Inspection Reports for
Nurse Care of Buckhead
2920 PHARR COURT SOUTH NW, ATLANTA, GA, 30305
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
23.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
384% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
150% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 6
Date: Dec 11, 2025
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements including resident care, abuse reporting, medication administration, safety, and facility assessment.
Findings
The facility was found deficient in multiple areas including failure to provide incontinence supplies, delayed and incomplete investigations of abuse allegations, unsafe resident transfers, inadequate supervision related to elopement risks, medication administration errors particularly with insulin, and an incomplete facility assessment that failed to identify a secure dementia care unit.
Deficiencies (6)
F 0558: The facility failed to ensure incontinence pads were available for one resident, increasing risk of skin breakdown.
F 0609: The facility failed to timely report and submit investigations of suspected abuse for multiple residents, risking resident safety.
F 0610: The facility failed to conduct thorough investigations of alleged resident-to-resident abuse incidents, missing interviews of involved residents and witnesses.
F 0689: The facility failed to ensure safe transfers for a resident requiring mechanical lift and failed to provide adequate supervision to prevent elopements for three residents.
F 0760: The facility failed to administer scheduled insulin as ordered for one resident, risking uncontrolled blood sugar levels.
F 0838: The facility assessment did not identify the fifth floor as a secure memory care unit, risking inadequate care planning and staff training.
Report Facts
Residents reviewed for incontinence supplies: 45
Residents reviewed for abuse allegations: 43
Residents affected by abuse reporting deficiency: 4
Residents affected by abuse investigation deficiency: 7
Residents sampled for supervision and elopement: 45
Residents affected by supervision and elopement deficiency: 4
Resident weight: 323
Residents on fifth floor: 53
Percentage of facility population on fifth floor: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT2 | Certified Med Tech | Witness to resident-to-resident abuse incident involving R35 and R36 |
| CNA 5 | Certified Nurse Aide | Witness to resident R21 transfer incident |
| UMLPN 2 | Unit Manager Licensed Practical Nurse | Involved in resident R21 transfer incident |
| MT | Maintenance Tech | Witness to resident R21 transfer incident |
| ADON2 | Assistant Director of Nursing | Witness to resident R21 transfer incident |
| RN4 | Registered Nurse | Confirmed insulin administration expectations for resident R40 |
| UMLPN1 | Unit Manager Licensed Practical Nurse | Confirmed insulin administration expectations and reviewed MAR for resident R40 |
| DON | Director of Nursing | Confirmed insulin administration expectations and transfer protocols |
| Administrator | Provided statements on abuse investigations, facility assessment, and transfer incidents |
Inspection Report
Immediate Jeopardy
Census: 212
Deficiencies: 21
Date: Jun 9, 2025
Visit Reason
The inspection was conducted due to regulatory oversight of a nursing home facility, including investigation of complaints, routine and focused surveys, and assessment of compliance with health and safety regulations.
Findings
The facility was found to have multiple deficiencies including failure to provide dignified care, medication management issues, failure to ensure resident rights, inadequate infection control, improper food handling, unsafe environment, and failure to ensure reliable dialysis transportation. Immediate jeopardy was identified related to comprehensive care plans, dialysis transportation, and medication management.
Deficiencies (21)
F0550: The facility failed to provide a dignified existence for residents related to uncovered Foley catheter bags and inadequate assistance during meals for residents with cognitive impairments.
F0554: The facility failed to assess one resident for self-administration of medications and failed to ensure proper medication management.
F0561: The facility failed to honor a resident's right to self-determination related to the choice to be transferred out of bed daily due to staffing and equipment issues.
F0568: The facility failed to provide quarterly resident trust fund statements to residents with accounts, violating resident rights.
F0578: The facility failed to ensure completion and follow-up of advance directives for a resident with severe cognitive impairment.
F0580: The facility failed to notify responsible parties and physicians of changes in residents' conditions following falls and injuries.
F0609: The facility failed to timely report suspected abuse and failed to report follow-up investigations to proper authorities.
F0610: The facility failed to thoroughly investigate allegations of abuse and failed to maintain proper documentation of investigations.
F0641: The facility failed to ensure Minimum Data Set (MDS) assessments were accurate and failed to coordinate PASARR recommendations into care planning for multiple residents.
F0656: The facility failed to develop and implement comprehensive care plans for multiple residents, including plans related to dialysis, PTSD, ADL care, pain management, and positioning.
F0689: The facility failed to provide an environment free of accident hazards, failed to conduct fall risk assessments and implement fall interventions, and failed to secure medications at the bedside.
F0697: The facility failed to provide timely pain management medications to a resident, resulting in untreated pain and multiple medication administration gaps.
F0698: The facility failed to ensure reliable transportation for residents requiring dialysis, resulting in missed dialysis treatments and avoidable hospitalizations.
F0755: The facility failed to ensure routine and PRN medications were available and administered timely to residents, resulting in medication gaps and untreated conditions.
F0804: The facility failed to provide meals at safe and appetizing temperatures and failed to maintain food palatability and proper food handling practices.
F0812: The facility failed to properly discard expired food, label and date food items, maintain sanitary practices in dietary and laundry services, and maintain an effective infection prevention and control program.
F0835: The facility failed to provide effective administrative oversight and leadership to ensure residents received physician-ordered dialysis treatments and transportation.
F0880: The facility failed to maintain infection control processes including sanitary resident rooms, proper hand hygiene, laundry practices, infection prevention and control program, antibiotic stewardship, water management, and proper wound care.
F0881: The facility failed to maintain an effective infection prevention and control program and antibiotic stewardship program, including surveillance, data analysis, and education.
F0883: The facility failed to develop and implement policies and procedures to ensure availability, offering, education, and documentation of COVID-19 vaccinations for residents and staff.
F0921: The facility failed to maintain a safe, functional, and sanitary environment in multiple resident rooms, including dirty air filters, stained ceiling tiles, holes in walls and doors, and unclean resident rooms.
Report Facts
Resident census: 212
Dialysis missed treatments R49: 7
Dialysis missed treatments R87: 7
Medication administration gaps R2 Percocet: 5
Medication administration gaps R55 Percocet: 3
Medication administration gaps R55 Eliquis and budesonide: 4
Expired COVID-19 test kits: 36
Missing narcotic count signatures: 40
Expired food items: 9
Missing medication signatures: 20
Resident rooms with dirty air filters: 11
Residents with missing or inaccurate care plans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DDD | Licensed Practical Nurse | Named in fall incident and termination for failure to assess resident after fall |
| CNA CCC | Certified Nursing Assistant | Named in fall incident report and failure to assess resident after fall |
| DON | Director of Nursing | Named in multiple interviews regarding oversight and expectations |
| Administrator | Facility Administrator | Named in interviews regarding oversight and corrective actions |
| RDCO | Regional Director of Clinical Operations | Named in root cause analysis and education |
| ICPN | Infection Preventionist Nurse | Named in interviews regarding infection control program deficiencies |
| Dietary Manager | Dietary Manager | Named in interviews regarding food temperature and handling issues |
| Maintenance Director | Maintenance Director | Named in interviews regarding facility maintenance and cleanliness |
| Pharmacy Tech EEE | Pharmacy Technician | Named in interview regarding medication refill processes |
Inspection Report
Immediate Jeopardy
Census: 106
Capacity: 212
Deficiencies: 18
Date: Jun 9, 2025
Visit Reason
The inspection was conducted due to regulatory oversight of a nursing home facility, including investigation of complaints, routine and focused surveys, and review of care and safety practices.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, medication management, resident rights, abuse reporting, care planning, fall prevention, medication availability, food safety, infection control, and dialysis transportation. Immediate jeopardy was identified related to dialysis transportation and medication management, which was removed during the survey.
Deficiencies (18)
F0550: The facility failed to provide a dignified existence for residents related to uncovered Foley catheter bags and inadequate assistance with meals for residents with cognitive impairment.
F0554: The facility failed to assess one resident for self-administration of medications and improperly discarded medications found at bedside.
F0561: The facility failed to honor resident rights related to choice to be transferred out of bed daily due to staffing and equipment issues.
F0568: The facility failed to provide quarterly resident trust fund statements to residents with accounts, violating resident rights.
F0580: The facility failed to notify responsible parties and physicians of changes in condition for residents after falls and failed to notify timely abuse allegations.
F0610: The facility failed to thoroughly investigate allegations of abuse and failed to maintain documentation of investigations.
F0641: The facility failed to ensure Minimum Data Set (MDS) assessments were accurate and failed to coordinate PASARR recommendations into care planning for multiple residents.
F0656: The facility failed to develop and implement comprehensive care plans for multiple residents including dialysis, PTSD, ADL care, pain management, and positioning.
F0689: The facility failed to provide a safe environment free of hazards including dirty air filters, broken doors, holes in walls, stained ceilings, and unsanitary resident rooms.
F0698: The facility failed to provide safe and reliable dialysis transportation resulting in missed treatments and hospitalizations for residents dependent on dialysis.
F0755: The facility failed to ensure timely availability and administration of routine and PRN medications for multiple residents, resulting in medication gaps and adverse effects.
F0804: The facility failed to ensure food was served at safe temperatures and failed to maintain sanitary food storage and preparation practices.
F0812: The facility failed to properly discard expired food, label and date food items, maintain sanitary kitchen and laundry practices, and provide adequate infection prevention documentation and education.
F0835: The facility failed to establish an effective Infection Prevention and Control Program and Antibiotic Stewardship program, including surveillance, education, and documentation.
F0880: The facility failed to maintain infection control practices including sanitary resident rooms, proper hand hygiene, appropriate wound care precautions, and laundry infection control.
F0881: The facility failed to maintain a sanitary, safe, and comfortable environment including clean air filters, repaired ceilings, and clean resident rooms.
F0921: The facility failed to maintain a safe, clean, and comfortable environment for residents including debris in resident rooms and dirty air vents.
F0883: The facility failed to develop and implement policies and procedures to ensure COVID-19 vaccination education, offering, and documentation for residents and staff.
Report Facts
Residents affected: 106
Facility census: 212
Dialysis missed treatments: 7
Dialysis missed treatments: 7
Medication administration gaps: 4
Medication administration gaps: 2
Expired food items: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DDD | Licensed Practical Nurse | Named in medication error and fall incident leading to termination |
| CNA CCC | Certified Nursing Assistant | Named in fall incident report and medication error |
| DON | Director of Nursing | Named in multiple findings related to medication management, infection control, and care oversight |
| Administrator | Facility Administrator | Named in oversight failures related to dialysis transportation and medication management |
| ICPN | Infection Preventionist Nurse | Named in infection control program deficiencies |
| RDCO | Regional Director of Clinical Operations | Named in dialysis transportation oversight |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Nurse Care of Buckhead, 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: 219
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2025-03-04.
Complaint Details
The revisit survey was conducted following a complaint survey on 3/4/2025; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 3/4/2025 complaint survey were found to be corrected during the revisit survey.
Report Facts
Census: 219
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations for nursing home operations, including resident care, staff qualifications, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to obtain signed admission packets for residents, failure to protect residents from verbal abuse by staff, incomplete employee background checks and fingerprinting, failure to follow physician orders for laboratory tests, failure to verify nurse aide training, failure to post accurate nurse staffing information, and failure to maintain effective medication aide training and competency documentation.
Deficiencies (7)
F579: The facility failed to provide and obtain signatures of six of 31 sampled residents on admission packets containing Medicare and Medicaid benefit information.
F600: The facility failed to protect two residents from verbal abuse by a staff member who used inappropriate language and was argumentative.
F607: The facility failed to complete criminal background checks and fingerprinting for multiple employees including nurses, administrators, medication aides, and maintenance staff.
F684: The facility failed to ensure physician orders for laboratory tests were followed for two residents, resulting in missing lab results.
F729: The facility failed to verify that one nurse aide had been trained and listed on the State of Georgia Nurse Aide Registry.
F732: The facility failed to post up-to-date and readable nurse staffing information and did not maintain staffing data for 18 months as required.
F940: The facility failed to provide evidence of effective medication aide training and competency check-offs for three certified medication aides.
Report Facts
Residents missing signed admission packets: 61
Sampled residents with missing admission packet signatures: 6
Facility census: 208
Employee files reviewed: 14
Certified Medication Aide Techs reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMAT LL | Certified Medication Aide Tech | Named in verbal abuse incident and missing employee file and competency check-off. |
| Administrator BB | Administrator | Mentioned in background check deficiencies and email communications about admission packet audits. |
| Regional Director of Business Development HH | Regional Director of Business Development | Responsible for admission packet oversight and background check deficiencies. |
| Human Resource Director | Interviewed regarding missing background checks and employee file audits. | |
| Consultant Pharmacist CCC | Consultant Pharmacist | Interviewed about medication pass observations. |
| CMAT MM | Certified Medication Aide Tech | Missing competency check-off documentation. |
| CMAT NN | Certified Medication Aide Tech | Missing competency check-off documentation. |
Inspection Report
Annual Inspection
Census: 208
Deficiencies: 2
Date: Mar 4, 2025
Visit Reason
A State Licensure survey was conducted at Nurse Care of Buckhead from February 11, 2025, through March 4, 2025, to assess compliance with state health regulations and licensure requirements.
Findings
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.
Deficiencies (2)
Failure to maintain personnel files for two of fourteen employees selected for review and failure to ensure criminal background and fingerprint checks were completed for multiple employees including Registered Nurses, Licensed Practical Nurses, Administrators, Certified Medication Aide Techs, Certified Nursing Assistants, Regional Director of Business Development, and Maintenance Director.
Failure to provide evidence of implementation and maintenance of an effective training program and medication administration skills competency check-offs for three of thirty Certified Medication Aide Techs.
Report Facts
Facility census: 208
Employees selected for personnel file review: 14
Certified Medication Aide Techs reviewed for competency: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SS | Registered Nurse, Minimum Data Set Director | Employee file lacked criminal background check |
| TT | Licensed Practical Nurse, MDS Coordinator | Employee file lacked criminal background check |
| BB | Administrator | Employee file lacked Georgia Criminal History Check System (GCHEXS) fingerprint check |
| CC | Administrator | Employee file not located for review |
| LL | Certified Medication Aide Tech | Employee file not located; no skills competency check-off |
| MM | Certified Medication Aide Tech | Employee file lacked GCHEXS fingerprint check and skills competency check-off |
| NN | Certified Medication Aide Tech | Employee file lacked GCHEXS fingerprint check and skills competency check-off |
| Certified Nursing Assistant | Employee file lacked GCHEXS fingerprint check | |
| HH | Regional Director of Business Development | Employee file lacked GCHEXS fingerprint check |
| RR | Maintenance Director | Employee file lacked GCHEXS fingerprint check |
| OO | Certified Nursing Assistant | Employee file had last satisfactory GCHEXS fingerprint check dated 5/21/2021 |
| PP | Certified Nursing Assistant | Employee file had last satisfactory GCHEXS fingerprint check dated 5/21/2021 |
Inspection Report
Complaint Investigation
Census: 208
Deficiencies: 7
Date: Mar 4, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted investigating complaints GA00253712 and GA00253724. The investigation was initiated due to allegations related to admission packet signatures and other compliance issues.
Complaint Details
Complaint GA00253712 was substantiated with deficiencies cited. Complaint GA00253724 was substantiated with no deficiencies cited.
Findings
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.
Deficiencies (7)
Failed to provide and obtain signatures of six of 31 sampled residents' admission packets containing Medicare and Medicaid information.
Failed to protect two residents from verbal abuse by a staff member.
Failed to ensure criminal background checks and fingerprinting were completed for multiple employees and failed to maintain employee files for two employees.
Failed to ensure physician's orders were followed for two residents to obtain laboratory tests.
Failed to ensure one of six employee files had evidence of verification with the State of Georgia's Nurse Aide Registry.
Failed to have up-to-date facility staffing information posted and maintain posted daily nurse staffing data for a minimum of 18 months.
Failed to provide evidence of implementation and maintenance of an effective training program for three Certified Medication Aide Techs' medication administration skills competency check off.
Report Facts
Residents missing signed admission packets: 61
Residents sampled: 31
Residents with verbal abuse incidents: 2
Employees with missing background checks or fingerprinting: 10
Residents with unperformed lab tests: 2
CMATs lacking competency check offs: 3
Facility census: 208
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Certified Medication Aide Tech | Named in verbal abuse incident and missing employee file and competency check offs. |
| MM | Certified Medication Aide Tech | Missing competency check offs. |
| NN | Certified Medication Aide Tech | Missing competency check offs. |
| SS | Registered Nurse | Missing criminal background check. |
| TT | Licensed Practical Nurse | Missing criminal background check. |
| BB | Administrator | Missing fingerprint check. |
| HH | Regional Director of Business Development | Missing fingerprint check. |
| RR | Maintenance Director | Missing fingerprint check. |
| Certified Nursing Assistant | Missing fingerprint check. | |
| OO | Certified Nursing Assistant | Fingerprint check not up to date. |
| PP | Certified Nursing Assistant | Fingerprint check not up to date. |
Inspection Report
Follow-Up
Census: 210
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
A revisit was conducted at Nurse Care of Buckhead to verify correction of deficiencies cited in the prior complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey; all prior deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected as of 2024-11-01.
Report Facts
Facility census: 210
Inspection Report
Re-Inspection
Census: 207
Deficiencies: 1
Date: Oct 24, 2024
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a previous citation.
Findings
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.
Deficiencies (1)
Failure to consistently practice hand hygiene during bathing and incontinent care for two residents.
Report Facts
Census: 207
Inspection Report
Routine
Census: 189
Deficiencies: 21
Date: Aug 1, 2024
Visit Reason
Routine inspection of Nurse Care of Buckhead to assess compliance with regulatory requirements including resident rights, safety, staffing, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including resident financial access, linen and laundry shortages, unresolved resident grievances, medication administration errors, inadequate staffing, infection control lapses, equipment maintenance issues, pest control problems, and failure to provide timely physician visits and vaccinations.
Deficiencies (21)
F0567: Facility failed to have residents' funds available for withdrawal after hours and on weekends, affecting 122 residents.
F0584: Facility failed to provide clean bedding, clothing, and bath linens; maintain ceiling/roof; and control persistent odors, affecting multiple floors and residents.
F0585: Facility failed to ensure resident grievances were resolved within 72 hours despite multiple complaints about laundry, meals, odors, and staff shortages.
F0602: Facility failed to protect residents from misappropriation of property by staff in one case involving unauthorized use of resident funds.
F0603: Facility failed to ensure one resident was free from involuntary seclusion when barricaded with wheelchairs in room.
F0623: Facility failed to notify resident and representative in writing of reason for hospital transfer for one resident.
F0658: Facility failed to provide timely respiratory care for one resident with tracheostomy during respiratory distress.
F0677: Facility failed to provide prompt incontinent care for two residents, placing them at risk for skin breakdown.
F0692: Facility failed to ensure hydration was accessible and adequate for four residents, risking dehydration.
F0693: Facility failed to ensure feeding tube pump was turned on per physician orders for one resident.
F0698: Facility failed to provide pre/post dialysis communication forms for two residents upon leaving for dialysis.
F0712: Facility failed to ensure physician visits every 60 days and documentation for one resident.
F0725: Facility failed to provide sufficient direct care staff coverage and licensed nurse on each shift for multiple days.
F0755: Facility failed to ensure three residents were free from significant medication errors including missed doses.
F0837: Governing body failed to ensure adequate linen, briefs, dietary, and laundry staff to provide timely care and clean linens.
F0880: Facility failed to ensure enhanced barrier precautions were used during high-contact care for one resident.
F0883: Facility failed to assess eligibility, offer, and document consent/refusal for influenza and pneumococcal vaccines for two residents.
F0887: Facility failed to offer/administer or document COVID-19 vaccination or consent/refusal for one resident.
F0908: Facility failed to maintain essential equipment including wheelchairs, ice machines, and walk-in freezer in safe operable condition.
F0924: Facility failed to ensure handrails were securely affixed and had end caps on four floors, creating safety hazards.
F0925: Facility failed to maintain an effective pest control program; residents and staff reported mice, flies, gnats, and fruit flies infestations.
Report Facts
Residents affected: 122
Facility census: 189
Medication not administered days: 9
Briefs ordered: 60
Briefs ordered: 45
Briefs ordered: 47
Briefs ordered: 42
Briefs ordered: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator AA | Administrator | Named in multiple interviews regarding facility issues including staffing, linen shortages, and management |
| Former Administrator WWW | Former Administrator | Named in interviews regarding facility issues including linen shortages and dietary problems |
| Former Director of Nursing OOO | Former Director of Nursing | Named in interviews regarding staffing shortages and medication errors |
| Director of Nursing DON | Director of Nursing | Named in interviews regarding staffing, medication administration, and resident care |
| Infection Preventionist IP | Infection Preventionist | Named in interviews regarding infection control and enhanced barrier precautions |
| Certified Nursing Assistant CNA BBBB | Certified Nursing Assistant | Named in observation and interview regarding incontinent care delays |
| Certified Medication Technician CMT LLLL | Certified Medication Technician | Named in interview regarding medication ordering and administration issues |
| Maintenance Director VV | Maintenance Director | Named in interviews regarding equipment maintenance and pest control |
| Assistant Maintenance Director XX | Assistant Maintenance Director | Named in interviews regarding pest control and maintenance issues |
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 20
Date: Aug 1, 2024
Visit Reason
A Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaint numbers from 6/26/2024 through 8/1/2024.
Complaint Details
The survey was conducted in response to multiple substantiated complaints related to infection control, resident care, and facility conditions.
Findings
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.
Deficiencies (20)
Failed to have residents' funds available for withdrawal after hours and on weekends.
Failed to provide a safe and sanitary homelike environment including clean linens, clothing, and odor control.
Failed to ensure resident grievances were resolved within 72 hours.
Failed to protect residents from misappropriation of property by facility staff.
Failed to ensure one resident was free from involuntary seclusion by barricading with wheelchairs.
Failed to provide written notice for transfer/discharge to hospital for one resident.
Failed to provide timely respiratory care consistent with professional standards for one resident requiring tracheostomy care.
Failed to provide prompt incontinent care for two residents placing them at risk for skin breakdown.
Failed to ensure hydration was easily accessible and provided for four residents placing them at risk of dehydration.
Failed to ensure tube feeding pump was turned on per physician's orders for one resident.
Failed to ensure pre/post dialysis communication form was provided for two residents.
Failed to have sufficient nursing staff coverage to meet resident needs.
Failed to ensure three residents were free from significant medication errors.
Failed to ensure adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meals timely.
Failed to ensure enhanced barrier precautions were utilized during high-contact care for one resident.
Failed to assess, offer, and document influenza and pneumococcal immunizations and refusals for two residents.
Failed to offer/administer or document consent/refusal for COVID-19 vaccines for one resident.
Failed to maintain essential equipment in safe and operable condition including wheelchairs, ice machines, and walk-in freezer.
Failed to ensure handrails were securely affixed and had end caps on four floors.
Failed to maintain an effective pest control program; observed flies, gnats, mice droppings, and open kitchen doors.
Report Facts
Facility census: 189
Medication not administered days: 9
Briefs ordered: 60
Briefs ordered: 45
Briefs ordered: 47
Briefs ordered: 38
Briefs ordered: 42
Walk-in freezer temperature: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator AA | Nursing Home Administrator | Discussed staffing shortages, linen and dietary issues, and personal purchases for facility supplies |
| Former Administrator WWW | Former Administrator | Reported issues with linens, laundry, and dietary services during tenure |
| Former Social Service Director NNN | Former Social Services Director | Reported ongoing linen shortages and grievances not addressed |
| Director of Nursing DON | Director of Nursing | Discussed staffing shortages and medication administration policies |
| Certified Medication Technician LLLL | Certified Medication Technician | Reported medication reorder process and medication shortages |
| Maintenance Director VV | Maintenance Director | Discussed roof repair, ice machine and pest control issues |
| Infection Preventionist IP | Infection Preventionist | Discussed confusion about enhanced barrier precautions and education responsibilities |
| Resident Representative RR63 | Reported resident R11 was barricaded with wheelchairs | |
| Certified Nursing Assistant CNA KKK | Certified Nursing Assistant | Reported resident R45 respiratory distress event |
Inspection Report
Routine
Census: 189
Deficiencies: 22
Date: Aug 1, 2024
Visit Reason
Routine inspection of Nurse Care of Buckhead to assess compliance with regulatory requirements including resident rights, safety, staffing, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including resident financial access, linen and laundry shortages, unresolved resident grievances, medication administration errors, inadequate staffing, infection control lapses, equipment maintenance issues, pest control problems, and failure to provide required vaccinations and physician visits.
Deficiencies (22)
F 0567: The facility failed to have residents' funds available for withdrawal after hours and on weekends, affecting 122 residents with trust fund accounts.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment due to linen shortages, ceiling/roof water damage, and persistent offensive odors on multiple floors.
F 0585: The facility failed to ensure resident grievances were resolved within 72 hours, with ongoing complaints about laundry, food, odors, and staffing.
F 0602: The facility failed to protect residents from misappropriation of property by staff in one case involving unauthorized use of a resident's funds totaling $830.
F 0603: The facility failed to ensure one resident was free from involuntary seclusion when barricaded with wheelchairs in their room against their will.
F 0623: The facility failed to notify a resident and their representative in writing of the reason for transfer/discharge to the hospital.
F 0658: The facility failed to provide timely respiratory care consistent with professional standards for one resident requiring tracheostomy care, resulting in delayed nurse response during respiratory distress.
F 0677: The facility failed to provide prompt incontinent care for two residents, placing them at risk for skin breakdown and diminished quality of life.
F 0692: The facility failed to ensure hydration was easily accessible and provided for four residents, placing them at risk of dehydration and related complications.
F 0693: The facility failed to ensure a feeding tube pump was turned on as ordered for one resident receiving parenteral nutrition, risking weight loss.
F 0698: The facility failed to provide safe, appropriate dialysis care by not providing pre/post dialysis communication forms for two residents.
F 0712: The facility failed to ensure physician visits were conducted every 60 days and documented for one resident.
F 0725: The facility failed to have sufficient nursing staff coverage to meet resident needs, with multiple days lacking RN coverage and staff pulled to non-nursing duties.
F 0727: The facility failed to provide an RN on duty for at least eight consecutive hours a day, seven days a week for three days in January 2024.
F 0755: The facility failed to ensure three residents were free from significant medication errors with multiple missed medication administrations documented.
F 0837: The governing body failed to ensure adequate linen supplies, briefs, and dietary and laundry staff to provide care, clean linens, and meals in a timely manner.
F 0880: The facility failed to ensure enhanced barrier precautions were utilized during high-contact care for one resident with chronic wounds.
F 0883: The facility failed to assess eligibility, offer, and document consent or refusal for influenza and pneumococcal vaccines for two residents.
F 0887: The facility failed to offer/administer or document consent/refusal for COVID-19 vaccines for one resident.
F 0908: The facility failed to maintain essential equipment safely including wheelchairs, ice machines, and walk-in freezer temperatures.
F 0924: The facility failed to ensure handrails were securely affixed and had end caps on four of five floors, creating safety hazards.
F 0925: The facility failed to maintain an effective pest control program, resulting in ongoing infestations of flies, gnats, mice, and fruit flies in resident rooms and kitchen areas.
Report Facts
Residents affected: 122
Facility census: 189
Medication administration errors: 9
Briefs ordered: 60
Briefs ordered: 45
Briefs ordered: 47
Briefs ordered: 42
Briefs ordered: 38
Briefs ordered: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator AA | Administrator | Named in multiple interviews regarding facility issues including staffing, supplies, and resident care |
| Former Director of Nursing OOO | Former Director of Nursing | Named in interviews regarding staffing shortages and medication investigations |
| Former Social Services Director NNN | Former Social Services Director | Named in interviews regarding grievances and linen shortages |
| Maintenance Director VV | Maintenance Director | Named in interviews regarding equipment and pest control issues |
| Infection Preventionist IP | Infection Preventionist | Named in interviews regarding infection control and enhanced barrier precautions |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 30, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00247193.
Complaint Details
Complaint number GA00247193 was investigated and found to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The facility was reviewed for compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a required seven-day reporting period.
Findings
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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
The facility was reviewed for compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a required seven-day reporting period.
Findings
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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The facility was reviewed for compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a seven-day period.
Findings
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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey completed on 10-26-2023 found that all previous citations have been corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Nurse Care of Buckhead, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 195
Deficiencies: 1
Date: Oct 25, 2023
Visit Reason
A revisit survey was conducted on 10/25/2023 to verify correction of deficiencies found during the 9/7/2023 recertification survey.
Findings
All deficiencies identified in the 9/7/2023 recertification survey were corrected except for deficiency F641, which will be recited.
Deficiencies (1)
Deficiency F641 remains uncorrected and will be recited.
Report Facts
Census: 195
Inspection Report
Routine
Deficiencies: 6
Date: Sep 7, 2023
Visit Reason
A State Licensure survey was conducted at Nurse Care of Buckhead from September 4, 2023 through September 7, 2023 to assess compliance with state health regulations.
Findings
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.
Deficiencies (6)
Failure to provide written notice of transfer to hospital including appeal rights and Ombudsman contact information for two residents.
Failure to promptly resolve resident grievances regarding call light response times and food quality affecting multiple residents.
Medication cart left unlocked when nurse not in attendance and medications left unsecured in resident's room.
Failure to provide necessary assistance with positioning and food tray set-up for one resident.
Inaccurate medical record documentation showing antibiotic administration after discontinuation.
Resident call system not functioning for one resident, preventing summoning staff.
Report Facts
Number of residents reviewed for hospitalization: 6
Number of residents sampled for grievances: 47
Number of medication carts observed: 8
Number of residents reviewed for ADLs: 1
Number of residents sampled for medical record review: 46
Number of residents sampled for call system functioning: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Stated that transfer forms did not include appeal rights or Ombudsman information. | |
| Administrator | Confirmed facility only provided written notice of appeal rights on 30-day involuntary discharge notices, not hospital transfers. | |
| Director of Nursing (DON) | Confirmed transfer forms lacked appeal rights information and call light response audits were conducted but no further action taken. | |
| Licensed Practical Nurse (LPN) 2 | Observed leaving medications unsecured and unlocked medication cart. | |
| Certified Nursing Assistant (CNA) 4 | Reported resident chose to sleep late and did not call for assistance with positioning or food tray. | |
| Unit Manager (UM) 2 | Acknowledged resident required repositioning and food tray assistance. | |
| Maintenance Director (MD) | Reported call system in resident's room was fixed on 9/6/2023 and no prior reports of malfunction. |
Inspection Report
Annual Inspection
Census: 189
Deficiencies: 13
Date: Sep 7, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for Nurse Care of Buckhead nursing home.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and homelike environment, unresolved resident grievances regarding call light response and food quality, inadequate notification of hospital transfer appeal rights, inaccurate resident assessments, insufficient assistance with activities of daily living, improper medication administration, lack of orthotic use for limited range of motion, poor communication with dialysis providers, unsecured medication storage, malfunctioning call light system, and ineffective pest control program with excessive flies throughout the facility.
Deficiencies (13)
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment for 189 residents, with holes, peeling paint, urine odors, dirty equipment, and damaged furnishings observed.
F 0585: Facility failed to promptly resolve resident grievances regarding call light response times and food quality, affecting resident council and six residents, with documented long wait times and no effective corrective actions.
F 0623: Facility failed to provide written notice of appeal rights and ombudsman contact information to two residents transferred to hospital, potentially causing lack of understanding of appeal rights.
F 0641: Facility failed to ensure accurate Minimum Data Set assessment for one resident, as nutrition section did not reflect 100% tube feeding intake, leading to inaccurate care planning.
F 0677: Facility failed to provide necessary assistance with positioning and food tray set-up for one resident, contrary to care plan and accepted standards.
F 0684: Facility failed to instruct one resident to rinse mouth after Advair Diskus administration, risking fungal infection.
F 0688: Facility failed to ensure one resident received a palm guard/orthotic for limited range of motion in right hand, with no physician order or documentation.
F 0698: Facility failed to ensure ongoing communication with dialysis unit for two residents, with missing post dialysis information and lack of documentation of communication.
F 0761: Facility failed to lock medication cart when unattended and left medications unsecured in one resident's room during medication pass observation.
F 0791: Facility failed to assist one resident in obtaining dentures, delaying dental services and contributing to nutritional and self-esteem issues.
F 0842: Facility failed to ensure medical record accuracy for one resident, documenting antibiotic administration after order was discontinued.
F 0919: Facility failed to ensure functioning call system for one resident, with call lights in room and bathroom not working, risking unmet needs or emergency response.
F 0925: Facility failed to maintain effective pest control program, with excessive flies observed throughout all five floors affecting multiple residents.
Report Facts
Residents affected: 189
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Named in medication administration and medication cart locking deficiencies |
| Maintenance Director | Maintenance Director | Named in environmental and call system deficiencies |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding call light, dialysis communication, medication documentation, and dental services |
| Unit Manager 2 | Unit Manager | Named in dialysis communication and medication administration deficiencies |
| Certified Nurse Aide 12 | Certified Nurse Aide | Named in orthotic use and call light system deficiencies |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Named in call light system and orthotic use deficiencies |
| Occupational Therapist | Occupational Therapist | Named in orthotic use deficiency |
| Social Services Worker 1 | Social Services Worker | Named in dental services deficiency |
| Social Services Director | Social Services Director | Named in dental services deficiency |
| Certified Medication Aide/Technician | Certified Medication Aide/Technician | Named in call light system deficiency |
Inspection Report
Complaint Investigation
Census: 189
Deficiencies: 13
Date: Sep 7, 2023
Visit Reason
A standard survey was conducted from September 4 through September 7, 2023, including investigations of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
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.
Findings
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.
Deficiencies (13)
Facility failed to maintain a clean, comfortable, and homelike environment with holes, peeling paint, urine odors, and dirty equipment observed throughout.
Facility failed to promptly resolve resident grievances regarding call light response times and food choices affecting multiple residents.
Facility failed to provide written notice of hospital transfer appeal rights and ombudsman contact information for two residents.
Minimum Data Set (MDS) assessment for one resident inaccurately reflected nutritional status related to feeding tube use.
Facility failed to provide necessary assistance with positioning and food tray set-up for one resident with limited range of motion.
Facility failed to ensure ongoing communication between the facility and dialysis unit following hemodialysis treatment for two residents.
Medication cart was left unlocked unattended and medications were left unsecured in a resident's room.
Resident was not instructed to rinse mouth after Advair Diskus administration, risking fungal infection.
Facility failed to ensure one resident received a palm guard/orthotic as needed to address limited range of motion in the right hand.
Medical record documentation inaccurately reflected antibiotic administration after discontinuation for one resident.
Resident's call system was not functioning, preventing effective summoning of staff.
Facility failed to maintain an effective pest control program; excessive flies were observed throughout the facility affecting multiple residents.
Facility failed to ensure one resident received assistance to obtain dentures, impacting nutrition and comfort.
Report Facts
Resident census: 189
Call light wait times: 27
Call light wait times: 23
Call light wait times: 18
Call light wait times: 23
Call light wait times: 20
Call light wait times: 20
Call light wait times: 16
Call light wait times: 22
Call light wait times: 22
Calories per day: 2340
Calories per day: 1680
Medication dosage: 500
Medication administration dates: 3
BIMS score: 3
BIMS score: 11
BIMS score: 13
BIMS score: 12
BIMS score: 12
BIMS score: 6
BIMS score: 6
BIMS score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN2 | Licensed Practical Nurse | Administered Advair Diskus without instructing resident to rinse mouth |
| Maintenance Director | Reported no formal process to audit call system and pest control; stated call system fixed on 9/6/2023 | |
| Director of Nursing | DON | Confirmed deficiencies in documentation, call system, dialysis communication, and transfer notices |
| Unit Manager 2 | Described dialysis communication process and issues with returned forms | |
| Certified Nurse Aide 12 | Observed resident without hand orthotic; unaware of call light malfunction | |
| Occupational Therapist | OT | Reported resident refused hand splint but agreed to palm guard at night; no physician order for palm guard |
| Social Services Worker 1 | SS | Reported resident waiting for dentures and insurance issues |
| Social Services Director | SSD | Reported resident now has insurance coverage for dentures |
Inspection Report
Life Safety
Census: 189
Capacity: 260
Deficiencies: 5
Date: Sep 7, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
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.
Deficiencies (5)
Failed to maintain multiple emergency lights on floors 1-5 hallways and stairwells.
Failed to maintain the sprinkler system; yellow tag placed on riser with sprinkler head deficiencies.
Exterior exit door out of stairwell on 1st floor adjacent to kitchen was hard to open due to tight fit.
Failed to document fire safety drills for the 2nd quarter (April-June) of 2023 for day and early morning shifts.
No records of monthly 30-minute load test for the generator within the last 12 months and no 4-hour load bank test within 36 months.
Report Facts
Census: 189
Total Capacity: 260
Residents at risk due to emergency lighting deficiency: 200
Residents at risk due to sprinkler system deficiency: 50
Residents at risk due to exterior exit door deficiency: 100
Residents at risk due to missing fire drill documentation: 270
Residents at risk due to lack of generator testing: 260
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and observations |
Inspection Report
Routine
Census: 189
Deficiencies: 13
Date: Sep 7, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, environment, grievance resolution, medication administration, and facility operations.
Findings
The facility was found deficient in maintaining a clean and homelike environment, timely response to call lights, proper notification of hospital transfers, accurate resident assessments, adequate assistance with activities of daily living, medication administration errors, restorative care, dialysis communication, medication security, dental services, medical record accuracy, call system functionality, and pest control.
Deficiencies (13)
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment for 189 residents, with observations of holes, peeling paint, urine odors, dirty equipment, and damaged furnishings.
F 0585: Facility failed to ensure prompt efforts to resolve resident grievances regarding call light response times and food choices, affecting resident council and six residents.
F 0623: Facility failed to provide written notice of appeal rights and ombudsman contact information to two residents transferred to hospital.
F 0641: Facility failed to ensure accurate Minimum Data Set assessment for one resident, inaccurately reflecting nutritional status related to feeding tube use.
F 0677: Facility failed to provide necessary assistance with positioning and food tray set-up for one resident, contrary to care plan and accepted standards.
F 0684: Facility failed to instruct resident to rinse mouth after Advair Diskus administration, risking fungal infection.
F 0688: Facility failed to ensure one resident received a palm guard/orthotic as needed to maintain range of motion in right hand.
F 0698: Facility failed to ensure ongoing communication with dialysis unit for two residents, resulting in missing post dialysis information.
F 0761: Facility failed to lock medication cart when unattended and left medications unsecured in one resident's room during medication pass.
F 0791: Facility failed to assist one resident in obtaining dentures, contributing to nutritional and self-esteem issues.
F 0842: Facility failed to ensure medical record accuracy for one resident, documenting antibiotic administration after order was discontinued.
F 0919: Facility failed to ensure functioning call system for one resident, creating risk of unmet needs or inability to summon staff.
F 0925: Facility failed to maintain effective pest control program, resulting in excessive flies throughout the building affecting multiple residents.
Report Facts
Residents affected: 189
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 10
Inspection Report
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Nurse Care of Buckhead, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 199
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
A revisit was conducted at Nurse Care of Buckhead on 10/31/22 to verify correction of deficiencies cited as a result of the complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey; all deficiencies from the complaint survey were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected as of 10/10/22.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Aug 26, 2022
Visit Reason
A Licensure Survey was conducted from 8/22/22 through 8/26/22 to assess compliance with licensure requirements for Nurse Care of Buckhead.
Findings
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.
Deficiencies (1)
Failure to follow physicians' orders and dietary recommendations regarding food intolerances for one resident (R#5).
Report Facts
Number of sampled residents: 14
Units of Lactaid medication: 9000
Number of Lactaid tablets: 3
Brief Interview for Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding meal tray checks and resident dietary compliance | |
| Licensed Practical Nurse (LPN) | Interviewed about diet sheet preparation and meal tray accuracy | |
| Dietary Manager (DM) | Interviewed about dietary staff responsibilities and tray checking procedures | |
| Registered Dietician (RD) | Interviewed about tray card preparation and dietary adherence |
Inspection Report
Complaint Investigation
Census: 192
Deficiencies: 1
Date: Aug 26, 2022
Visit Reason
A complaint investigation was initiated on 2022-08-22 and concluded on 2022-08-26 regarding multiple complaint numbers. Some complaints were substantiated with deficiencies, including one related to food allergies and intolerances.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to follow physicians' orders and dietary recommendations regarding food intolerances for one resident (R#5) with lactose intolerance.
Report Facts
Resident Census: 192
Sampled Residents: 14
Physician's Order Dosage: 9000
Annual Minimum Data Set Date: Jun 10, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant | Interviewed regarding meal tray checks and serving procedures |
| BB | Licensed Practical Nurse | Interviewed about diet sheet printing and staff expectations for meal tray accuracy |
| Dietary Manager | Interviewed about dietary staff responsibilities and tray checking procedures | |
| Registered Dietician | Interviewed about preparation of tray cards and dietary staff adherence to orders |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 21, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00225103.
Complaint Details
Complaint #GA00225103 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Nurse Care of Buckhead, indicating a regulatory inspection was conducted.
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
Abbreviated Survey
Census: 192
Deficiencies: 0
Date: Feb 23, 2022
Visit Reason
An Abbreviated Survey was conducted to investigate complaints #GA00221693 and #GA00220616 in conjunction with a Revisit Survey.
Complaint Details
Complaint #GA00221693 was unsubstantiated; Complaint #GA00220616 was substantiated; no regulatory violations were cited for either complaint.
Findings
Complaint #GA00221693 was unsubstantiated with no regulatory violations cited. Complaint #GA00220616 was substantiated but no regulatory violations were cited. All deficiencies from the December 30, 2021 standard survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 192
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
A revisit survey was conducted from February 22 through February 23, 2022, to investigate complaints GA00220616 and GA00221694 and to verify correction of deficiencies cited in the standard survey on December 30, 2021.
Complaint Details
Complaints GA00220616 and GA00221694 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were found to be unsubstantiated, and all previously cited deficiencies were corrected as of this revisit survey.
Inspection Report
Life Safety
Census: 174
Capacity: 220
Deficiencies: 0
Date: Jan 4, 2022
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with fire safety requirements and participation in Medicare/Medicaid at Nursecare of Buckhead.
Findings
The facility was found in compliance with the Life Safety Code requirements and related NFPA standards. The survey included inspection of the 4th floor hallways and stairwell enclosures, which met compliance standards.
Report Facts
Stories: 5
Construction Type: 1
Certified Beds: 220
Inspection Report
Renewal
Census: 172
Deficiencies: 4
Date: Dec 30, 2021
Visit Reason
The inspection was a Licensure Survey conducted from December 27, 2021 through December 30, 2021 to assess compliance with licensure requirements.
Findings
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.
Deficiencies (4)
Failed to use or discard emergency food supply prior to expiration and failed to discard molded food items in dry storage.
Failed to maintain sanitary conditions of kitchen equipment including grease buildup on range hood, stove, ovens, and warmers.
Failed to demonstrate proper use of the three-compartment sink during dishwashing process.
Failed to maintain holding temperatures of hot foods on the steam table above 135 degrees Fahrenheit.
Report Facts
Census: 172
Sample size: 50
Expired food items: 33
Steam table temperature: 125
Ice buildup: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chef CC | Chef | Observed improperly placing clean food processor lid on dirty end of three-compartment sink |
| Regional District Manager BB | Regional District Manager | Interviewed regarding proper use of three-compartment sink and steam table temperature monitoring |
| Registered Dietitian RR | Registered Dietitian | Provided oversight through monthly Sanitation Audit and described role as primarily clinical |
| Dietary Manager DM | Dietary Manager | Interviewed regarding expired food items, kitchen cleaning schedules, and ice buildup in freezer |
| Administrator | Administrator | Stated expectations for cleanliness and food safety compliance |
Inspection Report
Routine
Census: 172
Deficiencies: 3
Date: Dec 30, 2021
Visit Reason
A standard survey was conducted from December 27, 2021 through December 30, 2021, including investigation of four complaint intake numbers, all of which were unsubstantiated.
Complaint Details
Four complaint intake numbers (GA00218132, GA00218203, GA00218366, GA00219647) were investigated in conjunction with the standard survey and all complaints were unsubstantiated.
Findings
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.
Deficiencies (3)
Failed to ensure one of four sampled residents with mental illness had a Level I PASARR accurately completed prior to admission.
Failed to use or discard emergency food supply prior to expiration, failed to discard molded food items, failed to maintain sanitary kitchen conditions, failed to demonstrate proper use of three-compartment sink, and failed to maintain hot food holding temperatures above 135 degrees F.
Failed to dispose of garbage and refuse properly; outdoor garbage and refuse area was not maintained in a sanitary manner.
Report Facts
Resident census: 172
Expired food items: 33
Sample size: 50
Steam table temperature: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Regional District Manager | Interviewed regarding proper use of three-compartment sink and food temperature monitoring |
| CC | Chef | Observed improperly placing clean food processor lid on dirty sink area |
| RR | Registered Dietitian | Provided oversight via monthly Sanitation Audit and interviewed about dietary operations |
| Administrator | Confirmed incomplete PASARR, expectations for dietary and kitchen cleanliness, and responsibility for dumpster area sanitation | |
| DM | Dietary Manager | Observed during food safety inspection and interviewed about expired food and kitchen sanitation |
Inspection Report
Routine
Census: 172
Deficiencies: 3
Date: Dec 30, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to mental health screening (PASARR), food safety and sanitation, and proper disposal of garbage and refuse at the nursing facility.
Findings
The facility failed to accurately complete a Level I PASARR screening for a resident with mental illness, failed to discard expired and molded food items, maintain sanitary kitchen conditions, properly use the three-compartment sink, maintain hot food temperatures, and ensure the outdoor garbage area was clean.
Deficiencies (3)
F 0645 PASARR screening for mental disorders or intellectual disabilities was incomplete and inaccurate for one resident, missing critical information that should have triggered a Level II assessment.
F 0812 The facility failed to discard expired emergency food supplies and molded food items, maintain sanitary kitchen equipment, properly use the three-compartment sink, and maintain hot food holding temperatures above 135 degrees F.
F 0814 The outdoor garbage and refuse area was not maintained in a sanitary manner, with wet debris and decomposing paper observed around the dumpster.
Report Facts
Facility census: 172
Sample size: 50
Expired food items: 33
Temperature: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chef CC | Chef | Observed improper use of three-compartment sink and food handling |
| DM | Dietary Manager | Interviewed regarding expired food, kitchen sanitation, and dumpster area cleanliness |
| RDM BB | Regional District Manager | Interviewed about proper use of three-compartment sink and food temperature monitoring |
| RD RR | Registered Dietitian | Interviewed about clinical role and monthly sanitation audits |
| Administrator | Interviewed confirming expectations for kitchen cleanliness and PASARR screening accuracy |
Inspection Report
Re-Inspection
Census: 173
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the survey on September 21, 2021.
Findings
All deficiencies cited as a result of the survey on September 21, 2021 were found to be corrected.
Inspection Report
Re-Inspection
Census: 173
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
A revisit was conducted to verify correction of deficiencies cited in the survey on September 21, 2021.
Findings
All deficiencies cited as a result of the prior survey were found to be corrected during this revisit.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 21, 2021
Visit Reason
A Licensure Survey was conducted from September 10, 2021 through September 21, 2021 to assess compliance with nursing care requirements and facility policies.
Findings
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.
Deficiencies (1)
Failure to provide scheduled baths and showers to four dependent residents, including lack of hair washing and inadequate documentation.
Report Facts
Sample size: 15
Missed showers for R#1: 7
Missed showers for R#1: 6
Missed showers for R#1: 4
Missed showers for R#5: 4
Missed showers for R#5: 3
Missed showers for R#8: 12
Missed showers for R#9: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant (CNA) | Interviewed regarding shower schedules and documentation for R#1 |
| CC | Certified Nursing Assistant (CNA) | Interviewed regarding shower schedules and care for R#8 |
| EE | Certified Nursing Assistant (CNA) | Interviewed regarding care and bathing for R#9 |
| Licensed Practical Nurse (LPN) Unit Manager | Licensed Practical Nurse (LPN) Unit Manager | Interviewed regarding R#9 shower preferences |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding expectations for shower documentation and care |
| Administrator | Administrator | Interviewed regarding facility policy on dry shampoo use |
Inspection Report
Complaint Investigation
Census: 186
Deficiencies: 1
Date: Sep 21, 2021
Visit Reason
An Abbreviated/Partial Extended Survey and Focused Infection Control survey was conducted in response to multiple complaint intake numbers, some substantiated with deficiencies and others unsubstantiated, at Nurse Care of Buckhead from September 8 through September 10, 2021, with a follow-up investigation on September 21, 2021.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide scheduled showers and hair washing for dependent residents R#1, R#5, R#8, and R#9, with multiple missed showers and lack of documentation of hair washing over several months.
Report Facts
Census: 186
Missed showers for R#1: 7
Missed showers for R#1: 6
Missed showers for R#1: 4
Missed showers for R#5: 4
Missed showers for R#5: 0
Missed showers for R#5: 3
Missed baths/showers for R#8: 12
Missed baths/showers for R#9: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 22, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209699.
Complaint Details
Complaint #GA00209699 was substantiated with no regulatory violations.
Findings
The complaint #GA00209699 was substantiated but no regulatory violations were found during the survey.
Inspection Report
Routine
Census: 171
Deficiencies: 0
Date: Jan 12, 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 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Report Facts
Total census: 171
Inspection Report
Follow-Up
Census: 182
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 15, 2020 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on October 15, 2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the October 15, 2020 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 182
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 15, 2020 Complaint Survey.
Findings
All deficiencies cited as a result of the October 15, 2020 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 168
Deficiencies: 3
Date: Oct 15, 2020
Visit Reason
An Abbreviated/Partial Extended survey was conducted from 10/13/2020 through 10/15/2020 to investigate multiple complaint intake numbers. The survey revealed the facility was not in substantial compliance with Medicare/Medicaid regulations.
Complaint Details
The visit was complaint-related, investigating multiple complaint intake numbers. The complaint survey revealed noncompliance with Medicare/Medicaid regulations.
Findings
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.
Deficiencies (3)
Failed to follow care plan for pressure ulcers and accidents for sampled residents.
Failed to prevent development of pressure ulcers, properly assess and report pressure ulcers, and implement timely treatment for one resident.
Failed to ensure resident environment was free of accident hazards and provide adequate supervision and assistance devices to prevent accidents; resident fell due to improper transfer with Hoyer lift.
Report Facts
Resident census: 168
Braden Score: 14
Braden Score: 12
Number of wounds: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Care Physician | Provided information about Resident #5's wounds and treatment | |
| NN | Wound Care Nurse | Reported late discovery of wounds on Resident #5 and staff communication issues |
| LL | Certified Nursing Assistant | Reported noticing wounds on Resident #5 on 6/15/2020 |
| DD | Unit Manager | Interviewed regarding Resident #1 fall and care plan adherence |
Inspection Report
Complaint Investigation
Census: 168
Deficiencies: 2
Date: Oct 15, 2020
Visit Reason
An Abbreviated/Partial Extended survey was conducted from 10/13/2020 through 10/15/2020 to investigate multiple complaint intake numbers. The survey aimed to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to follow the care plan for Resident #5 regarding weekly skin assessments to prevent pressure ulcers.
Failure to follow the care plan for Resident #1 regarding safe transfer procedures, leading to a fall from a Hoyer lift due to one-person assist instead of two-person assist as required.
Report Facts
Resident Census: 168
Brief Interview Mental Status (BIMS) score: 3
Brief Interview Mental Status (BIMS) score: 0
Date of Resident #1 fall: Jan 6, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed on 10/15/2020 regarding Resident #1 fall and care plan compliance | |
| Social Worker | Interviewed on 10/15/2020 regarding Resident #1 fall and care plan compliance | |
| Employee DD | Unit Manager | Interviewed on 10/15/2020 regarding Resident #1 fall and care plan compliance |
Inspection Report
Routine
Census: 164
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 183
Deficiencies: 0
Date: Jul 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted at Nurse Care of Buckhead to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A Desk Review for the COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on May 28, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Routine
Census: 193
Deficiencies: 3
Date: Apr 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on April 7, 2020.
Findings
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.
Deficiencies (3)
Failure to ensure social distancing was practiced for six un-sampled residents during meal service.
Failure to ensure social distancing for seven of twelve residents during supervised smoking.
Failure to ensure hand hygiene was performed during laundry delivery on one of five floors.
Report Facts
Total Residents: 193
Residents observed during meal service: 6
Residents observed during supervised smoking: 12
Floors observed for hand hygiene during laundry delivery: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Provided information about resident seating during meal service | |
| Laundry Aide (LA) #1 | Observed failing to perform hand hygiene during laundry delivery | |
| Activity Aide #2 | Observed handing out cigarettes and not moving residents to maintain social distancing | |
| Administrator | Observed and intervened to move residents to maintain social distancing | |
| Director of Nursing | Present during staff training review | |
| Infection Control Nurse | Present during staff training review |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 29, 2020
Visit Reason
A complaint survey was conducted from 2020-01-27 to 2020-02-03 to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint 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
Complaint Investigation
Deficiencies: 0
Date: Jun 10, 2019
Visit Reason
A complaint survey was conducted from 2019-06-04 to 2019-06-10 to investigate multiple complaints identified by their codes.
Complaint Details
The survey investigated complaints GA00196127, GA00197129, GA00196930, GA00196185, GA00195758, and GA00195272 and found no deficiencies.
Findings
The investigation found no deficiencies; the facility was in compliance with Federal and State Long Term Care Requirements.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 7, 2019
Visit Reason
A Revisit Survey was conducted from 3/5/19 through 3/7/19 to determine if previously cited deficiencies from the Complaint survey of 2/11/19 had been corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 2/11/19; deficiencies cited in that complaint survey were found corrected.
Findings
The revisit survey determined that the previously cited deficiencies from the complaint survey had been corrected as alleged in the Plan of Correction.
Inspection Report
Re-Inspection
Census: 205
Deficiencies: 0
Date: Mar 7, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey conducted from 12/21/2018 to 2/11/2019 for complaint # GA00193631.
Complaint Details
The revisit survey was conducted following a complaint investigation for complaint # GA00193631. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the prior complaint survey were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 11, 2019
Visit Reason
A complaint survey was conducted from December 21, 2018 to February 11, 2019 to investigate complaint GA00193631 regarding compliance with Federal and State Long Term Care Requirements.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Facility failed to provide an accurate Minimum Data Set (MDS) assessment for one resident by not coding the MDS accurately.
Facility failed to develop and implement a comprehensive, person-centered care plan for one resident, lacking measurable planning or interventions for schizophrenia and psychotropic medication monitoring.
Facility failed to provide monitoring for behaviors and adverse reactions related to psychotropic medications Depakote and risperidone for one resident.
Facility failed to provide a safe environment by not ensuring video monitoring equipment was functional in the lobby and allowing the front desk to be unattended, resulting in a resident eloping undetected.
Report Facts
Resident reviewed: 1
Dates of admission and discharge: Resident R#1 admitted on 2018-10-22 and discharged on 2018-12-20.
MDS date: MDS dated 2018-11-19 for Resident R#1.
Psychotropic medication doses: Risperidone 0.5 mg twice daily started 2018-11-15, increased to 1 mg twice daily on 2018-11-21; Depakote 250 mg twice daily started 2018-12-06, increased to 325 mg twice daily on 2018-12-14.
Security camera downtime: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding care plan deficiencies and resident elopement; acknowledged deficiencies and lack of camera monitoring. | |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies and psychotropic medication monitoring; acknowledged omissions were unacceptable. |
| Physician II | Physician | Interviewed by telephone; confirmed knowledge of resident and medication orders. |
| Receptionist AA | Front Desk Receptionist | Reported leaving front desk unattended briefly leading to resident elopement; informed manager about non-functional camera. |
| Receptionist CC | Front Desk Attendant | On duty during resident elopement; confirmed front door unlocked and cameras not monitored prior to incident. |
| Receptionist GG | Front Desk Receptionist | Reported frequent brief absences from front desk and recent inservice about locking doors and camera monitoring. |
| Maintenance Director | Maintenance Director | Interviewed regarding security camera system maintenance; unaware of camera downtime prior to elopement. |
| Psychiatric Nurse Practitioner | Psychiatric Nurse Practitioner | Assessed resident and prescribed psychotropic medications; provided monitoring instructions. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00193724 and GA00194376.
Complaint Details
Complaint numbers GA00193724 and GA00194376 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 24, 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 deficiencies had been corrected during the follow-up visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
The abbreviated survey was conducted to investigate complaints #GA00192381 and GA00192862.
Complaint Details
The survey was complaint-related, investigating complaints #GA00192381 and GA00192862, with no deficiencies found.
Findings
No deficiencies were cited during the abbreviated survey.
Inspection Report
Re-Inspection
Census: 208
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the October 18, 2018 standard survey.
Findings
All deficiencies cited in the prior October 18, 2018 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 10, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags, with all but one deficiency corrected.
Findings
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.
Deficiencies (1)
Facility failed to maintain smoke barrier walls with construction having a fire resistance rating of at least one-half hour, including unsealed penetrations and improper sealing methods.
Report Facts
Residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G confirmed the findings during the facility tour |
Inspection Report
Life Safety
Census: 206
Capacity: 220
Deficiencies: 3
Date: Oct 18, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
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.
Deficiencies (3)
The stairwells were not properly sealed between the fifth floor and roof deck and had multiple unsealed penetrations.
Corridor doors were not properly maintained to resist the passage of smoke, with gaps greater than 0.5 inch on several room doors.
Smoke barrier walls had unsealed penetrations, improperly sealed penetrations using sheetrock compound instead of fire caulk, and fire caulk applied on top of sheetrock compound.
Report Facts
Census: 206
Certified beds: 220
Number of deficient room doors: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Staff interviewed and confirmed findings during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA0000189304 and GA00190084 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to two complaints, and no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 6, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00188785 and GA00188777 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation of #GA00188785 and GA00188777; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00188217 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00188217 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00185843 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00185843 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Census: 211
Deficiencies: 0
Date: Feb 9, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey on December 21, 2017.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 5, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 214
Capacity: 220
Deficiencies: 2
Date: Dec 19, 2017
Visit Reason
The 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) 101 Life Safety Code 2012 Edition.
Findings
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.
Deficiencies (2)
Failed to repair or replace door closer at elevator door in basement mechanical room and exit door at rehab area.
Failed to maintain emergency lighting on the 3rd and 4th floor south corridor.
Report Facts
Census: 214
Certified Beds: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M interviewed and confirmed findings during the tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 11, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaints #GA00180387 and GA00180848 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
The complaint survey investigated complaints #GA00180387 and GA00180848 and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted on 11/11/2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2017
Visit Reason
Complaint investigation was conducted on 9/28/2017 involving staff and resident interviews and observations throughout the facility.
Complaint Details
Complaint investigation was substantiated; however, no citations were issued for substantiated healthcare practice.
Findings
The complaint was substantiated based on the information obtained, but the facility was not cited for substantiated healthcare practice.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 19, 2017
Visit Reason
A follow-up inspection was conducted to verify correction of previously identified deficiencies.
Findings
All deficiencies identified in prior inspections had been corrected as of the follow-up visit.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 6, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate Complaints GA00176673.
Complaint Details
The survey was complaint-related for Complaints GA00176673. No deficiencies were cited indicating compliance.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Requirements. No deficiencies were cited.
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