cited.
Complaint Details
The complaint was partially substantiated.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
Jul 11, 2018
Visit Reason
A revisit survey was conducted in conjunction with a Complaint survey to verify correction of deficiencies cited in the May 31, 2018 Complaint Survey.
Findings
All deficiencies cited as a result of the May 31, 2018 Complaint Survey were found to be corrected.
Complaint Details
The revisit survey was conducted in conjunction with a Complaint survey; all prior deficiencies were corrected.
Report Facts
Census: 116
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 15, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00189282.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was partially substantiated but no deficiencies were cited.
Complaint Details
The complaint was partially substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 7, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate allegations identified as GA00188148 and GA00187457.
Findings
The investigations for GA00187457 and GA00188148 were unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigations GA00187457 and GA00188148 were unsubstantiated due to lack of sufficient evidence.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 26, 2018
Visit Reason
A Revisit Survey was conducted on 3/26/18 in conjunction with the investigation of Complaint Intake Number GA00186421 to verify correction of deficiencies cited in the prior complaint survey of 2/22/18.
Findings
All deficiencies cited as a result of the complaint survey of 2/22/18 were found to be corrected. The complaint investigation found GA00186421 unsubstantiated with no deficiencies.
Complaint Details
Complaint Intake Number GA00186421 was investigated and found unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00186421 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00186421 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 22, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA0185281 from February 16, 2018 to February 22, 2018.
Findings
The complaint was unsubstantiated but deficiencies were found related to inaccurate staging of pressure ulcers for two residents. The facility failed to correctly stage pressure ulcers, including misclassifying a pressure ulcer covered with tan slough as Stage II and continuing to assess an open wound as a suspected deep tissue injury (DTI).
Complaint Details
Complaint #GA0185281 was investigated and found to be unsubstantiated, but deficiencies related to pressure ulcer staging were identified.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to accurately stage a pressure ulcer for Resident #2, who had a pressure ulcer covered with tan slough but was documented as Stage II. | Level D |
| Failure to accurately stage a pressure ulcer for Resident #3, who had a pressure ulcer initially identified as a suspected deep tissue injury (SDTI) that opened, but continued to be assessed as a DTI despite the presence of an open wound bed. | Level D |
Report Facts
Dates of pressure ulcer assessments: Resident #2 pressure ulcer documented on 1/22/18, 2/1/18, 2/8/18, and 2/12/18
Pressure ulcer measurement: 1.5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 4, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00183606.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was substantiated but no deficiencies were cited.
Complaint Details
The complaint was substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 5, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00182584.
Findings
The complaint was unsubstantiated following the investigation.
Complaint Details
Complaint GA00182584 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 20, 2017
Visit Reason
A revisit survey was conducted on 9/14/17 for the Recertification survey of 8/3/17 to verify correction of previously cited deficiencies.
Findings
The revisit survey revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 9/8/17.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 13, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as of the follow-up survey date.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180928 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00180928 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180530 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00180530 was investigated and found to have no deficiencies.
Inspection Report
Life Safety
Census: 105
Capacity: 167
Deficiencies: 12
Sep 18, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with egress doors, ramps and exits, emergency lighting, hazardous area enclosures, cooking facilities, sprinkler system maintenance, corridor doors, smoke barriers, electrical system, and storage of flammable liquids and gas cylinders.
Severity Breakdown
E: 5
F: 1
D: 6
Deficiencies (12)
| Description | Severity |
|---|---|
| Doors in required means of egress had multiple or unapproved locking devices, including slidebolts and padlocks not accessible from inside. | E |
| Exterior landings and ramps greater than 30 inches above grade lacked code compliant guards and handrails were not continually graspable. | F |
| Emergency lighting was not operational in multiple areas including east dining room and exterior locations. | E |
| Hazardous areas such as janitor closets, laundry, housekeeping supply, and kitchen dry storage were not properly enclosed or smoke tight. | E |
| Cooking equipment suppression system piping was not properly aimed and appliances were not properly positioned under the hood. | D |
| Sprinkler system piping was not properly supported and maintained smoke tight in some areas. | D |
| Corridor doors to resident rooms were not closing and latching properly. | E |
| Smoke doors were not maintained smoke tight; South A Hall corridor door gap exceeded 1/8 inch. | D |
| Smoke barrier penetrations at South B Hall were not protected with a listed fire stop system. | D |
| Electrical system deficiencies included missing cover plates, inadequate clearance at electrical panels, unlabeled circuits, unapproved wiring, and cords run through doors. | D |
| Flammable liquids (six 5-gallon gasoline cans) were improperly stored inside the building. | D |
| Oxygen cylinders at the south nurses station were not labeled as full or empty. | D |
Report Facts
Census: 105
Total Capacity: 167
Number of gasoline cans: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00178021 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00178021 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Census: 105
Deficiencies: 0
Jun 1, 2017
Visit Reason
A Revisit Survey was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies cited in the prior inspection had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 4, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00173084 and #GA00173315 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The visit was complaint-related, investigating two complaints (#GA00173084 and #GA00173315), and no deficiencies were found.
Inspection Report
Routine
Deficiencies: 7
Mar 17, 2017
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal regulations related to resident care, safety, infection control, and facility administration.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident privacy during care, inadequate care plan revisions following elopements and falls, insufficient professional care for residents with mental health needs, ineffective pest control program with roach infestations, incomplete nursing assistant competency and training, incomplete resident bathing documentation, and ineffective quality assurance processes.
Severity Breakdown
D: 3
K: 2
F: 1
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure personal privacy for residents during wound and incontinent care, exposing residents' nude bodies to hallway traffic and roommates. | D |
| Failure to revise care plans after resident elopements and falls to include appropriate interventions. | K |
| Failure to provide appropriate treatment and services for a resident with mental disorder and psychosocial adjustment difficulties, placing resident at risk for harm. | D |
| Failure to maintain an effective pest control program, evidenced by live and dead roaches found throughout the facility. | F |
| Failure to ensure nurse aides demonstrate competency and receive required annual inservice training. | E |
| Failure to maintain complete and accurate resident medical records, including documentation of bathing assistance. | D |
| Failure to maintain an effective quality assurance program that addresses elopements, falls, care plan revisions, and pest control. | K |
Report Facts
Performance evaluation missing: 2
Inservice training hours: 9
Resident elopement risk score: 5
Resident fall risk score: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA XX | Certified Nursing Assistant | Observed failing to change gloves and wash hands during incontinent care |
| CNA KK | Certified Nursing Assistant | Observed providing incontinent care without privacy curtain and poor infection control |
| CNA II | Certified Nursing Assistant | Observed placing soiled linens on floor and poor infection control |
| CNA YY | Certified Nursing Assistant | Reported resident self-injurious behavior and had insufficient inservice training |
| Administrator | Interviewed regarding elopement investigations, pest control, QA program, and staff training deficiencies | |
| Director of Nursing | DON | Interviewed regarding care plan revisions, infection control, QA program, and staff competency |
| LPN AA | Licensed Practical Nurse | Interviewed regarding resident care, infection control, and staff training |
| Housekeeping Supervisor FF | Housekeeping Supervisor | Interviewed regarding pest control procedures and cleaning schedules |
| Food Service Supervisor | Interviewed regarding pest control in kitchen and food storage areas |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted from 3/1/17 through 3/3/17.
Complaint Details
The survey was conducted in response to complaints GA00172039, GA00169712, and GA172150. No deficiencies were found.
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