Inspection Reports for North Decatur Health and Rehabilitation Center
2787 NORTH DECATUR ROAD, GA, 30033
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Abbreviated Survey
Census: 65
Deficiencies: 0
Jan 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00219535.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00219535 was investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Dec 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for North Decatur Health and Rehabilitation Center following a survey completed on December 29, 2021.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Dec 29, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the November 10, 2021 survey.
Findings
All deficiencies cited in the prior November 10, 2021 survey were found to be corrected during the December 29, 2021 revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Nov 10, 2021
Visit Reason
The inspection was a Licensure survey conducted from 11/8/2021 to 11/10/2021 to assess compliance with regulatory requirements for the facility license renewal.
Findings
The facility failed to ensure that one of four sampled residents (R#41) was served a vegetarian diet as ordered by the physician. The Dietary Manager confirmed that non-vegetarian items were served to the resident despite the vegetarian diet order, which was an oversight by staff.
Deficiencies (1)
| Description |
|---|
| Failure to provide a vegetarian diet as ordered by the physician for resident #41. |
Report Facts
Number of sampled residents: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed the vegetarian diet order was not followed and acknowledged oversight by staff. |
| Corporate Dietary Manager | Corporate Dietary Manager | Provided information on facility policy regarding food preferences and assessments. |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Nov 10, 2021
Visit Reason
A standard survey was conducted from 11/8/2021 through 11/10/2021, including investigation of multiple complaint intake numbers (GA00218823, GA00212930, GA00218096, GA00217921). The survey aimed to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, specifically failing to provide a resident (R#41) with a physician-ordered vegetarian diet. Observations and interviews confirmed the resident was served non-vegetarian items despite documented orders and preferences.
Complaint Details
The survey included investigation of complaint intake numbers GA00218823, GA00212930, GA00218096, and GA00217921 in conjunction with the standard survey.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one resident was served a vegetarian diet as ordered by the physician, including serving non-vegetarian items such as hamburger steak, fish fillet, and boiled eggs. | SS= D |
Report Facts
Resident census: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed resident received non-vegetarian food despite vegetarian diet order |
| Corporate Dietary Manager | Corporate Dietary Manager | Confirmed facility policy requires assessment of resident food preferences within 48 hours of admission |
Inspection Report
Life Safety
Census: 63
Capacity: 72
Deficiencies: 0
Nov 9, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found to be in compliance with the Life Safety Code requirements, including the Emergency Preparedness Program and NFPA 101 Life Safety Code 2012 edition standards.
Inspection Report
Routine
Census: 38
Deficiencies: 0
Feb 23, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 7, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00206393, #GA00207071, #GA00209862, and #GA00201904.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints #GA00206393, #GA00207071, #GA00209862, and #GA00201904 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 56
Deficiencies: 0
Nov 11, 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 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Jul 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195881.
Findings
The complaint was found to be unsubstantiated during the survey.
Complaint Details
Complaint GA00195881 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 19, 2019
Visit Reason
A complaint survey was conducted on 2/18/19 - 2/19/19 to investigate complaint GA00194841 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA00194841 was investigated and no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 7, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Jan 31, 2019
Visit Reason
A Revisit Survey to the Standard Survey of December 6, 2018 was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies cited during the Standard Survey had been corrected.
Inspection Report
Routine
Census: 61
Deficiencies: 11
Dec 6, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including safe environment maintenance, comprehensive assessments, baseline and comprehensive care plans, medication management, infection control, and immunization documentation.
Severity Breakdown
E: 2
D: 9
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe, clean, comfortable, and homelike environment in nine resident rooms with issues such as dust, peeling paint, stained curtains, and cobwebs. | E |
| Failed to conduct comprehensive assessments including depression assessment for resident #24. | D |
| Failed to develop baseline care plan within 48 hours of admission for resident 'A' related to constipation care. | D |
| Failed to develop and implement comprehensive care plans for residents #55, #38, #214, and #29 including restorative care, ADL care, and oxygen therapy. | E |
| Failed to provide restorative nursing care for resident #55 related to range of motion and splint use. | D |
| Failed to maintain respiratory and tracheostomy care equipment in a sanitary manner for residents #29, #38, and #3; improper tracheostomy care technique observed. | D |
| Resident #17 had duplicated medication orders leading to unnecessary drug therapy; resident #54 received incorrect vitamin D dosage. | D |
| Medication error rate exceeded 5% with 4 errors in 29 medication opportunities for residents #17 and #54. | D |
| Facility failed to discard expired medications found in supply room including mineral oil and cough syrup. | D |
| Facility failed to maintain infection control standards including unlabeled personal care items and improper hand hygiene during tracheostomy care. | D |
| Facility failed to document influenza vaccine refusal rationale and provide vaccine information statement (VIS) and pneumococcal vaccine offering and VIS to resident #24 and resident 'B'. | D |
Report Facts
Resident census: 61
Medication error rate: 13.79
Medication opportunities observed: 29
Medication errors: 4
Resident sample size: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse | Administered medications with errors and performed tracheostomy care without proper hand hygiene |
| BB | Registered Nurse | Verified medication errors and infection control concerns during survey |
| GG | Certified Nursing Assistant | Reported on restorative nursing care for resident #55 |
| AA | Certified Nursing Assistant | Reported on nail care duties and resident assignments |
| DON | Director of Nursing | Interviewed regarding care plan and immunization documentation issues |
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 1
Dec 6, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to address corrosion on 3 to 4 sprinkler heads as noted on a yellow tag dated 05/08/2018, which could place 10 residents and 5 staff at risk if the sprinkler heads do not activate properly.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to comply with sprinkler system maintenance and testing requirements; 3 to 4 sprinkler heads needed cleaning or replacement due to corrosion. | SS= D |
Report Facts
Residents at risk: 10
Staff at risk: 5
Census: 65
Total licensed beds: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system yellow tag during facility tour |
Inspection Report
Annual Inspection
Deficiencies: 5
Dec 6, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at North Decatur Health and Rehabilitation Center.
Findings
The inspection identified multiple deficiencies including infection control lapses such as unlabeled and unbagged personal care items, improper hand hygiene during tracheostomy care, medication administration errors including incorrect dosages and duplicated orders, inadequate nursing care related to personal hygiene and care plan implementation, failure to ensure use of splinting devices as ordered, and incomplete documentation and education regarding influenza and pneumococcal vaccinations.
Deficiencies (5)
| Description |
|---|
| Infection control procedures not followed: unlabeled and unbagged personal care items observed in resident bathrooms and improper hand hygiene during tracheostomy care. |
| Medication administration errors including failure to administer correct dosage of vitamin D3 and duplicated medication orders. |
| Nursing care deficiencies including failure to provide assistance with activities of daily living such as nail care and personal hygiene as per care plan. |
| Failure to ensure resident wore prescribed splinting devices as ordered and lack of documentation of restorative services. |
| Failure to document influenza vaccine refusal properly and to provide required vaccine information sheet (VIS) education to resident or responsible party; lack of documentation regarding pneumococcal vaccine education and administration. |
Report Facts
Medication dosage: 2000
Medication dosage: 25
Medication dosage: 150
Medication dosage: 10
Medication dosage: 5
Medication dosage: 600
Medication dosage: 400
Medication dosage: 1000
Medication dosage: 60
Medication dosage: 300
Medication dosage: 20
Medication dosage: 81
Medication dosage: 8.6
Medication dosage: 30
Medication dosage: 17
Splinting duration: 8
Splinting schedule: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse | Named in infection control and medication administration findings |
| BB | Registered Nurse | Verified infection control concerns and medication order discrepancies |
| AA | Certified Nursing Assistant | Interviewed regarding daily care and nail care practices |
| GG | Certified Nursing Assistant | Interviewed regarding splinting device application and resident care |
| Director of Clinical Services | Interviewed regarding infection control and vaccine documentation | |
| Director of Nursing | Interviewed regarding vaccine education and resident care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00192378 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint investigation for complaint #GA00192378; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 13, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00190487 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey conducted on 9/13/2018 to 9/14/2018.
Complaint Details
Complaint investigation for complaint #GA00190487; no deficiencies were found.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 0
Apr 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey on 2018-02-23.
Findings
All deficiencies cited as a result of the 2/23/18 standard survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 26, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted by the surveyor.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 16, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186425 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00186425 was investigated and found to have no deficiencies.
Inspection Report
Routine
Census: 66
Deficiencies: 5
Feb 23, 2018
Visit Reason
A Federal Monitoring Survey was conducted to assess compliance with Medicare and Medicaid regulations for long term care facilities.
Findings
The facility was found non-compliant with multiple regulatory requirements including medication administration without physician orders, improper catheter care, expired and incorrectly administered medications, food safety violations, and inadequate infection control practices related to glucometer disinfection.
Severity Breakdown
E: 3
D: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents had a physician's order for intramuscular medication before administration and medications were given as prescribed. | E |
| Failure to provide catheter care to prevent urinary tract infections. | D |
| Failure to ensure residents received medications as prescribed and did not receive expired medications. | E |
| Failure to ensure food items were properly labeled, stored at correct temperatures, and kitchen equipment was clean and sanitary to prevent cross-contamination. | F |
| Failure to maintain an effective infection prevention and control program, specifically failure to follow policy for glucometer disinfection and placement after cleaning. | E |
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 1
Residents affected: 60
LPNs observed: 3
Residents observed: 3
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 4
Feb 22, 2018
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted by CMS following a state survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and related NFPA codes.
Findings
The facility was found not in substantial compliance with life safety code requirements, including issues with egress door hardware height, cooking equipment installation, corridor door latching and smoke resistance, and smoke barrier fire resistance due to penetrations.
Severity Breakdown
E: 2
D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Egress doors had latching hardware installed above the maximum allowed height of 48 inches AFF, affecting four doors. | E |
| Cooking equipment in the kitchen failed to meet NFPA 96 requirements; specifically, a deep fat fryer was installed too close to a surface flame cooktop without the required baffle plate. | D |
| Corridor doors failed to maintain required latching and smoke resistance; one door had a kick down stop preventing self-closing and did not latch, another door had a hole compromising integrity. | E |
| Smoke barrier at resident room 15 was penetrated by conduit, wires, and pipes with failed firestopping resulting in gaps compromising the ½-hour fire resistance rating. | D |
Report Facts
Number of affected doors: 4
Gap size: 0.5
Distance fryer installed from cooktop: 4
Required minimum distance fryer from cooktop: 16
Door gap: 1.5
Hole size: 0.375
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present and identified smoke barriers and deficiencies | |
| Maintenance Director | Present when deficiencies were identified |
Inspection Report
Routine
Census: 65
Deficiencies: 0
Jan 25, 2018
Visit Reason
A standard survey was conducted at North Decatur Health and Rehabilitation Center from January 23, 2018 through January 25, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 65
Capacity: 73
Deficiencies: 0
Jan 23, 2018
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 to be in substantial compliance with the Life Safety Code requirements, including the emergency preparedness plan and fire safety standards.
Report Facts
Certified Beds: 73
Census: 65
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 25, 2017
Visit Reason
Complaint investigation was conducted on 8/24/17 and 8/25/17 involving staff and resident interviews and facility observations.
Findings
Based on the information obtained during the investigation, the complaint was unsubstantiated.
Complaint Details
Complaint investigation was conducted and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 28, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey on 2017-02-09.
Findings
All deficiencies cited as a result of the recertification survey on 2017-02-09 were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 66
Capacity: 73
Deficiencies: 0
Feb 7, 2017
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 in substantial compliance with the life safety code requirements related to fire safety and the National Fire Protection Association standards.
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