Inspection Reports for Park Place Nursing Facility
1865 BOLD SPRINGS ROAD, MONROE, GA, 30655
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 5, 2025, found no deficiencies, confirming correction of issues cited in the prior April 10, 2025 survey. Earlier inspections showed a pattern of deficiencies related mainly to medication security, expired supplies, and incomplete care plans for residents receiving oxygen therapy, as well as some fire safety code issues. Complaint investigations generally resulted in unsubstantiated findings or substantiated complaints without deficiencies, except for a substantiated abuse reporting deficiency in early 2024 involving delayed notification to law enforcement. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent surveys indicating correction of previously cited deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
145 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 145
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the April 10, 2025 Recertification Survey.
Findings
All deficiencies cited in the prior April 10, 2025 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Deficiencies: 0
Date: Jun 5, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Park Place Nursing Facility, indicating a regulatory inspection was conducted.
Findings
The report contains only initial comments with no specific deficiencies or findings detailed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 29, 2025
Visit Reason
Life Safety Code Revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted during the Life Safety Code Revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was conducted as a State Licensure survey from April 8 through April 10, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for failing to secure medications left unattended on a medication cart and for storing expired sterile resident care items. Additionally, the facility failed to develop a comprehensive care plan including oxygen and nebulizer treatments for one resident receiving oxygen therapy.
Deficiencies (2)
Medication was left unattended on top of one medication cart and expired sterile resident care items were found in a medication storage room.
Failure to develop a comprehensive care plan that included the use of oxygen and nebulizer treatments for one resident receiving oxygen therapy.
Report Facts
Medication carts: 8
Medication storage rooms: 2
Residents: 24
Oxygen flow rate: 2
Expiration date: 202503
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Observed leaving medications unattended on medication cart and confirmed expectations regarding medication storage. |
| DON | Director of Nursing | Confirmed expectations for medication storage and responsibility for removal of expired items. |
| Assistant Director of Nursing | Provided expectations regarding medication storage and destruction of expired medications. | |
| LPN MDS BB | Licensed Practical Nurse | Described the care plan process and confirmed inclusion of respiratory treatments in care plans. |
Inspection Report
Annual Inspection
Census: 148
Deficiencies: 4
Date: Apr 10, 2025
Visit Reason
A standard annual survey was conducted at Park Place Nursing Facility from April 8, 2025, through April 10, 2025, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to develop comprehensive care plans addressing oxygen and nebulizer treatments, failure to revise care plans to reflect updated advance directives, administering oxygen without a physician's order, and medication storage issues including unsecured medication carts and expired sterile supplies.
Deficiencies (4)
Failed to develop a comprehensive care plan including oxygen and nebulizer treatments for one resident receiving oxygen therapy.
Failed to revise care plan to specifically address updated advance directives for one resident.
Administered oxygen without a physician's order for one resident receiving oxygen therapy.
Failed to secure medication left unattended on medication cart and failed to ensure sterile resident care items were not expired.
Report Facts
Residents present: 148
Residents receiving oxygen therapy: 24
Residents sampled for advance directive care plan review: 59
Residents with advance directive deficiency: 1
Medication carts observed: 8
Medication carts with unsecured medication: 1
Medication storage rooms observed: 2
Expired sterile urethral catheter trays found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse MDS | Interviewed regarding care plan development and comprehensive care plan process |
| FF | Licensed Practical Nurse | Interviewed regarding resident unresponsiveness and CPR initiation |
| AA | Licensed Practical Nurse | Interviewed regarding oxygen therapy and lack of physician order |
| CC | Licensed Practical Nurse | Observed leaving medication unattended and confirmed medication storage policy |
| DON | Director of Nursing | Interviewed regarding oxygen therapy orders, medication storage policies, and overall facility compliance |
| Assistant Director of Nursing | Interviewed regarding medication storage expectations and expired medication handling |
Inspection Report
Life Safety
Census: 156
Capacity: 165
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to ensure the fire alarm was marked red and locked out on the electrical panel, which could potentially affect all residents.
Deficiencies (1)
Fire Alarm was not marked red and locked out on the electrical panel in the Mechanical room.
Report Facts
Census: 156
Total Capacity: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire alarm during facility tour |
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 0
Date: Mar 19, 2025
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaints from March 17, 2025 through March 19, 2025.
Complaint Details
Complaints GA00254012, GA00250419, GA00249865, and GA00244784 were substantiated with no deficiencies cited. Complaints GA00245635 and GA00245943 were unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS and CDC recommended practices for COVID-19. Several complaints were substantiated with no deficiencies cited, and others were unsubstantiated with no deficiencies cited.
Report Facts
Number of complaints investigated: 6
Inspection Report
Follow-Up
Census: 156
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
A Health revisit survey was conducted to verify correction of previously cited deficiencies from a Complaint Investigation survey concluded on February 28, 2024.
Findings
All previously cited deficiencies from the prior Complaint Investigation survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 155
Deficiencies: 2
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as a State Licensure survey at Park Place Nursing Facility from February 22, 2024 through February 28, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient for failing to report an allegation of sexual abuse against a resident to the State Survey Agency and local law enforcement within the required timeframe. Additionally, the facility failed to ensure a fingerprint background check was conducted for one Certified Nursing Assistant. State Health deficiencies were cited during the survey.
Deficiencies (2)
Failure to report an allegation of sexual abuse against one resident to the State Survey Agency within two hours and to notify law enforcement.
Failure to ensure a Georgia Criminal History Check System fingerprint check was conducted for one Certified Nursing Assistant.
Report Facts
Facility census: 155
Employee files reviewed: 10
Sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named as alleged perpetrator in sexual abuse allegation and lacking fingerprint background check |
| LPN CC | Licensed Practical Nurse | On duty during abuse allegation incident and involved in reporting |
| CNA DD | Certified Nursing Assistant | Provided interview regarding abuse reporting procedures |
| CNA EE | Certified Nursing Assistant | Provided interview regarding abuse reporting procedures |
| Administrator | Spoke about reporting procedures and follow-up on abuse allegation | |
| Human Resources Director | HRD | Responsible for background checks and confirmed missing fingerprint check for CNA BB |
Inspection Report
Complaint Investigation
Census: 155
Deficiencies: 2
Date: Feb 28, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00242762 and GA00244005, which were substantiated with deficiencies.
Complaint Details
Complaints GA00242762 and GA00244005 were substantiated. The facility failed to report an allegation of sexual abuse by CNA BB against Resident R5 to law enforcement within two hours as required, although the State Survey Agency was notified. The allegation involved molestation and rape. The resident later stated the allegation was not true, which influenced the facility's reporting to law enforcement.
Findings
The facility failed to ensure a fingerprint background check was conducted for one Certified Nursing Assistant and failed to report an allegation of sexual abuse against a resident to law enforcement within the required timeframe.
Deficiencies (2)
Failure to ensure that a Georgia Criminal History Check System fingerprint check was conducted for one Certified Nursing Assistant.
Failure to report an allegation of sexual abuse against one resident to the State Survey Agency within two hours and to notify law enforcement.
Report Facts
Facility census: 155
Employee files reviewed: 10
Complaint sample size: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in deficiency for lack of fingerprint check and alleged perpetrator in sexual abuse complaint |
| Human Resources Director | Responsible for background checks and confirmed fingerprint check was not conducted for CNA BB | |
| Administrator | Spoke with staff about background checks and abuse reporting; acknowledged failure to notify law enforcement | |
| Licensed Practical Nurse CC | Licensed Practical Nurse | On duty during abuse allegation; did not notify anyone else of the allegation |
| CNA DD | Certified Nursing Assistant | Reported knowledge of abuse reporting procedures |
| CNA EE | Certified Nursing Assistant | Reported facility conducts weekly abuse in-service training |
Inspection Report
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Park Place Nursing Facility, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the report.
Inspection Report
Re-Inspection
Census: 147
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 1/20/23 Standard Survey and Complaint investigation.
Findings
All deficiencies cited in the prior 1/20/23 Standard Survey and Complaint investigation were found to be corrected during the revisit survey.
Inspection Report
Abbreviated Survey
Census: 147
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
An Abbreviated/Partial Extended Survey investigating GA00233126 and GA00233763 was initiated on March 22, 2023 and concluded on March 23, 2023.
Findings
The investigations GA00233126 and GA00233763 were unsubstantiated with no deficiencies cited.
Report Facts
Census: 147
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 10, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 152
Capacity: 165
Deficiencies: 3
Date: Jan 25, 2023
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) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain outside emergency lighting, exit sign lighting in the kitchen, and proper clearance below sprinkler heads in multiple storage closets, which could place residents and staff at risk during an emergency evacuation.
Deficiencies (3)
Failed to maintain outside emergency lights around the perimeter of the nursing home, placing occupants at risk during evacuation to a dark environment.
Failed to maintain exit sign lighting in the kitchen area, placing staff at risk during fire evacuation.
Failed to maintain 18 inches clearance below sprinkler heads in multiple storage closets, including the PPE closet behind the laundry area, potentially impairing sprinkler operation.
Report Facts
Census: 152
Total Capacity: 165
Number of occupants at risk due to emergency lighting failure: 300
Number of staff at risk due to exit sign lighting failure: 5
Number of residents at risk due to sprinkler clearance deficiency: 7
Required clearance below sprinkler heads: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting, exit sign lighting, and sprinkler clearance deficiencies during facility tour |
Inspection Report
Routine
Census: 5
Deficiencies: 1
Date: Jan 20, 2023
Visit Reason
The inspection was conducted as a State Licensure survey from January 16, 2023 through January 20, 2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to provide pharmaceutical services that assured accurate medication administration for two residents (R#13 and R#17), specifically failing to administer medications within one hour of the scheduled time as required by facility policy.
Deficiencies (1)
Failure to administer medications within one hour of the scheduled time for residents R#13 and R#17.
Report Facts
Residents reviewed for medication administration: 5
Medication administration delay times: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Stated that medication could be late due to emergencies or new admissions and explained potential consequences of late medication administration. |
| HH | Licensed Practical Nurse (LPN) | Stated that morning medications should be administered within an hour of the scheduled time and that supervisors could assist if nurses were running late. |
| II | Licensed Practical Nurse (LPN) | Reported frequent delays in medication administration and described medication pass timing and documentation practices. |
| Director of Nursing | Director of Nursing (DON) | Stated that medications should be given within one hour of the scheduled time and that nurses should contact physicians if late. |
| Administrator in Training | Administrator in Training (AIT) | Expected medications to be passed timely per doctor's orders and documented timely. |
Inspection Report
Complaint Investigation
Census: 163
Deficiencies: 3
Date: Jan 20, 2023
Visit Reason
A standard survey was conducted from January 16, 2023 through January 20, 2023, including investigation of multiple complaint intake numbers related to Park Place Nursing Facility.
Complaint Details
The visit included investigation of multiple complaint intake numbers (GA00218143, GA00218562, GA00220237, GA00220261, GA00221164, GA00224095, GA00228199, GA00229386, GA00230257). The facility failed to timely report abuse allegations for one resident (R#2), reporting four days late after the resident reported staff being 'rough' during care.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report abuse allegations, failure to complete and transmit discharge Minimum Data Set (MDS) assessments timely, and failure to administer medications within one hour of the scheduled time for two residents.
Deficiencies (3)
Failure to report allegations of abuse timely for one resident (R#2).
Failure to ensure discharge Minimum Data Set (MDS) assessments were completed and transmitted timely for three residents (R#32, R#129, R#131).
Failure to administer medications within one hour of the scheduled time for two residents (R#13 and R#17).
Report Facts
Resident census: 163
Days overdue: 96
Days overdue: 124
Number of residents with late discharge MDS: 3
Number of residents with medication administration issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Stated medications could be late due to emergencies or new admissions and explained potential consequences of late medication administration |
| HH | Licensed Practical Nurse (LPN) | Stated morning medications should be administered within one hour of scheduled time and supervisors could assist if nurses were running late |
| II | Licensed Practical Nurse (LPN) | Reported frequent delays in medication administration due to high resident and medication volume |
Inspection Report
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Park Place Nursing Facility following a survey completed on November 16, 2021.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
A revisit was conducted from 11/10/21 to 11/16/21 for the Recertification inspection originally conducted on 9/17/21.
Findings
All deficiencies identified in the prior inspection were found to be corrected as of 11/1/21.
Inspection Report
Renewal
Deficiencies: 1
Date: Sep 17, 2021
Visit Reason
A licensure survey was conducted from 09/14/21 to 09/17/21 to assess compliance with state regulations and facility licensure requirements.
Findings
The facility failed to ensure timely notification to a resident's responsible party regarding the resident's death. Specifically, notification to the family of Resident #137 was delayed by approximately three hours after the resident's death.
Deficiencies (1)
Failure to ensure a resident's responsible party was notified timely of their death for one (1) of 42 sampled residents, Resident #137.
Report Facts
Sampled residents: 42
Notification delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Nurse who assessed Resident #137 and delayed notifying the responsible party |
| LPN JJ | Licensed Practical Nurse | Nurse who eventually notified the responsible party approximately three hours after death |
| LPN YY | Hospice Nurse | Hospice nurse contacted during the event |
| Administrator | Facility Administrator who apologized to the family for delayed notification | |
| Clinical Administrator | Interviewed regarding notification procedures and staff responsibilities |
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 2
Date: Sep 17, 2021
Visit Reason
A recertification survey was conducted at Park Place Nursing and Rehab from September 14 through September 17, 2021, including three complaint surveys, one substantiated and two unsubstantiated.
Complaint Details
Three complaint surveys were conducted: GA00217066 was substantiated with a deficiency; GA00215777 and GA00215700 were unsubstantiated.
Findings
The facility was found not in compliance with 42 CFR §483.80, with deficiencies including failure to timely notify a resident's responsible party of death and failure to provide ordered specialized rehabilitative services for one resident.
Deficiencies (2)
Failure to ensure a resident's responsible party was notified timely of their death for one resident (R#137).
Failure to provide specialized rehabilitative services (Physical, Speech, and Occupational Therapy) as ordered for one resident (R#99).
Report Facts
Total census: 134
Sampled residents: 42
Notification delay: 3
Occupational Therapy treatment frequency: 5
Occupational Therapy treatment duration: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Nurse who assessed resident #137 and delayed notifying responsible party of death |
| LPN JJ | Licensed Practical Nurse | Nurse who eventually notified responsible party of resident #137's death |
| LPN YY | Hospice Nurse | Hospice nurse contacted regarding resident #137's pronouncement |
| Director of Rehabilitation | Provided information about discontinuation of therapy services for resident #99 | |
| Director of Nursing | Interviewed regarding lack of payment for rehabilitation services for resident #99 | |
| Administrator | Discussed notification delay and therapy service discontinuation issues | |
| Clinical Administrator | Commented on notification responsibilities for resident #137's death |
Inspection Report
Routine
Census: 134
Deficiencies: 0
Date: Sep 17, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health from September 14 through September 17, 2021.
Findings
The facility was found to be in compliance with 42 CFR §483.73 for Emergency Preparedness and 42 CFR §483.80 for infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Life Safety
Census: 139
Capacity: 165
Deficiencies: 0
Date: Sep 16, 2021
Visit Reason
A Life Safety Code survey was conducted to review the Emergency Preparedness Program and compliance with fire safety regulations at Park Place Nursing Facility.
Findings
The facility was found to be in compliance with the requirements of 42 CFR 483.73 for emergency preparedness and 42 CFR Subpart 483.90(a) for life safety from fire, including adherence to NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Date: Apr 7, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted on April 6-7, 2021 to investigate complaints #GA00213042 and #GA00211347.
Complaint Details
Complaints #GA00213042 and #GA00211347 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Census: 110
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 15, 2021 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 2
Date: Jan 15, 2021
Visit Reason
The visit was a complaint investigation and follow-up related to multiple complaint numbers and a COVID-19 focused infection control survey, initiated due to concerns about infection control practices and resident admissions during the COVID-19 pandemic.
Complaint Details
Complaints GA00207523 and GA00207640 were partially substantiated with deficiencies; GA00205978 and GA00210564 were substantiated with deficiencies; GA00207027 and GA00210728 were unsubstantiated.
Findings
The facility failed to implement a dedicated COVID-19 unit and observation unit for new admissions, failed to consistently screen staff for COVID-19 symptoms, and admitted COVID-19 positive residents into general population areas without dedicated staff. These failures led to an outbreak with multiple residents and staff testing positive and two resident deaths. The facility implemented corrective actions including establishing dedicated COVID-19 and PUI units, staff screening protocols, staff education, and ongoing monitoring.
Deficiencies (2)
Failure to ensure consistent and active screening of staff for COVID-19 symptoms at the start of shifts.
Failure to implement a dedicated COVID-19 unit and observation unit for new admissions, resulting in COVID-19 positive residents being placed throughout the facility without dedicated staff.
Report Facts
Residents tested positive for COVID-19: 24
Staff tested positive for COVID-19: 27
Residents expired: 2
New admissions: 18
Staff educated: 165
Staff tested twice weekly: 165
Residents on COVID-19 unit: 18
Residents on PUI unit: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Interviewed regarding screening and infection control practices |
| DON | Director of Nursing | Interviewed regarding infection control, staff screening, and COVID-19 unit implementation |
| Administrator | Facility Administrator | Interviewed regarding facility policies and COVID-19 unit decisions |
| Clinical Administrator | Clinical Administrator | Interviewed regarding COVID-19 unit and staff screening |
| Medical Director | Medical Director | Participated in QAPI meetings and interviewed about COVID-19 policies |
| CNA AA | Certified Nursing Assistant | Interviewed regarding staff screening and COVID-19 unit knowledge |
| CNA/Screener GG | Certified Nursing Assistant / Screener | Interviewed regarding staff screening duties |
| Unit Clerk EE | Unit Clerk / Screener | Interviewed regarding staff and visitor screening process |
| Dietary Aide VV | Dietary Aide | Interviewed regarding infection control and staff screening |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 18, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00210375.
Complaint Details
Complaint #GA00210375 was substantiated with no deficiencies cited.
Findings
The complaint #GA00210375 was substantiated, but no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
The visit was conducted as a complaint investigation related to complaint #GA00204471, initially by desk review from 4/16/2020 through 4/20/2020, followed by an onsite COVID-19 Focused Survey on 6/16/2020.
Complaint Details
Investigation was initiated due to complaint #GA00204471. The initial desk review was limited due to lack of facility access, with onsite activities planned after entry restrictions were lifted. No substantiated abuse, neglect, or immediate jeopardy was found.
Findings
No deficiencies were cited during the COVID-19 Focused Survey on June 16, 2020. No abuse, neglect, or immediate jeopardy concerns were noted at the time of the investigation.
Report Facts
Resident Census: 119
Inspection Report
Routine
Census: 119
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted to assess compliance with Medicare/Medicaid regulations related to COVID-19 preparedness.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, and specifically compliant with 42 CFR §483.73 related to emergency preparedness.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 1, 2020
Visit Reason
An investigation by desk review of complaint #GA00204746 was conducted at Park Place Nursing Facility from 4/27/2020 through 5/1/2020 due to a complaint received.
Complaint Details
Complaint GA00204746 was investigated initially by desk review and later onsite. The complaint was unsubstantiated with no regulatory violations cited.
Findings
The investigation was initially conducted by desk review without onsite activities due to lack of access. No abuse, neglect, or immediate jeopardy concerns were noted at that time. The complaint was later converted to an onsite event and investigated on 6/16/2020, resulting in an unsubstantiated finding with no regulatory violations cited.
Inspection Report
Re-Inspection
Census: 156
Deficiencies: 0
Date: Jan 21, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey conducted from 11/12/19 through 11/15/19.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Routine
Census: 163
Deficiencies: 5
Date: Nov 15, 2019
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance with several regulatory requirements including grievance handling, nurse staffing information posting, food safety and sanitation, use of outside resources, and maintenance of essential equipment.
Deficiencies (5)
Failed to make prompt effort to file a grievance for a resident missing her lower denture.
Failed to categorize licensed and unlicensed nursing staff per shift and failed to post accurate and current staffing information.
Failed to ensure opened food items were securely covered, labeled and dated; failed to discard food by expiration date; failed to maintain sanitary kitchen conditions; failed to maintain proper cold food holding temperatures; and failed to follow proper puree food handling procedures.
Failed to provide documentation of a written agreement with the company providing outpatient hemodialysis services for a resident.
Failed to maintain essential kitchen equipment in safe operating condition as evidenced by ice buildup inside and around the walk-in freezer door frame.
Report Facts
Resident census: 163
Residents receiving hemodialysis: 3
Resident sample size: 57
Food safety temperature: 41
Food safety temperature observed: 47.9
Food safety temperature observed: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Certified Nursing Assistant | Named in grievance finding related to resident missing dentures |
| DD | Dietary Cook | Named in food safety and puree process findings |
| Social Service Director | Interviewed regarding grievance process and missing denture grievance | |
| Certified Food Service Manager | CFSM | Interviewed regarding food safety, kitchen sanitation, and equipment maintenance |
| Assistant Administrator | Interviewed regarding lack of dialysis contract | |
| Administrator | Interviewed regarding lack of dialysis contract |
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 5
Date: Nov 15, 2019
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to promptly file a grievance for a resident missing her lower denture and concerns about food storage, sanitation, and food temperature management in the kitchen.
Complaint Details
Complaint investigation related to a resident missing her lower denture and multiple food safety and sanitation concerns in the kitchen.
Findings
The facility failed to promptly file a grievance for a resident missing her lower denture and did not maintain proper food safety standards, including uncovered and unlabeled food items, expired food, unsanitary kitchen conditions, improper food holding temperatures, and unsafe food handling practices during pureeing.
Deficiencies (5)
Failure to make prompt effort to file a grievance for a resident missing her lower denture.
Opened food items in dry storage were not securely covered, labeled, or dated; expired food items were not discarded.
Unsanitary kitchen conditions including wet nesting of cookware, dirty food slicer, and unclean shelving.
Failure to maintain proper holding temperatures for cold food items during meal service.
Unsafe food handling during puree process, including not changing gloves and not allowing blender parts to air dry.
Report Facts
Residents receiving oral diet: 161
Sample size: 57
Food temperatures: 47.9
Food temperatures: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant CC | Certified Nursing Assistant | Reported resident missing lower denture during mealtime. |
| Social Service Director | Social Service Director | Interviewed regarding grievance procedures and confirmed no grievance was filed for missing dentures. |
| Certified Food Service Manager | Certified Food Service Manager | Interviewed regarding food storage, sanitation, temperature monitoring, and kitchen policies. |
| Dietary Cook DD | Dietary Cook | Observed during puree food process and interviewed about glove use and food handling. |
Inspection Report
Life Safety
Census: 163
Capacity: 165
Deficiencies: 3
Date: Nov 12, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with fire safety regulations and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically failing to properly maintain the fire alarm and sprinkler systems, including lack of sensitivity testing for smoke detectors, sprinkler piping not protected from freezing, and painted and loaded sprinkler heads.
Deficiencies (3)
Fire alarm system was not properly maintained; no current sensitivity testing of smoke detectors.
Fire sprinkler system was not properly maintained; plastic piping and riser room not protected from freezing.
Fire sprinkler system maintenance and testing deficiencies; painted and loaded sprinkler heads found.
Report Facts
Residents at risk: 163
Certified beds: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
A revisit survey was conducted on September 19, 2018, in conjunction with the investigation of Complaint Intake Number GA 00191295.
Complaint Details
Complaint Intake Number GA 00191295 was investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the July 19, 2018 Standard Survey were found to be corrected. The complaint investigation was found unsubstantiated with no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 19, 2018
Visit Reason
A revisit survey was conducted on September 19, 2018, in conjunction with the investigation of Complaint Intake Number GA 00191295.
Complaint Details
Complaint Intake Number GA 00191295 was investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the July 19, 2018 Standard Survey were found to be corrected. The complaint investigation was found unsubstantiated with no deficiencies.
Inspection Report
Routine
Census: 155
Deficiencies: 2
Date: Jul 19, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations, prompted by an incident where Resident #40 was improperly transferred resulting in injury.
Findings
The facility failed to follow the comprehensive care plan for Resident #40 regarding safe transfer techniques, resulting in two fractured ribs. The ADL communication tool used by CNAs inaccurately documented the resident's transfer needs, leading to improper transfer without assistance or use of a Hoyer lift. Multiple staff interviews and record reviews confirmed the resident was totally dependent and required two-person assistance or a Hoyer lift for transfers.
Deficiencies (2)
Failure to follow comprehensive care plan for safe transfers resulting in injury to Resident #40.
Failure to ensure accurate communication of resident transfer needs on ADL sheet leading to unsafe transfers.
Report Facts
Resident census: 155
Sample size: 46
Date of incident: Jul 5, 2018
Rib fractures: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Transferred Resident #40 improperly without assistance or Hoyer lift, resulting in injury |
| LPN FF | Licensed Practical Nurse | Assigned nurse on 7/5/18 who confirmed ADL sheet inaccuracies and transfer issues |
| Director of Nursing | Director of Nursing | Investigated incident, confirmed transfer errors and ADL sheet inaccuracies |
| CNA GG | Certified Nursing Assistant | Reported Resident #40 required Hoyer lift starting May 2018 and was never truly a one-person assist |
| LPN AA | Licensed Practical Nurse | Documented Resident #40 as totally dependent requiring Hoyer lift |
| Medical Doctor | Medical Doctor | Confirmed Resident #40 was totally dependent and unsafe to transfer by one person |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 1
Date: Jul 19, 2018
Visit Reason
The inspection was conducted following a complaint or incident involving improper transfer of Resident #40, which resulted in injury.
Complaint Details
The investigation revealed that CNA BB, who had never worked with Resident #40 before, transferred the resident without assistance and without using the required Hoyer lift, causing injury. The ADL sheet incorrectly documented the resident as needing one-person assistance, while the resident was actually totally dependent and required two-person assistance or a Hoyer lift. The Director of Nursing confirmed these findings.
Findings
The facility staff failed to follow the comprehensive care plan for Resident #40 regarding safe transfer procedures, leading to the resident sustaining two fractured ribs. The care plan and ADL sheet were inconsistent and not properly updated, contributing to the improper transfer by a CNA unfamiliar with the resident's needs.
Deficiencies (1)
Failure to follow the comprehensive care plan for safe transfer of Resident #40, resulting in injury.
Report Facts
Sample size: 46
Number of fractured ribs: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in the investigation for improper transfer of Resident #40 |
| LPN FF | Licensed Practical Nurse | Interviewed regarding staff knowledge and ADL sheet documentation |
| Director of Nursing | Director of Nursing | Provided explanation and confirmation of findings related to the transfer incident |
Inspection Report
Life Safety
Census: 157
Capacity: 165
Deficiencies: 0
Date: Jul 18, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 13, 2017
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
Routine
Census: 161
Deficiencies: 0
Date: Sep 28, 2017
Visit Reason
A standard survey was conducted at Park Place Nursing Facility from September 25, 2017 through September 28, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 163
Capacity: 165
Deficiencies: 12
Date: Sep 26, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements including emergency lighting, hazardous area enclosures, fire alarm system installation and initiation, sprinkler system installation and maintenance, portable fire extinguisher maintenance, smoke barrier construction, utilities maintenance, HVAC makeup air, smoking regulations, and oxygen cylinder storage.
Deficiencies (12)
Emergency lighting not provided for full distance to public way from F Hall.
Activity Storage Room greater than 50 sq. ft. has no self-closer on door.
Fire alarm system deficiencies including pull stations mounted too high, not within 5 feet of egress doors, visual notification devices mounted too low, and missing smoke detector for fire alarm panel.
Smoke detectors improperly located in HVAC air flow stream.
Facility failed to have full fire sprinkler system coverage; Activity Storage Closet not protected.
Fire sprinkler system maintenance deficiencies including no backflow testing, no data plate on risers, painted sprinkler heads, sprinkler heads loaded with insulation and grease, no 5 year internal and slope tests, and unidentified fire department connections.
Fire extinguishers mounted too high throughout facility.
Smoke barriers and rated walls and ceilings improperly maintained with unprotected penetrations and holes in multiple areas including attics and mechanical rooms.
Electrical system deficiencies including flexible cords run through walls and missing junction box cover in attic.
HVAC fuel fired equipment does not get makeup air from outside.
Smoking area lacks required metal container with self-closing lid; provided ashtray is plastic.
Oxygen cylinder storage deficiencies including empty cylinders not identified and full and empty cylinders mixed together.
Report Facts
Census: 163
Total Capacity: 165
Residents at risk: 42
Residents at risk: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member interviewed and confirmed findings during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 10, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint No. GA00176991.
Complaint Details
Complaint No. GA00176991 was substantiated with no deficiencies cited.
Findings
The complaint was substantiated but no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 26, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint 3 GA00174483 at Park Place Nursing Facility.
Complaint Details
Complaint 3 GA00174483 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was concluded as unsubstantiated with no deficiencies noted in the report.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 7, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00172317, GA00167389, and GA00169422 at Park Place Nursing Facility to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The complaint investigation found no deficiencies and determined compliance with applicable regulations.
Findings
No deficiencies were cited during the complaint survey conducted by a Registered Nurse at the facility.
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