Inspection Reports for Madison Health and Rehab
2036 SOUTH MAIN STREET, MADISON, GA, 30650
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 8, 2025, identified deficiencies that were subsequently corrected by June 25, 2025, as confirmed by revisit surveys. Earlier inspections showed a pattern of issues related to resident privacy, medication storage, and safety hazards such as defective bed controls and fire safety system deficiencies. Complaint investigations from prior years included one substantiated case involving failure to report abuse allegations and investigation results, while most other complaints were unsubstantiated. The facility has not faced fines, immediate jeopardy findings, or license actions according to the available reports. Recent revisit surveys indicate the facility has addressed prior deficiencies, suggesting improvement in compliance over time.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
66 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Madison Health and Rehab, indicating a regulatory inspection was conducted and corrective actions are planned.
Findings
The report contains initial comments and references deficiencies identified during the inspection, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Standard Survey on May 21, 2025.
Findings
All deficiencies cited in the May 21, 2025 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Census: 66
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the Recertification survey concluded on May 21, 2025.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 65
Capacity: 70
Deficiencies: 4
Date: May 21, 2025
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 not in substantial compliance with life safety requirements, with deficiencies including ceiling tile penetrations, fire doors not closing properly, sprinkler system deficiencies, and an electrical panel misalignment.
Deficiencies (4)
Facility failed to ensure that the ceiling tiles had no penetration in the phone room.
Facility failed to ensure that the fire doors closed properly; East Hall Fire Doors did not close properly.
Facility failed to ensure the sprinkler system was in good standing; sprinkler system was yellow tagged with deficiencies.
Facility failed to have electrical panel aligned with the casing; electrical panel had an open space.
Report Facts
Census: 65
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the tour and observations |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 3
Date: May 21, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Madison Health and Rehab from May 19, 2025 through May 21, 2025 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to maintain resident privacy by posting clinical information openly, failure to dispose of expired medical supplies in the medication storage room, and failure to ensure a safe resident environment due to defective bed controls with exposed wires.
Deficiencies (3)
Facility failed to ensure the right to respect, dignity, and privacy by displaying clinical information related to incontinence care and pressure ulcer care openly in the room for one resident.
Facility failed to dispose of expired medical supplies in one medication storage room, potentially placing residents at risk for infection and ineffective treatment.
Facility failed to ensure the resident environment was free from accident hazards; specifically, a defective bed control with exposed wires was present for one resident.
Report Facts
Facility census: 66
Sampled residents: 26
Significant Change Minimum Data Set date: Apr 29, 2025
Quarterly Minimum Data Set date: Apr 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant | Interviewed regarding the sign posted above resident R63's bed |
| BB | Licensed Practical Nurse | Interviewed regarding the sign above resident R63's bed and medication storage room |
| Director of Nursing | Director of Nursing | Interviewed regarding the purpose and policy of signs posted in resident rooms |
| ADON | Assistant Director of Nursing | Interviewed regarding responsibility for medication storage and bed control safety |
| Maintenance | Maintenance Staff | Interviewed regarding safety checks and bed control replacement |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 3
Date: May 21, 2025
Visit Reason
A standard annual survey was conducted at Madison Health and Rehab from May 19, 2025, through May 21, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain resident privacy by posting clinical information openly, failure to ensure a safe resident environment due to defective bed controls with exposed wires, and failure to dispose of expired medical supplies in the medication storage room.
Deficiencies (3)
Failure to ensure the right to respect, dignity, and privacy by displaying clinical information related to incontinence care and pressure ulcer care openly in the room for one resident.
Failure to ensure the resident environment was free from accident hazards due to defective bed control with exposed wires.
Failure to dispose of expired medical supplies in one medication storage room, risking infection and ineffective treatment.
Report Facts
Resident census: 66
Sampled residents: 26
MDS date: Apr 29, 2025
MDS date: Apr 24, 2025
Expired item dates: 201801
Expired item dates: Mar 31, 2025
Expired item dates: Mar 28, 2025
Expired item dates: Apr 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant AA | Certified Nursing Assistant | Interviewed regarding the sign above resident R63's bed |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Interviewed about the sign above resident R63's bed and medication storage room |
| Director of Nursing | Director of Nursing | Interviewed about facility policy on signs above residents' beds |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding bed control wires and expired medication supplies |
| Maintenance | Maintenance Staff | Interviewed about room safety checks and defective equipment |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 18, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by numbers GA00236321, GA00238295, GA00238297, GA00238310, and GA00238796.
Complaint Details
The survey investigated complaint numbers GA00236321, GA00238295, GA00238297, GA00238310, and GA00238796. No deficiencies were found related to these complaints.
Findings
No deficiencies were cited related to the investigated complaints during the survey conducted from 09/11/2023 to 09/18/2023.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Date: May 17, 2023
Visit Reason
A revisit was conducted at Madison Home and Rehab beginning 5/16/2023 through 5/17/2023 to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 5/1/2023.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 15, 2023
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
Routine
Census: 61
Deficiencies: 2
Date: Mar 26, 2023
Visit Reason
The inspection was conducted to assess compliance with dietary service preparation and pharmacy management regulations, including medication orders and stop dates.
Findings
The facility failed to ensure dietary staff followed recipes for preparing pureed foods, affecting seven of 61 residents receiving an oral diet, resulting in poor consistency and potential nutritional compromise. Additionally, the facility did not implement a required stop date for antipsychotic medication for one resident, increasing the risk of adverse consequences.
Deficiencies (2)
Dietary staff did not follow recipes for preparing pureed foods, resulting in soup-like consistency and compromised nutritive value, flavor, or appearance affecting seven residents.
Failure to ensure a stop date was implemented, not to exceed 14 days, for antipsychotic medications for one resident, increasing potential for adverse consequences.
Report Facts
Residents affected: 7
Residents reviewed for unnecessary medications: 6
Medication administrations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Interviewed regarding expectations for following puree food recipes |
| Dietary cook DD | Dietary Cook | Observed preparing pureed foods without following recipes |
| Director of Nursing | Director of Nursing | Interviewed regarding lack of stop date on PRN antipsychotic medication order |
Inspection Report
Routine
Census: 62
Deficiencies: 5
Date: Mar 26, 2023
Visit Reason
A standard survey was conducted at Madison Health and Rehab from 3/24/2023 through 3/26/2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with several regulations including failure to complete background checks for nursing staff, lack of stop dates on antipsychotic medications, improper preparation of pureed foods, inadequate food storage and hygiene practices, and incomplete COVID-19 vaccination among staff.
Deficiencies (5)
Failed to complete background check screening process for two of ten nursing staff reviewed.
Failed to ensure a stop date was implemented, not to exceed 14 days, for antipsychotic medications for one of six residents reviewed.
Failed to ensure dietary staff followed recipes for preparing pureed foods, affecting seven of 61 residents.
Failed to label and date opened food items, ensure male staff cover facial hair, and properly store pans to prevent contamination, affecting 61 of 62 residents.
Failed to ensure 100% of staff providing care were fully vaccinated against COVID-19.
Report Facts
Resident census: 62
Residents affected by pureed food deficiency: 7
Residents affected by food storage and hygiene deficiency: 61
Staff vaccination rate: 100
Completely vaccinated staff: 80
Granted exemptions: 14
Partially vaccinated staff: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Human Resources Staff GG | Interviewed regarding background check process for new nurses | |
| Dietary cook DD | Observed and interviewed regarding preparation of pureed foods and failure to follow recipes | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding lack of stop date on antipsychotic medication order |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding expectations for following puree food recipes |
| Kitchen Manager (KM) | Kitchen Manager | Interviewed regarding food storage, labeling, and hygiene deficiencies |
| Infectious Control Preventionist (ICP) | Infectious Control Preventionist | Interviewed regarding COVID-19 vaccination policy and staff education |
| Certified Nursing Assistant (CNA) AA | Certified Nursing Assistant | Interviewed regarding COVID-19 vaccination status and PPE use |
| Certified Nursing Assistant (CNA) BB | Certified Nursing Assistant | Interviewed regarding COVID-19 vaccination status and PPE use |
| Certified Nursing Assistant (CNA) CC | Certified Nursing Assistant | Interviewed regarding COVID-19 vaccination status and PPE use |
Inspection Report
Life Safety
Census: 62
Capacity: 70
Deficiencies: 4
Date: Mar 25, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructed means of egress, non-functional emergency lighting, inadequate separation of hazardous areas, and improper electrical wiring using an extension cord as permanent wiring.
Deficiencies (4)
Means of egress was obstructed by storage of linen carts, PPE carts, furniture, and containers, blocking full use in case of emergency.
Emergency lighting units were not maintained to be fully functional; specifically, the emergency lighting unit in the kitchen dining area failed to operate when tested.
Hazardous areas were not properly separated from other spaces due to a large section of sheetrock removed in the storage room beside room #121.
Building services electrical systems were not maintained in accordance with NFPA 70; an extension cord was used as permanent wiring for a washing machine.
Report Facts
Census: 62
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/11/2023 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 1/11/2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 1/11/2023 Complaint Survey were found to be corrected.
Report Facts
Census: 60
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
There were no State Health deficiencies cited during the survey conducted from January 10 to January 11, 2023.
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 2
Date: Jan 11, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints, including complaint numbers #GA00223113, #GA00223266, GA#00224238, and #GA00225057.
Complaint Details
Complaint GA#00224238 was substantiated with deficiencies. The investigation found failures in reporting abuse allegations and investigation results to the state survey agency. Other complaints (#GA00223113, #GA00223266, and #GA00225057) were found to be unsubstantiated.
Findings
The facility was found to be in compliance with infection control regulations. Four complaints were investigated; three were unsubstantiated, and one complaint (#GA00224238) was substantiated with deficiencies related to failure to immediately report allegations of abuse and failure to report investigation results to the state survey agency for two residents.
Deficiencies (2)
Failure to immediately report an allegation of abuse to the state survey agency and failure to report the results of abuse investigations for two residents.
Failure to thoroughly investigate an allegation of sexual abuse for one resident.
Report Facts
Resident Census: 64
Complaint Numbers Investigated: 4
Residents Reviewed for Abuse: 3
Residents with Reporting Deficiencies: 2
Residents with Investigation Deficiency: 1
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 0
Date: Oct 25, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC regulations 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 CMS and CDC recommended practices for COVID-19.
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 0
Date: Aug 2, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the June 10, 2021 Recertification Survey.
Findings
All deficiencies cited in the June 10, 2021 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 60
Deficiencies: 3
Date: Jun 10, 2021
Visit Reason
Routine inspection to assess compliance with environmental sanitation, physical plant standards, and food safety regulations at Madison Health and Rehab.
Findings
The facility failed to maintain a safe, clean, and homelike environment, including rust and water damage in bathrooms, stained and bulging ceiling tiles, dirty and cluttered master baths, inadequate privacy curtains in resident rooms, and multiple food safety violations such as unlabeled and improperly thawed food items and unclean kitchen equipment.
Deficiencies (3)
Facility failed to provide a safe, clean, comfortable, homelike environment on one out of two halls and two out of two shower rooms, including rust stains, water damage, stained ceiling tiles, and dirty water fountains.
Privacy curtains did not provide full visual privacy in 11 of 12 rooms on one hall, with gaps up to 67 inches and no staff in-service provided.
Food storage and handling deficiencies including unlabeled and undated frozen meats and pantry items, improperly thawed meats, dirty kitchen equipment, and staff drinks stored with facility foods.
Report Facts
Facility census: 60
Number of rooms with inadequate privacy curtains: 11
Gap measurement in privacy curtains: 67
Number of stained ceiling tiles in room 127: 8
Number of shower curtains in Master Bath 1: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Certified Nursing Assistant (CNA) | Confirmed Master Bath 2 was dirty and described resident bathing assistance |
| BB | Certified Nursing Assistant (CNA) | Reported privacy curtains were not the correct size to provide privacy |
| FF | Floor Tech (FT) | Installed privacy curtains and reported width issues to Administrator |
| GG | CNA Supervisor | Aware of privacy curtain inadequacy but did not provide in-service training |
| Dietary Manager | Confirmed food storage and labeling deficiencies in kitchen | |
| Environmental Service Supervisor (EVS) | Confirmed housekeeping staff maintained master baths but both were dirty and unkept | |
| Maintenance Assistant (MA) | Confirmed water damage and rust stains, and reported resident complaint about privacy curtains | |
| Administrator | Aware of privacy curtain issues but did not initiate staff training or replace curtains |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 4
Date: Jun 10, 2021
Visit Reason
A recertification survey was conducted from June 7 through June 10, 2021, including investigation of Complaint Intake Number GA00213773 which was substantiated with deficiencies.
Complaint Details
Complaint Intake Number GA00213773 was investigated in conjunction with the standard survey and was substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and unclean environment conditions, lack of a qualified dietary manager, food safety violations, and inadequate privacy curtains in resident rooms.
Deficiencies (4)
Facility failed to provide a safe, clean, comfortable, and homelike environment including rust stains, stained and bulging ceiling tiles, dirty water fountains, and unclean master baths.
Facility failed to employ a qualified Dietary Manager as required by regulations.
Facility failed to properly label food items, properly thaw meat, maintain clean equipment, and keep staff drinks separate from facility foods.
Facility failed to ensure privacy curtains provided full visual privacy in 11 of 12 rooms on one hall.
Report Facts
Resident census: 60
Number of stained ceiling tiles: 8
Gap measurement in privacy curtains: 67
Number of rooms with inadequate privacy curtains: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Certified Nursing Assistant (CNA) | Confirmed Master Bath 2 was dirty |
| BB | Certified Nursing Assistant (CNA) | Reported privacy curtains not wide enough to provide privacy in room 127 |
| GG | CNA Supervisor | Aware privacy curtains were inadequate but did not provide in-service training |
| Dietary Manager | Employed without required certification | |
| Administrator | Aware of dietary manager certification requirements and privacy curtain issues | |
| Chief Operating Officer (COO) | Unaware of contract agency options for qualified dietary manager staffing | |
| FF | Floor Tech | Installed privacy curtains and reported width issue to Administrator |
| Environmental Service Supervisor (EVS) | Confirmed privacy curtain width issue and dirty master baths | |
| MA | Maintenance Assistant | Confirmed privacy curtain complaint and measurements |
Inspection Report
Life Safety
Census: 61
Capacity: 70
Deficiencies: 0
Date: Jun 8, 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 to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Inspection Report
Routine
Census: 55
Deficiencies: 0
Date: Jan 5, 2021
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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00199330.
Complaint Details
Complaint #GA00199330 was substantiated with no deficiencies.
Findings
The complaint #GA00199330 was substantiated with no deficiencies found during the survey.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Date: Jul 29, 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 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.
Inspection Report
Routine
Census: 58
Deficiencies: 0
Date: Jun 19, 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 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 related to emergency preparedness and infection control regulations for COVID-19.
Report Facts
Total census: 58
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: May 2, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a 3/13/19 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 3/13/19; deficiencies were corrected and compliance was achieved.
Findings
All deficiencies cited as a result of the 3/13/19 Complaint Survey were found to be corrected and the facility was in substantial compliance as of 4/22/19.
Report Facts
Census: 70
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 2
Date: Mar 13, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00194857, which was partially substantiated for Quality of Life.
Complaint Details
Complaint GA00194857 was partially substantiated for Quality of Life.
Findings
The facility failed to develop individualized person-centered care plans for activities and failed to provide an ongoing program of activities based on resident preferences for three residents reviewed. Observations and interviews revealed residents were not engaged in activities and staff did not provide 1:1 activities or sufficient variety. Care plans lacked measurable goals addressing activity preferences.
Deficiencies (2)
Failed to develop and implement individualized person-centered care plans for activities with measurable objectives and timeframes for three residents.
Failed to provide an ongoing program of activities based on resident preferences for three residents, resulting in lack of engagement and insufficient activity options.
Report Facts
Resident census: 64
Number of residents reviewed: 3
Activity participation counts: 6
Activity participation counts: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant Supervisor AA | Certified Nursing Assistant Supervisor | Stated she helps get residents to activities but does not assist or provide 1:1 activities |
| Social Services Director | Social Services Director | Discussed resident B's requests for different activities and communication with Activity Director |
| Activity Director | Activity Director | Described activity schedule, participation levels, and documentation practices |
| Administrator | Administrator | Stated residents are encouraged to get up and participate in activities and restorative programs |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 13, 2019
Visit Reason
The inspection was conducted to evaluate compliance with nursing care requirements, specifically focusing on the development of individualized person-centered care plans for activities for residents.
Findings
The facility failed to develop individualized person-centered care plans for activities for three residents reviewed, lacking measurable objectives and timeframes to meet residents' individual needs. Observations revealed residents were not engaged in activities and no staff were present during group activities.
Deficiencies (1)
Failure to develop individualized person-centered care plans for activities for three residents, lacking measurable objectives and timeframes.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant Supervisor | Interviewed regarding assistance with resident activities, stated no 1:1 activities are done. | |
| Administrator | Interviewed regarding resident encouragement to participate in activities and restorative programs. |
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Date: Nov 7, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey on 2018-09-16.
Findings
All deficiencies cited as a result of the recertification survey on 2018-09-16 were found to be corrected.
Inspection Report
Life Safety
Census: 68
Capacity: 70
Deficiencies: 0
Date: Sep 6, 2018
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 emergency preparedness.
Findings
The facility was found to be in substantial compliance with the emergency preparedness plan requirements and the Life Safety Code standards as per NFPA 101 2012 edition.
Report Facts
Census: 68
Total Capacity: 70
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 5, 2017
Visit Reason
A follow-up to the Recertification survey of August 17, 2017 was conducted to verify correction of previously identified deficiencies.
Findings
All deficiencies identified in the prior Recertification survey were corrected, and the facility was found to be in substantial compliance as of October 1, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 69
Capacity: 70
Deficiencies: 9
Date: Aug 14, 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 failure to provide required notification for Class K fire extinguishers, improper maintenance of ceilings, fire alarm system, sprinkler system installation and maintenance, fire extinguisher mounting, corridor doors, smoke barriers, and electrical systems.
Deficiencies (9)
Failed to provide required notification placards for Class K fire extinguishers in kitchen.
Failed to properly maintain facility ceilings; plywood cut to fit ceiling grid in loading dock washroom.
Failed to properly maintain fire alarm system; pull stations mounted too high and smoke detector located in HVAC air stream.
Fire sprinkler system not properly installed; hydraulic name plate not metal or hard plastic and not permanently marked.
Failed to maintain sprinkler system; no quarterly inspections conducted, backflow valves not tested annually, missing escutcheon plates.
Failed to properly maintain portable fire extinguishers; extinguishers mounted too high throughout facility.
Failed to properly maintain corridor doors; room 111 door will not latch.
Failed to properly maintain rated walls and ceilings; unprotected and improperly protected penetrations and walls not built according to listing.
Failed to properly maintain electrical systems; missing junction box covers above ceiling at rooms 125 and 130, electrical panels obstructed in activity storage.
Report Facts
Census: 69
Total Capacity: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and interviews |
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