Inspection Reports for
Nurse Care of Buckhead

The survey revealed multiple deficiencies including missing employee files, failure to conduct required criminal background and fingerprint checks for several employees, and lack of evidence of effective training and competency check-offs for Certified Medication Aide Techs. The facility census was 208 residents.

Complaint GA00253712 was substantiated with deficiencies cited. Complaint GA00253724 was substantiated with no deficiencies cited.

The facility was found deficient in obtaining signed admission packets for residents, protecting residents from verbal abuse by staff, ensuring proper background checks and fingerprinting for employees, following physician orders for laboratory tests, verifying nurse aide registry status, maintaining proper staffing information postings, and providing evidence of medication aide competency training.

The facility failed to consistently follow infection control protocols related to hand hygiene during bathing and incontinent care for two residents. Staff did not wash hands appropriately after glove removal and between care tasks, violating infection prevention standards.

The survey was conducted in response to multiple substantiated complaints related to infection control, resident care, and facility conditions.

The facility was found deficient in multiple areas including failure to provide residents access to funds on weekends, inadequate linen and clothing supplies, unsafe and unsanitary environment, unresolved resident grievances, misappropriation of resident funds, involuntary seclusion, failure to provide timely physician visits, insufficient nursing staff, medication administration errors, inadequate infection control practices, lack of immunization documentation, malfunctioning essential equipment, unsecured handrails, and ineffective pest control.

The facility failed to report complete COVID-19 information to the NHSN between 02/12/2024 and 02/18/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.

The facility did not report complete COVID-19 data to the NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.

The facility failed to report complete COVID-19 information to the NHSN between 01/29/2024 and 02/04/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.

The facility failed to report complete COVID-19 information to the NHSN between 01/22/2024 and 01/28/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.

The facility did not report complete COVID-19 data to the NHSN between 01/15/2024 and 01/21/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.

All deficiencies identified in the 9/7/2023 recertification survey were corrected except for deficiency F641, which will be recited.

The survey revealed multiple deficiencies including failure to provide written notice of transfer appeal rights for hospital transfers, unresolved resident grievances regarding call light response times and food quality, unsecured medication carts and medication storage, inadequate assistance with positioning and food tray set-up, inaccurate medical record documentation, and a non-functioning resident call system.

Complaint Intake numbers GA00227956, GA00230048, and GA00230341 were substantiated with deficiencies cited. Complaint Intake numbers GA00227686, GA00227752, GA00228200, GA00229204, and GA00227492 were found to be unsubstantiated.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain a clean environment, unresolved resident grievances about call light response and food quality, failure to provide written notice of hospital transfer appeal rights, inaccurate medical record documentation, failure to provide necessary assistance with activities of daily living, improper medication administration, lack of ongoing dialysis communication, unsecured medication carts, non-functioning call system for a resident, and ineffective pest control with excessive flies throughout the facility.

The facility was found not in substantial compliance with life safety code requirements, including failure to maintain emergency lighting on multiple floors, deficiencies in the sprinkler system, a hard-to-open exterior exit door, missing documentation of fire drills for the 2nd quarter of 2023, and lack of required generator load testing records.

The facility failed to follow physicians' orders and dietary recommendations regarding food intolerances for one resident (R#5) of 14 sampled residents, specifically related to lactose intolerance and dietary restrictions.

The complaint investigation involved multiple complaint numbers. Some complaints were unsubstantiated, some substantiated with no deficiencies, and one complaint (GA00225955) was substantiated with deficiencies related to food allergy and intolerance management.

The facility failed to follow physicians' orders and dietary recommendations regarding food intolerances for one resident (R#5) who is lactose intolerant. The resident was repeatedly served dairy products despite orders for no dairy and lactose intolerance precautions. Interviews with staff revealed lapses in meal tray checks and dietary staff responsibilities.

The facility failed to properly manage emergency food supplies by not discarding expired items and moldy food, maintain sanitary kitchen conditions including grease buildup and improper use of the three-compartment sink, and failed to maintain hot food temperatures above 135 degrees Fahrenheit on the steam table.

Four complaint intake numbers (GA00218132, GA00218203, GA00218366, GA00219647) were investigated in conjunction with the standard survey and all complaints were unsubstantiated.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to accurately complete PASARR screening for a resident with mental illness, improper food safety practices including use of expired and molded food, unsanitary kitchen conditions, improper use of the three-compartment sink, failure to maintain hot food temperatures, and unsanitary outdoor garbage area.

The facility failed to ensure that activities of daily living (ADL), specifically baths and showers, were provided for four dependent residents (R#1, R#5, R#8, and R#9) as scheduled. Documentation and interviews confirmed multiple missed showers and lack of hair washing, despite resident requests and care plans.

Complaint Intake Numbers GA00216721 and GA00214898 were substantiated with deficiencies related to failure to provide adequate ADL care including bathing and hair washing. Other complaint intake numbers were either substantiated without deficiencies or unsubstantiated.

The facility failed to ensure that activities of daily living (ADL), specifically bathing and hair washing, were provided for four dependent residents. Documentation and interviews revealed multiple missed showers and lack of hair washing for residents R#1, R#5, R#8, and R#9 over several months, despite care plans and schedules. The facility was found in compliance with emergency preparedness and infection control regulations.

The visit was complaint-related, investigating multiple complaint intake numbers. The complaint survey revealed noncompliance with Medicare/Medicaid regulations.

The facility failed to follow care plans for pressure ulcers and accident prevention for sampled residents. Specifically, the facility failed to prevent pressure ulcers, properly assess and report them, and implement timely treatment for one resident. Additionally, the facility failed to transfer a resident safely using two-person assist, resulting in a fall. Documentation of post-fall assessments was also incomplete.

The visit was complaint-related, investigating multiple complaint intake numbers. The complaint survey revealed noncompliance with Medicare/Medicaid regulations. Resident #1's fall was substantiated as the staff failed to follow the care plan requiring two-person assist for transfers.

The facility was found not in substantial compliance with Medicare/Medicaid regulations. Deficiencies included failure to follow care plans for two residents: one related to pressure ulcer prevention and another related to safe transfer procedures, resulting in a resident fall.

The facility was found to be in compliance with emergency preparedness regulations but not in compliance with infection control regulations. Deficiencies included failure to ensure social distancing during meal service and supervised smoking, and failure to ensure hand hygiene during laundry delivery, increasing the risk of infection spread.

The complaint was substantiated with deficiencies cited related to inaccurate assessments, inadequate care planning, lack of psychotropic medication monitoring, and unsafe environment leading to resident elopement.

The facility was found deficient in multiple areas including failure to provide accurate Minimum Data Set assessments, failure to develop and implement comprehensive care plans for schizophrenia and psychotropic medication monitoring, failure to monitor behaviors and side effects related to psychotropic medications, and failure to maintain a safe environment due to non-functional video monitoring equipment and unattended front desk leading to a resident elopement.

The facility failed to maintain smoke barrier walls with a fire resistance rating of at least one-half hour, including unsealed and improperly sealed penetrations, placing 40 residents at risk in the event of fire. These findings were confirmed by staff during the tour.

The facility was found not in substantial compliance with fire safety requirements, including failure to properly maintain stairwells as smokeproof, corridor doors to resist smoke passage, and smoke barrier walls with required fire resistance rating. These deficiencies could place residents at risk in the event of fire.

The facility was found not in substantial compliance due to failure to repair or replace door closers at the elevator door in the basement mechanical room and the exit door at the rehab area, and failure to maintain emergency lighting on the 3rd and 4th floor south corridor, which could place residents and staff at risk.