Inspection Reports for Marietta Center for Nursing and Healing
811 Kennesaw Ave NW, Marietta, GA 30060, United States, GA, 30060
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Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 0
Dec 10, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints.
Findings
The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices. All complaints investigated were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaints GA00252384, GA00251206, GA00250735, and GA00250986 were investigated and found to be unsubstantiated.
Report Facts
Facility census: 132
Inspection Report
Abbreviated Survey
Census: 130
Deficiencies: 0
Jul 30, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their codes between July 24, 2024 and July 30, 2024.
Findings
All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00244227, GA00244742, GA00245312, GA00247685, GA00247788, and GA00248536 were investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Complaints investigated: 6
Census: 130
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Jun 12, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00247577.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint #GA00247577 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 1, 2024
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
Deficiencies: 0
Mar 28, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for the Marietta Center for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 129
Deficiencies: 0
Mar 28, 2024
Visit Reason
A Revisit Survey was conducted from March 27, 2024 through March 28, 2024 at Marietta Center for Nursing and Healing to verify correction of deficiencies cited in the Standard/Complaint Survey concluded on February 15, 2024.
Findings
All deficiencies cited as a result of the Standard/Complaint Survey concluded on February 15, 2024 were found to be corrected.
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 6
Feb 15, 2024
Visit Reason
A State Licensure survey was conducted at Marietta Center for Nursing and Healing from February 13, 2024 through February 15, 2024 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to provide appropriate assistance with eating for a dependent resident, improper management of psychotropic medication orders, inadequate infection control practices including improper use of PPE and hand hygiene, unsafe self-administration and storage of medications by residents, failure to follow wound care plans, and unsafe use of an electric blanket posing a burn hazard.
Deficiencies (6)
| Description |
|---|
| Failure to provide appropriate assistance with eating meals and timely meal delivery for one dependent resident (R25), risking weight loss. |
| Failure to indicate a 14-day stop date for psychotropic medication for one resident (R35) and failure to ensure evaluation of PRN psychiatric medications beyond 14 days for another resident (R22). |
| Failure to properly utilize personal protective equipment (PPE) in isolation room and failure to perform hand hygiene between residents when delivering meals, risking infection spread. |
| Failure to ensure five residents (R22, R39, R90, R81, R1) did not have medications stored at bedside without proper authorization or assessment, risking unsafe self-administration. |
| Failure to follow wound care plan for one resident (R42) with surgical wound, with multiple undocumented treatments. |
| Failure to ensure environment free from hazards by allowing one resident (R111) to use an electric blanket, posing risk of burns. |
Report Facts
Residents sampled: 41
Facility census: 127
Medication tablets: 27
Missed wound treatments: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding psychotropic medication orders and infection control practices |
| CNA PP | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene practices during meal delivery |
| CNA FF | Certified Nursing Assistant | Observed and interviewed regarding PPE use and electric blanket handling |
| Unit Manager LPN AA | Licensed Practical Nurse Unit Manager | Interviewed regarding medication storage and self-administration policies |
| RN DD | Registered Nurse | Interviewed regarding medication administration and bedside medication observations |
| LPN BB | Licensed Practical Nurse | Interviewed regarding medication orders and bedside medication observations |
| Medical Director | Medical Director | Interviewed regarding psychotropic medication re-evaluation responsibilities |
| Administrator | Facility Administrator | Interviewed regarding medication storage and electric blanket policy awareness |
| Social Worker | Social Worker | Interviewed regarding resident R1's dental visit records |
Inspection Report
Routine
Census: 127
Deficiencies: 10
Feb 15, 2024
Visit Reason
A standard survey was conducted at Marietta Center for Nursing and Healing from February 13, 2024, through February 15, 2024, including investigation of multiple complaint intake numbers.
Findings
The facility was found in substantial compliance with Medicare/Medicaid regulations but had deficiencies including failure to provide appropriate assistance with eating, improper medication storage and administration, incomplete wound care documentation, unsafe use of heating devices, inadequate respiratory equipment maintenance, psychotropic medication order issues, unsanitary food storage and kitchen conditions, unsecured dumpster lids, and improper use of PPE and hand hygiene.
Complaint Details
Complaint Intake Numbers GA00243636 and GA00242885 were substantiated with federal citations. Complaint Intake Numbers GA00243049 and GA00242518 were unsubstantiated.
Deficiencies (10)
| Description |
|---|
| Failure to provide appropriate assistance with eating meals for a dependent resident (R25), risking weight loss. |
| Failure to ensure medications were not stored at bedside without proper orders and assessments for five residents, risking unsafe medication administration. |
| Failure to follow care plan for wound treatment for resident R42, with multiple undocumented wound care treatments. |
| Failure to provide wound care and document treatments as ordered for residents R42 and R81, risking wound infection and decline. |
| Failure to ensure resident R111 was not exposed to heating device (electric blanket) posing risk of burns. |
| Failure to change and date oxygen tubing weekly for three residents, clean CPAP filters for two residents, and lack of CPAP orders for one resident. |
| Failure to indicate a 14-day stop date for psychotropic medication for one resident and failure to evaluate PRN psychotropic medication use beyond 14 days for another resident. |
| Failure to ensure food items were properly stored, labeled, dated, and expired items disposed of timely; kitchen areas were unsanitary with debris and possible mold. |
| Failure to maintain dumpster lids securely closed and fitted, risking pest and insect harboring. |
| Failure to properly use PPE in isolation room for one resident and failure to perform hand hygiene between delivering meals to multiple residents, risking infection spread. |
Report Facts
Resident census: 127
Medication tablets: 27
Wound care documentation missing: 20
Wound dressing changes documented: 3
Wound dressing changes documented: 8
Wound dressing changes documented: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Named in medication administration deficiency related to leaving medications at bedside |
| LPN AA | Licensed Practical Nurse Unit Manager | Named in medication administration deficiency and oxygen equipment maintenance |
| LPN BB | Licensed Practical Nurse | Named in medication administration deficiency |
| LPN HH | Licensed Practical Nurse | Named in medication administration and wound care deficiencies |
| LPN JJ | Licensed Practical Nurse Unit Manager | Named in medication administration, wound care, and oxygen equipment deficiencies |
| LPN NN | Licensed Practical Nurse | Named in wound care deficiency |
| CNA FF | Certified Nursing Assistant | Named in PPE and hand hygiene deficiency |
| CNA PP | Certified Nursing Assistant | Named in PPE and hand hygiene deficiency |
| DM KK | Dietary Manager | Named in food storage and kitchen sanitation deficiency |
| Maintenance Director LL | Maintenance Director | Named in dumpster sanitation deficiency |
| DON | Director of Nursing | Named in multiple deficiencies including medication, wound care, oxygen equipment, psychotropic medication, PPE, and hand hygiene |
Inspection Report
Life Safety
Census: 127
Capacity: 154
Deficiencies: 3
Feb 13, 2024
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) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in fire alarm system testing and maintenance, corridor door openings, and smoke barrier construction. Specific issues included non-functioning smoke detectors, door penetrations allowing smoke passage, and smoke barrier penetrations.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire alarm notification system devices were not working at maximum efficiency; 7 smoke detectors failed sensitivity testing and needed replacement. | D |
| Facility failed to maintain corridor doors to resist possible passage of smoke; door handle to resident room #M-12 had a penetration around it. | D |
| Facility failed to maintain smoke barriers to resist passage of smoke; a penetration existed in the smoke barrier near resident room #B-3. | D |
Report Facts
Smoke detectors failed sensitivity testing: 7
Smoke compartments affected: 1
Smoke compartments affected: 1
Smoke compartments affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Deficiencies: 0
Dec 14, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Marietta Center for Nursing and Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 125
Deficiencies: 0
Dec 14, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/19/23 Complaint Survey and to investigate multiple complaint intake numbers GA00232844, GA00240350, GA00241330, and GA00241694.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected. The complaint investigations for the listed intake numbers were unsubstantiated with no deficiencies identified.
Complaint Details
Complaint Intake Numbers GA00232844, GA00240350, GA00241330, and GA00241694 were investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Complaint Intake Numbers Investigated: 4
Inspection Report
Re-Inspection
Census: 125
Deficiencies: 0
Dec 14, 2023
Visit Reason
An unannounced visit was conducted to investigate multiple complaints (GA00232844, GA00240350, GA00241330, GA00241694) in conjunction with a Revisit Survey from 12/11/2023 through 12/14/2023.
Findings
The complaint investigation found all complaints unsubstantiated with no deficiencies identified during the revisit survey.
Complaint Details
Complaint Intake Numbers GA00232844, GA00240350, GA00241330, and GA00241694 were investigated and found unsubstantiated with no deficiencies.
Report Facts
Complaint Intake Numbers: 4
Inspection Report
Renewal
Deficiencies: 2
Oct 19, 2023
Visit Reason
A Licensure Survey was initiated on 9/27/2023 and concluded on 10/19/2023 to assess compliance with licensure requirements at Marietta Center for Nursing and Healing.
Findings
The facility failed to appropriately address and document grievances for five residents related to care and services, including delayed assistance with toileting during mealtimes. Additionally, five residents were not provided timely Activities of Daily Living (ADL) care, with documented delays in incontinent care during meal service, causing resident distress and potential harm.
Deficiencies (2)
| Description |
|---|
| Failure to take appropriate corrective action and document follow-up resolutions for five residents' grievances related to care and services. |
| Failure to provide timely Activities of Daily Living (ADL) care to five residents, including incontinent care delays during meal service. |
Report Facts
Residents with unresolved grievances: 5
Residents not provided ADL care: 5
Duration of delayed incontinent care: 2
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Named in relation to delaying incontinent care during meal service and enforcing facility policy. |
| CNA MM | Certified Nursing Assistant | Named in relation to passing trays and not assisting residents with incontinent care during meal service. |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding facility policy and expectations for ADL care during meal service. |
| Ombudsman CCC | Ombudsman | Reported multiple complaints from residents regarding incontinent care delays and intimidation. |
| SSD/GO EE | Social Services Director / Grievance Official | Responsible for grievance process; involved in grievance resolution discussions. |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 5
Oct 19, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints regarding resident care and grievances at Marietta Center for Nursing and Healing.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Key findings included failure to provide timely incontinent care to residents, resulting in psychosocial harm; failure to properly address and resolve resident grievances; and misappropriation of resident property by staff, including unauthorized access to a resident's home and misuse of resident funds.
Complaint Details
The complaint investigation was initiated due to multiple complaints alleging failure to provide timely incontinent care, improper handling of resident grievances, and misappropriation of resident property. Several complaints were substantiated, including residents being left in soiled briefs for hours during meal service and staff taking resident funds and accessing a resident's home without permission.
Severity Breakdown
SS=G: 3
SS=E: 1
SS=D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity and provided timely incontinent care, resulting in psychosocial harm. | SS=G |
| Failure to take appropriate corrective action and document resolutions for resident grievances. | SS=E |
| Failure to ensure a resident was free from misappropriation of personal property, including unauthorized use of resident funds and unauthorized access to resident's home. | SS=G |
| Failure to report alleged violations of misappropriation of resident property immediately to the administrator and other agencies. | SS=D |
| Failure to provide Activities of Daily Living (ADL) care, including incontinent care, to dependent residents in a timely manner, causing psychosocial harm. | SS=G |
Report Facts
Resident census: 132
Number of sampled residents: 43
Number of substantiated complaints: 15
BIMS scores: 15
Wait time for incontinent care: 2
Amount of money misappropriated: 40
Months of misappropriated retirement checks: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nursing Assistant | Named in misappropriation of resident property and unauthorized access to resident's home |
| Psychotherapist GG | Psychotherapist | Named in unauthorized access to resident's home and involvement with resident's property |
| LPN JJ | Licensed Practical Nurse | Named in failure to provide incontinent care and observations of resident neglect |
| CNA MM | Certified Nursing Assistant | Named in failure to provide incontinent care during meal service |
| Medical Records Staff NN | Observed ignoring resident calls for incontinent care | |
| Director of Nursing | Director of Nursing | Provided statements on expected care and policy regarding incontinent care |
| Social Services Director EE | Social Services Director | Named as grievance official and involved in grievance process |
| Ombudsman CCC | Ombudsman | Received multiple complaints from residents about incontinent care and intimidation |
| LPN LL | Licensed Practical Nurse | Named in failure to provide incontinent care |
| CNA LLL | Certified Nursing Assistant | Named in failure to provide incontinent care during meal service |
| CNA OO | Certified Nursing Assistant | Named in facility policy to not provide incontinent care during meal service |
| LPN SS | Licensed Practical Nurse | Observed ignoring resident calls for incontinent care |
| LPN HH | Licensed Practical Nurse | Stated incontinent care is delayed during meal service due to cross contamination policy |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 6, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00235879 and #GA00229609.
Findings
Complaint #GA00235879 was substantiated with no deficiencies cited, and complaint #GA00229609 was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint #GA00235879 was substantiated with no deficiencies cited. Complaint #GA00229609 was unsubstantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Nov 15, 2021
Visit Reason
A revisit inspection was conducted to verify correction of deficiencies cited in the prior survey on September 24, 2021.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit inspection.
Inspection Report
Follow-Up
Census: 109
Deficiencies: 0
Nov 15, 2021
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the survey on September 24, 2021.
Findings
All deficiencies cited as a result of the survey on September 24, 2021 were found to be corrected.
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