Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Deficiencies: 0
Apr 17, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 0
Apr 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 16, 2025 Recertification Survey.
Findings
All deficiencies cited in the prior February 16, 2025 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 1, 2025
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 visit.
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 16, 2025
Visit Reason
A State Licensure survey was conducted at The Lodge from February 14, 2025, through February 16, 2025, to assess compliance with state health and safety regulations.
Findings
The survey revealed deficiencies related to infection control practices including improper covering and labeling of resident personal care items, inadequate disinfection during medication administration, and failure to discard expired food items and properly store kitchen equipment. These deficiencies posed risks for infection spread and foodborne illnesses.
Deficiencies (2)
| Description |
|---|
| Facility failed to properly cover resident personal care items when not in use on two of four halls and ensure infection control during medication administration for three residents. |
| Facility failed to discard food by expiration date, label and date leftovers, and store dishwasher crates off the floor, risking foodborne illness for 67 of 73 residents receiving an oral diet. |
Report Facts
Residents receiving oral diet: 67
Total residents: 73
Expired food items: 7
Dish crates stored on floor: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Certified Nurse Assistant (CNA) | Stated urinals should not be in the sink and should be bagged and labeled |
| AA | Unit Manager (UM)/Licensed Practical Nurse (LPN) | Verified bath basins were not bagged or labeled and confirmed expectations for PPE removal and cleaning procedures |
| BB | Licensed Practical Nurse (LPN) | Observed not disinfecting blood pressure cuffs between residents and improper PPE removal |
| Director of Nursing (DON) | Director of Nursing | Stated expectations for infection control practices including PPE removal and cleaning of equipment |
| ADM | Assistant Dietary Manager | Confirmed findings related to expired food and improper storage |
| DM | Dietary Manager | Confirmed dietary staff responsibilities and expectations for food safety compliance |
Inspection Report
Routine
Census: 106
Deficiencies: 2
Feb 16, 2025
Visit Reason
A standard survey was conducted at The Lodge from February 14, 2025, through February 16, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with regulations related to food safety practices, infection control, and medication administration. Deficiencies included failure to discard expired food, improper storage of food items, inadequate infection control practices such as uncovered personal care items and improper PPE use, and failure to disinfect equipment between residents.
Severity Breakdown
F: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to discard food by expiration date, label and date leftovers, and store dishwasher crates off the floor, risking foodborne illness for 67 of 73 residents receiving oral diets. | F |
| Failure to properly cover resident personal care items and ensure infection control during medication administration for three of five residents, risking spread of infection. | E |
Report Facts
Residents receiving oral diet: 67
Residents receiving oral diet total: 73
Facility census: 106
Expired food items: 7
Dish crates stored on floor: 4
Resident personal care items uncovered: 4
Residents observed for medication administration: 5
Residents with infection control deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed failing to disinfect blood pressure cuff between residents and improper PPE removal during medication administration |
| ADM | Assistant Dietary Manager | Confirmed findings related to food storage and labeling deficiencies |
| DM | Dietary Manager | Confirmed food safety policy expectations and acknowledged deficiencies |
| CNA CC | Certified Nurse Assistant | Stated urinals should be bagged and labeled |
| UM/LPN AA | Unit Manager / Licensed Practical Nurse | Verified uncovered personal care items and improper PPE removal; confirmed blood pressure cuff disinfection expectations |
| DON | Director of Nursing | Stated expectations for personal care item storage, PPE removal, and PICC line cleaning |
Inspection Report
Life Safety
Census: 75
Capacity: 160
Deficiencies: 5
Feb 15, 2025
Visit Reason
The visit was a 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 vertical openings enclosure, missing escutcheon plates on sprinkler heads, corroded sprinkler heads in laundry and kitchen, presence of prohibited portable space heaters, and use of extension cords as permanent wiring.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Hole in the ceiling in a storage room near the riser room allowing smoke migration. | SS= D |
| Missing escutcheon plates on multiple sprinkler heads throughout the facility allowing smoke migration. | SS= D |
| Corroded sprinkler heads in the laundry and kitchen which can cause sprinkler malfunction. | SS= D |
| Presence of a portable space heater under the nurse's station desk, prohibited in healthcare occupancies. | SS= D |
| Use of an extension cord as permanent wiring for the check-in kiosk. | SS= D |
Report Facts
Residents affected: 15
Residents affected: 10
Residents affected: 10
Residents affected: 5
Residents affected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 2/15/2025 |
Inspection Report
Plan of Correction
Census: 79
Deficiencies: 0
Dec 12, 2024
Visit Reason
A Desk Review survey was conducted to verify correction of deficiencies cited during the October 24, 2024 Complaint Survey.
Findings
All deficiencies cited as a result of the October 24, 2024 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on October 24, 2024; all cited deficiencies were corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 24, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint intake number GA00251062, initiated on October 2, 2024, and concluded on October 24, 2024.
Findings
The facility failed to report an injury of unknown origin, specifically left acute distal tibial and fibular fractures, within the required time frame for one of three sampled residents. The complaint was substantiated with deficiencies related to delayed reporting of the fracture.
Complaint Details
Complaint intake number GA00251062 was substantiated with deficiencies related to delayed reporting of fractures for resident R3.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin, specifically left acute distal tibial and fibular fractures, within the required time frame for one resident. | SS= D |
Report Facts
Complaint intake number: 1
Number of sampled residents with deficiency: 1
Dates related to injury and reporting: X-ray dated 2024-06-14, fracture incident dated 2024-06-20, report to State Survey Agency dated 2024-06-21
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
May 23, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by their codes GA00237482, GA00238307, GA00239252, GA00241045, and GA00241111.
Findings
The complaints investigated were found to be unsubstantiated, and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00237482, GA00238307, GA00239252, GA00241045, and GA00241111 were investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 14, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 82
Deficiencies: 0
Dec 14, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/20/2022 Recertification Survey.
Findings
All deficiencies cited as a result of the 10/20/2022 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 9, 2022
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 noted by the follow-up survey.
Inspection Report
Routine
Census: 88
Deficiencies: 2
Oct 20, 2022
Visit Reason
A standard survey was conducted from 10/18/22 through 10/20/22, including investigation of Complaint Intake Numbers GA00228799 and GA00227900, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility failed to maintain proper food safety standards, including holding hot food items above 135 degrees and removing expired or unlabeled food from the kitchen cooler. These deficiencies potentially affected 79 of 88 residents receiving regular or mechanical soft diets.
Complaint Details
Complaint Intake Numbers GA00228799 and GA00227900 were investigated in conjunction with the standard survey.
Severity Breakdown
F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure all hot food items were held above 135 degrees on the steam table to prevent food borne illness. | F |
| Failed to remove expired foods from the cooler and ensure all food was labeled and dated. | F |
Report Facts
Resident census: 88
Food temperature: 130
Food temperature: 125
Food temperature: 130
Food temperature: 124
Food temperature: 130
Food temperature: 134
Food temperature: 135
Food temperature: 142
Food temperature: 135
Expired food items: 3
Residents potentially affected: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed expired and unlabeled foods and food temperatures during observation and interview |
| Administrator | Administrator | Interviewed regarding lack of systems to ensure proper food temperatures and discard expired food |
Inspection Report
Original Licensing
Deficiencies: 4
Oct 19, 2022
Visit Reason
A Licensure Survey was conducted from 10/18/22 through 10/20/22 to assess compliance with physical plant standards and food safety regulations.
Findings
The facility failed to maintain hot food items at or above 135 degrees on the steam table and did not remove expired or unlabeled food items from the main kitchen cooler, posing a risk of foodborne illness to residents.
Deficiencies (4)
| Description |
|---|
| Hot food items were not held above 135 degrees on the steam table to prevent food borne illness. |
| Expired foods were stored in the main kitchen cooler beyond their expiration dates. |
| Food items in the cooler were not labeled or dated as required. |
| Spoiled food items, including wilted lettuce and discolored cabbage, were stored in the cooler. |
Report Facts
Residents potentially affected: 79
Total residents: 88
Food temperature readings: 130
Food temperature readings: 125
Food temperature readings: 130
Food temperature readings: 124
Food temperature readings: 130
Food temperature readings after reheating: 134
Food temperature readings after reheating: 135
Food temperature readings after reheating: 142
Food temperature readings after reheating: 135
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed expired and unlabeled foods and food temperatures during observation and interview |
| Administrator | Administrator | Interviewed regarding lack of systems to ensure proper food temperatures and removal of expired foods |
Inspection Report
Life Safety
Census: 88
Capacity: 106
Deficiencies: 10
Oct 18, 2022
Visit Reason
A Life Safety Code Survey was 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 code requirements, including issues with smoke doors not closing properly, fire alarm system battery marking, sprinkler system maintenance, patient door latching, sealing of penetrations, electrical installations, and oxygen cylinder security.
Severity Breakdown
D: 6
E: 3
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Smoke doors failed to latch properly in 2 of 4 smoke compartments. | D |
| Fire alarm control panel (FACP) batteries were not marked with manufacturing month and year. | D |
| Sprinkler system was yellow tagged indicating maintenance/testing issues. | F |
| Sprinkler heads missing escutcheon rings in attic and main electrical room. | E |
| Patient room doors in rooms 102, 106, 108 failed to latch. | E |
| Facility failed to properly seal penetrations in mechanical room 500, dryer room access, and main electrical room with incorrect foam materials. | E |
| Improper installation of multi tap in 500 hall nursing station; multi tap was on the floor. | D |
| Panel boxes in life enrichment storage room were blocked by storage. | D |
| Two switches in main electrical room were missing covers. | D |
| Two oxygen cylinders were not secured in therapy storage room. | D |
Report Facts
Smoke doors failed to latch: 800
Certified beds: 106
Census: 88
Sprinkler heads missing escutcheon rings: 2
Oxygen cylinders unsecured: 2
Patient room doors failed to latch: 3
Switches missing covers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Deficiencies: 1
Jul 25, 2022
Visit Reason
The inspection was conducted to evaluate 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 seven-day period from 07/18/2022 to 07/24/2022 as required by regulation, 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 COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period. | F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Sep 14, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction following a facility survey conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 0
Sep 14, 2021
Visit Reason
A revisit survey was conducted on 9/13/21 through 9/14/21 to verify correction of deficiencies cited in the 6/24/21 Standard Survey.
Findings
All deficiencies cited as a result of the 6/24/21 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 0
Sep 14, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00217498.
Findings
The complaint was unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint #GA00217498 was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 18, 2021
Visit Reason
A Follow-Up Survey (Desk Review) was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 73
Capacity: 106
Deficiencies: 9
Jun 28, 2021
Visit Reason
The Life Safety Code Survey was 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 corridor obstructions, missing door closers, improper sealing of rated rooms and ceilings, lack of flame spread rating for wooden cubicles, sprinkler system maintenance issues such as sprinkler heads obstructed or covered by foam, missing escutcheon plates, and inadequate clearance around electrical panel boxes.
Severity Breakdown
E: 6
F: 2
D: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Corridors were obstructed with patients' medical equipment and patient lifts, affecting two smoke compartments. | E |
| Doors in the attic area and records room missing self-closing devices. | E |
| Improper sealing of fire rated rooms using spray foam in the outside panel room. | E |
| Improper sealing of penetrations in rated ceilings in the panel room with fire alarm panel. | E |
| Failure to provide flame spread rating for wooden cubicles installed in the facility. | E |
| Foam insulation covering or obstructing 30 to 35% of sprinkler heads in the attic. | F |
| Missing escutcheon plate on sprinkler head in storage room. | F |
| Sprinkler head flow obstructed by light fixtures in private dining area affecting two sprinkler heads. | E |
| Inadequate clearance around electrical panel boxes due to storage being too close, affecting two panel rooms. | D |
Report Facts
Census: 73
Total Capacity: 106
Percentage of sprinkler heads obstructed: 30
Number of sprinkler heads obstructed by light fixtures: 2
Number of panel rooms with inadequate clearance: 2
Number of smoke compartments affected by corridor obstruction: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Routine
Census: 65
Deficiencies: 1
Jun 24, 2021
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, specifically failing to follow Transmission Based Precautions (TBP) related to wearing appropriate Personal Protective Equipment (PPE) for new admission residents on isolation precautions in two rooms on the 400 Hall Isolation Unit.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow Transmission Based Precautions (TBP) by not wearing full PPE (gown, gloves, face shield) when providing care to residents on isolation precautions. | D |
Report Facts
Resident census: 65
Rooms on isolation unit: 7
Rooms with PPE noncompliance: 2
Quarantine period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed and interviewed regarding failure to wear full PPE as required for residents on isolation precautions |
| CNA BB | Certified Nursing Assistant | Observed and interviewed regarding failure to wear full PPE as required for residents on isolation precautions |
| Infection Control Preventionist | Interviewed regarding PPE requirements and isolation protocols | |
| Director of Nursing | Interviewed regarding PPE requirements and quarantine policies | |
| Administrator | Interviewed regarding PPE requirements for residents on Transmission Based Precautions |
Inspection Report
Renewal
Deficiencies: 1
Jun 21, 2021
Visit Reason
A Licensure Survey was conducted from 6/21/2021 through 6/24/2021 to assess compliance with licensure requirements.
Findings
The facility failed to follow Transmission Based Precautions related to wearing appropriate Personal Protective Equipment (PPE) for new admission residents on isolation precautions in two of seven rooms on the 400 Hall Isolation Unit. Staff were observed not donning required PPE including gowns, gloves, and face shields when providing care or delivering meals to residents on enhanced barrier precautions.
Deficiencies (1)
| Description |
|---|
| Failure to follow Transmission Based Precautions by not wearing required PPE (gown, gloves, face shield) when caring for residents on isolation precautions in rooms 408 and 412. |
Report Facts
Survey duration: 4
Number of rooms with PPE noncompliance: 2
Quarantine period: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed and interviewed regarding failure to wear full PPE when caring for residents on isolation precautions |
| CNA BB | Certified Nursing Assistant | Observed and interviewed regarding failure to wear full PPE when caring for residents on isolation precautions |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed regarding PPE requirements and quarantine protocols |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE requirements and quarantine protocols |
| Administrator | Administrator | Interviewed regarding PPE requirements and quarantine protocols |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 5, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208596.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00208596 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 58
Deficiencies: 0
Jul 7, 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 and §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00193686.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Complaint Details
Complaint GA00193686 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 25, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00192314.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Complaint Details
Complaint GA00192314 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 15, 2018
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 follow-up survey.
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Aug 30, 2018
Visit Reason
A standard survey was conducted at The Lodge from August 28, 2018 through August 30, 2018 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 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 75
Capacity: 106
Deficiencies: 2
Aug 28, 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 sprinkler system standards.
Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code requirements due to failure to provide proper signage on sprinkler system valves and failure to inspect and maintain the fire sprinkler system, including backflow preventer valves, placing residents at risk in the event of a fire.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide identifying signage on the inspector's test and main drain valve on the 2 wet sprinkler risers and on 3 auxiliary drain valves in mechanical closets. | SS=F |
| Failure to inspect, test, and maintain the fire sprinkler system in accordance with NFPA 25, including lack of inspection of backflow preventer valves in the past year. | SS=F |
Report Facts
Census: 75
Total Capacity: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler system deficiencies during inspection and record review |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 19, 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 noted by the surveyor.
Inspection Report
Renewal
Deficiencies: 0
Sep 14, 2017
Visit Reason
A revisit was conducted on 9/14/17 for the recertification survey originally conducted on 8/3/17.
Findings
The desk review revealed that all previously cited deficiencies had been corrected, and the facility was in substantial compliance as of 9/8/17.
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 3
Aug 3, 2017
Visit Reason
A standard annual survey was conducted at The Lodge from July 31, 2017 through August 3, 2017 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Deficiencies included failure to post the most recent State Agency survey results in an accessible location for residents and family without staff assistance, and inaccuracies in resident assessments, including failure to properly code feeding tube status and oral/dental status in Minimum Data Set (MDS) assessments for two residents.
Severity Breakdown
Level C: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to post the most recent State Agency survey results in an area accessible to residents and family members without having to ask staff. | Level C |
| Failure to accurately code the feeding tube status in the MDS assessment for resident #166. | Level D |
| Failure to ensure comprehensive assessment and proper coding of oral/dental status for resident #68 in the MDS assessment. | Level D |
Report Facts
Resident census: 71
Resident sample size: 25
Civil money penalty: 1000
Civil money penalty: 5000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | MDS Coordinator Licensed Practical Nurse (LPN) | Confirmed incorrect coding of feeding tube status in MDS assessment |
| CC | MDS Coordinator Licensed Practical Nurse (LPN) | Confirmed oral dental status did not trigger on annual MDS assessment |
| Unknown | Dietary Manager (DM) | Responsible for completing Section K of the MDS and admitted missing feeding tube coding |
| Unknown | Payroll and Human Resources Assistant | Interviewed regarding accessibility of survey results |
| Unknown | Administrator | Interviewed regarding availability of survey results |
| Unknown | Social Service Director (SSD) | Interviewed regarding dental consult for resident #68 |
Inspection Report
Life Safety
Census: 74
Capacity: 106
Deficiencies: 2
Aug 1, 2017
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 National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to improper exit signage on doors that could be confused as exits and failure to separate hazardous areas with self-closing and latching doors. These deficiencies could place residents at risk in the event of a fire.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not properly identify doors that could be confused as exits with the proper signage. | SS= D |
| Facility failed to separate hazardous areas from the rest of the facility with doors that the self closer did not close and latch. | SS= D |
Report Facts
Census: 74
Total Capacity: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to exit signage and hazardous area door deficiencies during the tour of the facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00162681, GA00166811, and GA00171766 at The Lodge in Warner Robins, GA, to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted by a Registered Nurse on 02/21/2017.
Complaint Details
The visit was complaint-related, investigating three specific complaints, and no deficiencies were found, indicating no substantiated issues.
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