Inspection Reports for Lumber City Nursing & Rehabilitation Center
93 HIGHWAY 19, LUMBER CITY, GA, 31549
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 31, 2022, cited one deficiency related to a substantiated complaint, while two other complaints investigated at that time were unsubstantiated. Earlier inspections showed a mix of results, including a period in early 2020 when multiple deficiencies were cited involving resident care, infection control, dietary management, and notification procedures, as well as some life safety code issues related to fire alarm and sprinkler maintenance. Complaint investigations were mostly unsubstantiated except for the one in March 2022 and two substantiated complaints in March 2020, which led to several cited deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed many prior deficiencies over time, with fewer issues noted in the most recent inspection compared to earlier years.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
61 residents
Based on a March 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 1
Date: Mar 31, 2022
Visit Reason
A licensure survey was conducted from March 29, 2022 through March 31, 2022, including investigation of three complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00219146 and GA00219123 were unsubstantiated; GA00216764 was substantiated with a deficiency cited.
Findings
Two complaints were found to be unsubstantiated, one complaint was substantiated with a deficiency cited, and no State health deficiencies were cited.
Deficiencies (1)
Deficiency cited related to substantiated complaint GA00216764
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 17, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00214529 and #GA00214937.
Complaint Details
Complaints #GA00214529 and #GA00214937 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints #GA00214529 and #GA00214937 were found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 3, 2020
Visit Reason
A desk review was conducted to verify that the approved Plan of Correction (POC) was being followed and that previous citations had been corrected.
Findings
All previous citations were found to have been corrected according to the Fire Safety Supervisor's review.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA#00207106.
Complaint Details
Complaint GA#00207106 was investigated and found to be unsubstantiated.
Findings
The complaint GA#00207106 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 50
Deficiencies: 0
Date: Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
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 for COVID-19.
Report Facts
Total census: 50
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A revisit survey was conducted from July 20, 2020 through July 23, 2020 to verify correction of deficiencies cited during the standard survey conducted from March 2, 2020 through March 6, 2020.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 66
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
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, implementing recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 70
Deficiencies: 13
Date: Mar 6, 2020
Visit Reason
A standard survey was conducted from March 2, 2020 through March 6, 2020, including investigation of two substantiated complaints.
Complaint Details
Complaint Intake Numbers GA00202195 and GA00201144 were investigated and both complaints were substantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to obtain required signatures on DNR orders, failure to notify responsible parties of condition changes, incomplete baseline care plans, failure to follow care plans, dietary management deficiencies, food safety violations, infection control lapses, failure to post census on nurse staffing information, failure to notify physician of x-ray results, and failure to provide influenza and pneumococcal vaccinations.
Deficiencies (13)
Failed to obtain two Physician signatures and a Guardian signature for a DNR Provider Orders for one resident.
Failed to promptly notify the responsible party for a change in condition for one resident.
Failed to make information on how to file a grievance or complaint available for five residents.
Failed to ensure baseline care plans were completed and reviewed with residents/family within 48 hours for three residents.
Failed to follow care plan related to potential alterations in cardiac function for one resident.
Failed to follow Physician's order for a 1500 ml fluid restricted diet for one resident.
Failed to ensure infection control practices during wound care for one resident.
Failed to post census information on nurse staffing information on three of four days.
Failed to notify physician of x-ray results for one resident.
Failed to ensure Dietary Manager was certified or had equivalent qualifications.
Failed to ensure food safety including labeling, dating, cleaning of ice machine, dry storage and pantry refrigerator temperature logs.
Failed to ensure proper handwashing and sanitizing during meal service for one hall.
Failed to provide or document influenza and pneumococcal vaccinations offered or given to one resident.
Report Facts
Resident census: 70
Deficiencies cited: 12
Missing refrigerator temperature logs: 16
Expired food items: 2
Juice expiration dates: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff AA | Admission/Marketing Director | Interviewed regarding POLST and advanced directives process |
| Social Service Director BB | Social Service Director | Interviewed regarding POLST and resident code status |
| LPN CC | Licensed Practical Nurse | Interviewed regarding resident code status identification |
| LPN JJ | Licensed Practical Nurse Wound Care Nurse | Observed and interviewed regarding wound care infection control lapses |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage, labeling, and ice machine cleaning |
| Administrator | Facility Administrator | Interviewed regarding dietary staffing, infection control, and vaccine policies |
| CNA FF | Certified Nursing Assistant | Observed and interviewed regarding hand sanitizing during meal delivery |
| Physician II | Physician | Interviewed regarding expectations for notification of x-ray results |
| RN HH | Previous Director of Nursing | Interviewed regarding resident care and x-ray report documentation |
| LPN KKK | Licensed Practical Nurse | Interviewed regarding notification of physician about resident condition |
| Maintenance Director | Maintenance Director | Interviewed regarding ice machine cleaning |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 6, 2020
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations including resident care, infection control, vaccination administration, and notification procedures.
Findings
The facility failed to promptly notify the responsible party of a resident's change in condition, did not follow the care plan for cardiac function assessment, failed to ensure proper infection control during wound care and meal service, and did not provide or document offering influenza and pneumonia vaccines to a resident.
Deficiencies (5)
Failed to promptly notify the responsible party for a change in condition for one resident (R#218).
Failed to follow the care plan related to potential alterations in cardiac function for one resident (R#218).
Failed to ensure infection control practices during wound care for one resident (R#5).
Failed to ensure proper handwashing and sanitizing during meal service for one of three halls.
Failed to provide vaccination against influenza or pneumonia and failed to provide evidence that the resident was offered these vaccines for one resident (R#5).
Report Facts
Residents reviewed for change in condition: 33
Residents reviewed for care plans: 33
Residents reviewed for wound care: 3
Residents reviewed for vaccines: 5
Lunch trays observed on 100 Hall: 12
Lunch trays with improper sanitizing: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse (LPN) Wound Care Nurse | Named in infection control deficiency related to wound care practices |
| FF | Certified Nursing Assistant (CNA) | Named in infection control deficiency related to improper hand sanitizing during meal service |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for notification, care plan adherence, and infection control |
| Administrator | Facility Administrator | Interviewed regarding expectations for hand sanitizing and vaccine administration |
Inspection Report
Life Safety
Census: 70
Capacity: 86
Deficiencies: 2
Date: Mar 3, 2020
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to deficiencies in the fire alarm system notification signals and maintenance of automatic sprinkler heads, including a trouble signal on the fire alarm panel and rust on a sprinkler head in the kitchen cooler.
Deficiencies (2)
Fire alarm panel notification signals were not in operating condition, indicated by a trouble signal on the main fire alarm panel.
Automatic sprinkler heads were not properly maintained, evidenced by rust on a sprinkler head located in the cooler in the kitchen.
Report Facts
Census: 70
Total Capacity: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm trouble signal and sprinkler head rust during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 18, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00196727.
Complaint Details
Complaint GA00196727 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: Nov 2, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies from the annual survey conducted on August 28-30, 2018.
Findings
All deficiencies resulting from the prior annual survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 19, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 68
Deficiencies: 3
Date: Aug 30, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations at Lumber City Nursing & Rehabilitation Center from August 27 through August 30, 2018.
Findings
The facility was found not in substantial compliance with federal regulations related to resident mobility and range of motion, failure to provide restorative nursing programs after skilled therapy discontinuation, and improper assessment and consent for bedrail use. Additionally, bedrails were not regularly inspected for safety and maintenance.
Deficiencies (3)
Failure to provide restorative nursing programs to maintain or improve mobility for residents after discontinuation of skilled therapy services.
Failure to assess residents for risk of entrapment from bed rails, obtain informed consent, and attempt alternatives prior to bedrail use for two residents.
Failure to conduct regular inspections of bed frames, mattresses, and bed rails to identify areas of possible entrapment and ensure compatibility.
Report Facts
Resident census: 68
Fall risk score: 12
Fall risk score: 10
Bedrail gap measurement: 3.5
Maximum allowable bedrail gap: 4.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of restorative nursing program and bedrail policies | |
| Therapy Director | Interviewed regarding discontinuation of restorative nursing program and therapy services | |
| PT Assistant | Interviewed regarding therapy services provided to residents | |
| Certified Nursing Assistant (CNA) | Interviewed regarding care provided to residents and ROM services | |
| Maintenance Director | Interviewed regarding bedrail maintenance and safety inspections |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Aug 30, 2018
Visit Reason
Licensure survey conducted from August 27, 2018 through August 30, 2018 to determine compliance with State Long Term Care Requirements.
Findings
No State health deficiencies were cited during the licensure survey.
Inspection Report
Life Safety
Census: 68
Capacity: 86
Deficiencies: 1
Date: Aug 27, 2018
Visit Reason
The visit was a Life Safety Code survey conducted to assess compliance with fire safety requirements under 42 CFR subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to protect hazardous areas with smoke rated partitions and self-closing doors, specifically the medical records office being used as a storage room without a self-closing door, placing 25 residents at risk in the event of fire.
Deficiencies (1)
Facility failed to protect hazardous areas with smoke rated partitions and doors with self-closing devices, including the medical records office used as storage without a self-closing door.
Report Facts
Residents at risk: 25
Census: 68
Total capacity: 86
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 0
Date: Aug 24, 2017
Visit Reason
A standard survey was conducted at Lumber City Nursing and Rehabilitation from August 21, 2017 through August 24, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be 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: 74
Capacity: 86
Deficiencies: 0
Date: Aug 21, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements for participation in Medicare/Medicaid.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 8, 2017
Visit Reason
A Desk Review Revisit was conducted on 6/8/17 to the complaint investigation of 4/14/17.
Complaint Details
The revisit was related to a complaint investigation dated 4/14/17.
Findings
It was determined that all previously cited deficiencies were corrected.
Inspection Report
Abbreviated Survey
Census: 79
Deficiencies: 1
Date: Apr 14, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00173836 and assess compliance with Federal and State Long Term Care regulations.
Complaint Details
The complaint was unsubstantiated and no deficiencies were written related to the complaint.
Findings
The complaint was unsubstantiated with no deficiencies related to it; however, the facility was found to have insufficient nursing hours per patient day on multiple days, failing to meet the minimum 2.5 hours ratio required.
Deficiencies (1)
Facility failed to have adequate nursing hours per patient per day for eight of fourteen days and for five days of an additional fourteen day period, with nursing hours per patient day below the minimum 2.5 ratio on specified dates.
Report Facts
Nursing hours per patient day: 2.28
Nursing hours per patient day: 2.4
Nursing hours per patient day: 2
Nursing hours per patient day: 2.3
Nursing hours per patient day: 2
Nursing hours per patient day: 2.44
Nursing hours per patient day: 2.3
Nursing hours per patient day: 2.4
Nursing hours per patient day: 2.37
Nursing hours per patient day: 2.3
Facility census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding CNA shortage and staffing | |
| Director of Nursing | Interviewed regarding CNA shortage and staffing |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Date: Apr 7, 2017
Visit Reason
A complaint survey was conducted at Lumber City Nursing and Rehabilitation Center on April 7, 2017.
Complaint Details
Complaint survey was unsubstantiated with no deficiencies.
Findings
The complaint survey was unsubstantiated with no deficiencies found at the facility.
Report Facts
Facility census: 81
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