Inspection Reports for
Marietta Center for Nursing and Healing
811 Kennesaw Ave NW, Marietta, GA 30060, United States, GA, 30060
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
182% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
81% occupied
Based on a June 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 1
Date: Sep 29, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols, specifically related to transmission-based precautions and hand hygiene practices.
Findings
The facility failed to follow infection control protocols and precaution measures for one resident with wounds, including improper use of personal protective equipment (PPE) and inadequate hand hygiene by staff during wound care. The deficient practice had the potential to spread microorganisms and infections.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Staff did not consistently follow transmission-based precautions and hand hygiene protocols during wound care for one resident, risking infection spread.
Report Facts
Residents Affected: 1
Date of wound dressing applied: Sep 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Performed wound care and was observed not sanitizing hands properly before donning gloves. |
| BB | Certified Nursing Assistant (CNA) | Assisted with wound care and repositioning without proper PPE and hand hygiene. |
| AA | Unit Manager Registered Nurse (RN) | Reported that staff did not follow infection control protocols and planned to re-inservice nursing staff. |
Inspection Report
Routine
Census: 124
Deficiencies: 4
Date: Jun 15, 2025
Visit Reason
Routine inspection of Marietta Center for Nursing and Healing to assess compliance with safety, food handling, sanitation, and infection control regulations.
Findings
The facility was found deficient in maintaining safe water temperatures, proper food labeling and storage, dumpster sanitation, and adherence to infection control PPE protocols. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (4)
F 0689: The facility failed to maintain safe water temperatures, with readings exceeding 120 degrees Fahrenheit in one shower room, risking resident burns.
F 0812: The facility failed to ensure opened food items were labeled and dated and failed to remove a dented can from storage, risking foodborne illness for 117 residents.
F 0814: The facility failed to ensure dumpster side doors were closed and the surrounding ground was free from trash debris, risking pest attraction and disease transmission.
F 0880: The facility failed to ensure staff wore personal protective equipment when providing care to a resident on Contact Precautions, risking infection spread.
Report Facts
Residents affected: 117
Facility census: 124
Water temperature: 122
Water temperature: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse | Named in infection control PPE deficiency for failing to wear PPE when providing care to resident on Contact Precautions |
| Maintenance Director | Interviewed regarding water temperature issues and adjustments | |
| President of Property Management (VP) | Interviewed regarding water heater and mixing valve issues | |
| Director of Dietary (DD) | Interviewed regarding food labeling, storage, and dumpster sanitation deficiencies | |
| Director of Maintenance (DM) | Interviewed regarding dumpster sanitation deficiencies | |
| Lead Housekeeper (LH) | Interviewed regarding dumpster sanitation responsibilities | |
| Infection Preventionist (IP) | Interviewed regarding PPE expectations for Contact Precautions | |
| Director of Nursing | Interviewed regarding PPE expectations for Contact Precautions |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 15, 2025
Visit Reason
The inspection was conducted to assess compliance with safety and infection control regulations, including water temperature safety and proper use of personal protective equipment (PPE) for residents under contact precautions.
Findings
The facility failed to maintain safe water temperatures, with readings exceeding 120 degrees Fahrenheit in one shower room, posing a burn risk to residents. Additionally, staff failed to wear appropriate PPE when providing care to a resident on contact precautions, risking infection transmission.
Deficiencies (2)
F 0689: The facility failed to maintain safe water temperatures, with water exceeding 120 degrees Fahrenheit in the South Hall Shower Room, risking burns to residents.
F 0880: The facility failed to protect residents from infection by not wearing personal protective equipment when providing care to a resident on contact precautions.
Report Facts
Water temperature: 122
Water temperature: 126
Water temperature: 108
Water temperature: 106
Water temperature: 102.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in infection control deficiency for failing to wear PPE when providing care to resident on contact precautions. |
| Maintenance Director | Interviewed regarding water temperature issues and adjustments. | |
| President of Property Management | Interviewed about water heater changes and temperature monitoring. | |
| Administrator | Interviewed about water temperature monitoring and expectations. | |
| Infection Preventionist | Interviewed about PPE expectations for contact precautions. | |
| Director of Nursing | Interviewed about PPE expectations for contact precautions. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Marietta Center for Nursing and Healing.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 0
Date: 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.
Complaint Details
Complaints GA00252384, GA00251206, GA00250735, and GA00250986 were investigated and found to be unsubstantiated.
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.
Report Facts
Facility census: 132
Inspection Report
Abbreviated Survey
Census: 130
Deficiencies: 0
Date: 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.
Complaint Details
Complaints GA00244227, GA00244742, GA00245312, GA00247685, GA00247788, and GA00248536 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Report Facts
Complaints investigated: 6
Census: 130
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
Date: Jun 12, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00247577.
Complaint Details
Complaint #GA00247577 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Routine
Deficiencies: 10
Date: Feb 15, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with healthcare regulations and standards at Marietta Center for Nursing and Healing.
Findings
The facility was found deficient in multiple areas including resident care assistance, medication self-administration, wound care documentation and treatment, environmental safety hazards, respiratory care equipment maintenance, psychotropic medication management, food safety and sanitation, refuse disposal, and infection control practices.
Deficiencies (10)
F 0550: The facility failed to provide appropriate assistance with eating meals for one dependent resident (R25), risking weight loss.
F 0554: The facility failed to ensure five residents (R22, R39, R90, R81, R1) did not have unauthorized medications stored at bedside, risking unsafe self-administration.
F 0656: The facility failed to follow the care plan for wound care for one resident (R42), resulting in missed treatments.
F 0684: The facility failed to provide wound care treatment and documentation as ordered for two residents (R42 and R81), risking wound infection and decline.
F 0689: The facility failed to ensure one resident (R111) was protected from accident hazards by allowing use of an electric blanket, risking burns.
F 0695: The facility failed to maintain and clean respiratory equipment properly for four residents (R36, R84, R54, R61) and lacked CPAP orders for one resident (R50).
F 0758: The facility failed to indicate a 14-day stop date for psychotropic medication for one resident (R35) and failed to ensure PRN psychiatric medications were re-evaluated beyond 14 days for another resident (R22).
F 0812: The facility failed to ensure food items were properly labeled, dated, and stored, and failed to maintain kitchen sanitation, risking food safety for 123 residents.
F 0814: The facility failed to maintain dumpster lids in good repair and secured, risking pest infestation and contamination.
F 0880: The facility failed to properly use PPE in an isolation room for one resident (R95) and failed to perform hand hygiene between delivering meals to residents on East-C hall, risking infection spread.
Report Facts
Residents sampled: 41
Facility census: 127
Medication tablets: 27
Wound care dressing changes documented: 3
Wound care dressing changes documented: 8
Wound care dressing changes documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Unit Manager | Verified medications at bedside not authorized for self-administration for residents R22 and R39 |
| RN DD | Registered Nurse | Observed leaving medications at bedside for resident R90 without supervision |
| LPN HH | Licensed Practical Nurse | Confirmed resident R1 was not approved for self-administration of medications |
| Unit Manager JJ | Licensed Practical Nurse | Verified respiratory equipment maintenance issues and hand hygiene expectations |
| DON | Director of Nursing | Provided multiple interviews confirming deficiencies and expectations for medication orders, wound care, respiratory care, and infection control |
| DM KK | Dietary Manager | Reported food labeling and kitchen sanitation deficiencies |
| Maintenance Director LL | Maintenance Director | Reported unawareness of dumpster lid conditions and responsibility for maintenance |
| CNA PP | Certified Nursing Assistant | Observed not performing hand hygiene between meal tray deliveries and not using PPE in isolation room |
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 6
Date: 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)
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
Date: 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.
Complaint Details
Complaint Intake Numbers GA00243636 and GA00242885 were substantiated with federal citations. Complaint Intake Numbers GA00243049 and GA00242518 were unsubstantiated.
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.
Deficiencies (10)
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
Routine
Deficiencies: 6
Date: Feb 15, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements including resident care, medication administration, wound care, respiratory care, psychotropic medication use, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate assistance with eating for a dependent resident, improper medication storage and administration practices, incomplete wound care documentation, inadequate respiratory equipment maintenance, lack of psychotropic medication stop dates and re-evaluations, and improper use of personal protective equipment and hand hygiene.
Deficiencies (6)
F 0550: The facility failed to provide appropriate assistance with eating meals for one dependent resident, risking potential weight loss.
F 0554: The facility failed to ensure five residents did not have unauthorized medications stored at bedside, risking unsafe self-administration.
F 0684: The facility failed to document wound care treatments as ordered for two residents, risking wound deterioration and infection.
F 0695: The facility failed to change and date oxygen tubing weekly, clean CPAP filters, and have CPAP orders for one resident, risking respiratory complications.
F 0758: The facility failed to indicate a 14-day stop date for psychotropic medication for one resident and failed to ensure re-evaluation of PRN psychotropic medications beyond 14 days for another.
F 0880: The facility failed to properly use PPE in an isolation room and failed to perform hand hygiene between delivering meals to residents, risking infection spread.
Report Facts
Residents sampled: 41
Facility census: 127
Medication tablets: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Unit Manager | Verified medication storage issues and lack of self-administration orders |
| RN DD | Registered Nurse | Observed leaving medications at bedside without supervision |
| LPN HH | Licensed Practical Nurse | Interviewed regarding medication storage and wound care documentation |
| Unit Manager JJ | Licensed Practical Nurse | Verified respiratory equipment issues and hand hygiene deficiencies |
| DON | Director of Nursing | Provided multiple interviews regarding facility policies and deficiencies |
| CNA PP | Certified Nursing Assistant | Observed failing to perform hand hygiene between meal deliveries |
| CNA FF | Certified Nursing Assistant | Observed entering isolation room without PPE |
| LPN BB | Licensed Practical Nurse | Interviewed about medication orders and administration |
| LPN BB | Licensed Practical Nurse | Interviewed about medication orders and administration |
| Medical Director | Interviewed regarding psychotropic medication re-evaluation |
Inspection Report
Life Safety
Census: 127
Capacity: 154
Deficiencies: 3
Date: 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.
Deficiencies (3)
Fire alarm notification system devices were not working at maximum efficiency; 7 smoke detectors failed sensitivity testing and needed replacement.
Facility failed to maintain corridor doors to resist possible passage of smoke; door handle to resident room #M-12 had a penetration around it.
Facility failed to maintain smoke barriers to resist passage of smoke; a penetration existed in the smoke barrier near resident room #B-3.
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
Date: 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
Date: 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.
Complaint Details
Complaint Intake Numbers GA00232844, GA00240350, GA00241330, and GA00241694 were investigated and found to be unsubstantiated with no deficiencies.
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.
Report Facts
Complaint Intake Numbers Investigated: 4
Inspection Report
Re-Inspection
Census: 125
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Intake Numbers GA00232844, GA00240350, GA00241330, and GA00241694 were investigated and found unsubstantiated with no deficiencies.
Findings
The complaint investigation found all complaints unsubstantiated with no deficiencies identified during the revisit survey.
Report Facts
Complaint Intake Numbers: 4
Inspection Report
Renewal
Deficiencies: 2
Date: 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)
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
Deficiencies: 5
Date: Oct 19, 2023
Visit Reason
The inspection was conducted in response to complaints and allegations regarding failure to provide timely incontinent care, misappropriation of resident property, and failure to address resident grievances.
Complaint Details
The complaint investigation substantiated multiple failures including delayed incontinent care causing psychosocial harm, failure to resolve grievances properly, and misappropriation of resident property by staff. The resident R16 was fearful of retaliation and reported staff took her keys and accessed her home without permission. The facility failed to report these allegations timely to authorities.
Findings
The facility failed to provide timely incontinent care to multiple residents, resulting in psychosocial harm and humiliation. The facility also failed to properly investigate and resolve resident grievances and failed to prevent misappropriation of resident property by staff, including unauthorized access to a resident's home and improper handling of resident funds.
Deficiencies (5)
F 0557: The facility failed to ensure three residents were treated with dignity related to Activities of Daily Living care, including ignoring calls for incontinent care and refusing assistance, causing psychosocial harm.
F 0585: The facility failed to take appropriate corrective action and document follow-up resolutions for five residents' grievances, including failure to investigate and resolve complaints about incontinent care delays.
F 0602: The facility failed to ensure one resident was free from misappropriation of personal property, including unauthorized staff access to the resident's home and improper handling of resident funds.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft involving misappropriation of resident property to the administrator and other agencies as required.
F 0677: The facility failed to provide Activities of Daily Living care, including incontinent care, to five residents, resulting in residents sitting in soiled briefs for extended periods and experiencing humiliation and psychosocial harm.
Report Facts
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 5
Wait time for incontinent care: 2
Wait time for incontinent care: 4
Wait time for incontinent care: 2
Wait time for incontinent care: 5
Wait time for incontinent care: 10
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 misappropriation investigation |
| LPN JJ | Licensed Practical Nurse | Named in incontinent care delay and failure to assist resident R30 |
| Director of Nursing | Director of Nursing | Provided statements on incontinent care policy and expectations |
| Social Services Director EE | Social Services Director | Named in grievance investigation and resident involvement |
| Business Manager RR | Business Manager | Named in resident funds management and misappropriation |
Inspection Report
Complaint Investigation
Census: 132
Deficiencies: 5
Date: 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.
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.
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.
Deficiencies (5)
Failure to ensure residents were treated with dignity and provided timely incontinent care, resulting in psychosocial harm.
Failure to take appropriate corrective action and document resolutions for resident grievances.
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.
Failure to report alleged violations of misappropriation of resident property immediately to the administrator and other agencies.
Failure to provide Activities of Daily Living (ADL) care, including incontinent care, to dependent residents in a timely manner, causing psychosocial harm.
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
Complaint Investigation
Deficiencies: 5
Date: Oct 19, 2023
Visit Reason
The inspection was conducted in response to complaints and allegations regarding failure to provide timely incontinent care, misappropriation of resident property, and failure to address resident grievances.
Complaint Details
The investigation was complaint-driven, focusing on allegations of delayed incontinent care, misappropriation of resident property by staff, failure to report and investigate abuse, and inadequate grievance resolution. The complaint was substantiated with findings of actual harm and minimal harm.
Findings
The facility failed to provide timely Activities of Daily Living (ADL) care, including incontinent care, resulting in psychosocial harm to residents. The facility also failed to prevent misappropriation of resident property by staff and did not properly investigate or report these incidents. Additionally, the facility did not adequately address or resolve resident grievances as required by policy.
Deficiencies (5)
F 0557: The facility failed to treat residents with dignity and respect by ignoring calls for incontinent care for extended periods, causing psychosocial harm to residents including humiliation and embarrassment.
F 0585: The facility failed to take appropriate corrective action and document resolutions for resident grievances, resulting in unresolved complaints and potential psychosocial harm.
F 0602: The facility failed to protect residents from misappropriation of personal property by staff who took resident keys and accessed a resident's home without permission, causing fear of retaliation.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft involving misappropriation of resident property to the administrator and other agencies as required.
F 0677: The facility failed to provide timely ADL care including incontinent care to multiple residents, resulting in residents sitting in soiled briefs for hours and experiencing psychosocial harm.
Report Facts
Residents sampled: 43
Residents affected: 5
Residents affected: 5
Residents affected: 1
BIMS scores: 15
BIMS score: 14
BIMS score: 13
BIMS score: 14
BIMS score: 15
Duration incontinent care delay: 2
Duration incontinent care delay: 4
Duration incontinent care delay: 2
Duration incontinent care delay: 5.25
Duration soiled clothes: 1
Check amount: 40
Months checks deposited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA DD | Certified Nursing Assistant | Named in findings of misappropriation of resident R16's property and unauthorized visits to resident's home |
| Psychotherapist GG | Psychotherapist | Named in findings of unauthorized access to resident R16's home and failure to report suspicions |
| LPN JJ | Licensed Practical Nurse | Named in findings related to incontinent care delays and staff instructions |
| CNA MM | Certified Nursing Assistant | Named in incontinent care delay findings |
| Director of Nursing | Director of Nursing | Provided statements on facility policy and expectations regarding incontinent care |
| Social Services Director EE | Social Services Director | Involved in grievance process and resident R16 case |
| Business Manager RR | Business Manager | Provided information on resident trust funds and financial controls |
| Ombudsman CCC | Ombudsman | Reported multiple resident complaints about incontinent care and intimidation |
| Licensed Practical Nurse HH | Licensed Practical Nurse | Provided statements on facility incontinent care policy during meal service |
| LPN LL | Licensed Practical Nurse | Provided statements on incontinent care timing and staff awareness |
| LPN UU | Licensed Practical Nurse | Provided statements on incontinent care policy |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00235879 and #GA00229609.
Complaint Details
Complaint #GA00235879 was substantiated with no deficiencies cited. Complaint #GA00229609 was unsubstantiated with no deficiencies cited.
Findings
Complaint #GA00235879 was substantiated with no deficiencies cited, and complaint #GA00229609 was unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Deficiencies: 10
Date: Mar 24, 2022
Visit Reason
Routine inspection of Marietta Center for Nursing and Healing to assess compliance with regulatory requirements including resident rights, abuse investigations, care planning, activities of daily living, wound care, staffing, behavioral health, and rehabilitation services.
Findings
The facility was found deficient in multiple areas including failure to ensure advanced directives were properly signed, incomplete abuse investigations, failure to notify ombudsman of hospital transfers, delayed care plan development, inadequate provision of showers and bed baths, inconsistent wound care and medication administration, insufficient nursing staff coverage, lack of follow-up psychiatric services, and failure to provide ordered speech therapy for a resident on the COVID unit.
Deficiencies (10)
F 0578: The facility failed to ensure advanced directives included a signature by the resident or health care Power of Attorney for one resident. Nursing staff signed POLST forms without resident or POA signatures and failed to document resident/family involvement.
F 0610: The facility failed to conduct a thorough investigation of alleged abuse for one resident by not obtaining statements from all relevant staff and inadequately addressing specific allegations.
F 0623: The facility failed to provide written notification to the resident, representative, and ombudsman of facility-initiated hospital transfers for two residents, limiting ombudsman review opportunities.
F 0656: The facility failed to develop a timely care plan for one resident receiving hospice services, missing the 14-day expectation after significant change assessment.
F 0657: The facility failed to ensure one resident participated in care plan meetings, with no meetings held for six months until recently scheduled.
F 0677: The facility failed to provide showers and bed baths as scheduled for seven residents, with multiple refusals and missed care documented, and inconsistent shower scheduling and documentation.
F 0684: The facility failed to ensure wound dressings and topical antibiotic ointments were changed as ordered for one resident, resulting in wound infection and inconsistent care during weekends and staff absences.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs including timely medication administration, dressing changes, answering call lights, and providing showers and bed baths for multiple residents.
F 0740: The facility failed to provide follow-up psychiatric services for one resident with depression after transfer to the COVID unit, missing medication effectiveness assessments and telehealth visits.
F 0825: The facility failed to provide speech therapy as ordered for one resident after transfer to the COVID unit, without notifying the physician or discontinuing the order.
Report Facts
Residents reviewed for advance directives: 27
Residents reviewed for abuse: 2
Residents transferred to hospital: 2
Residents reviewed for hospice care: 2
Residents reviewed for care plan participation: 27
Residents reviewed for ADL care: 27
Residents reviewed for wound care: 27
Residents reviewed for staffing adequacy: 9
Psychiatric follow-up interval: 1
Speech therapy frequency ordered: 5
Speech therapy duration ordered: 4
Resident weight: 159.8
Resident weight: 157
Resident weight: 156.6
Meal consumption: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN#1 | Licensed Practical Nurse | Signed POLST form without resident or POA signature; interviewed regarding abuse investigation |
| Wound Nurse | Reported inconsistent wound dressing changes and concerns to DON | |
| Social Service Director | SSD | Interviewed regarding advanced directives and abuse investigation |
| Psychiatrist | Provided psychiatric evaluation and medication changes for resident R#84 | |
| Nurse Practitioner | NP | Referred resident R#84 to Psychiatrist and provided care on COVID unit |
| Speech Therapist | Provided speech therapy to resident R#84 until transfer to COVID unit | |
| Regional Director of Operations | Interviewed regarding staffing and resident care issues | |
| Administrator | Interviewed regarding abuse investigation and speech therapy services | |
| [NAME] Clerk/Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing shortages and scheduling |
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Date: 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
Date: 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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