Inspection Reports for Parkside Center for Nursing and Rehab at Ellijay
1362 SOUTH MAIN STREET, GA, 30540
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Deficiencies: 0
Mar 21, 2025
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 have been corrected during the follow-up visit.
Inspection Report
Deficiencies: 0
Mar 20, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Parkside Center for Nursing and Rehab at Ellijay, 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: 84
Deficiencies: 0
Mar 20, 2025
Visit Reason
A revisit survey was initiated on 3/19/2025 and concluded on 3/20/2025 at Parkside Center for Nursing and Rehab to verify correction of deficiencies cited during the 1/31/2025 recertification survey.
Findings
All deficiencies cited as a result of the 1/31/2025 recertification survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Jan 31, 2025
Visit Reason
A State Licensure survey was conducted at Parkside Center for Nursing and Rehab from January 28, 2025, through January 31, 2025, to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to provide written transfer notices to residents or their representatives for emergent hospital transfers, failure to identify target behaviors for monitoring antipsychotic medication effectiveness, and failure to include oxygen use in a resident's comprehensive care plan.
Deficiencies (3)
| Description |
|---|
| The facility failed to ensure three of five residents and/or their representatives were provided with written transfer notice containing all required information for emergent hospital transfers. |
| The facility failed to identify target behaviors for monitoring effectiveness of antipsychotic medication for one resident reviewed for unnecessary medications. |
| The facility failed to complete the comprehensive care plan to include the use of oxygen for one resident reviewed for care planning. |
Report Facts
Residents reviewed for facility initiated emergent hospital transfer: 23
Residents with deficient transfer notices: 3
Residents reviewed for unnecessary medications: 23
Residents reviewed for care planning: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated discharge summaries were not provided in a language residents or family could understand | |
| Unit Manager (UM) 1 | Stated SBAR form, face sheet, and medication list were sent to hospital but separate discharge summary was not provided | |
| Director of Nursing (DON) | Stated facility did not have a separate discharge sheet indicating reason for hospital transfer in understandable language; also stated expectation for behavior documentation with medication administration and care plan inclusion of oxygen use | |
| Registered Nurse (RN) 3 | Unable to show documentation of behaviors indicating need for lorazepam | |
| Licensed Practical Nurse (LPN) 8 | Confirmed oxygen should be on care plan to communicate resident care needs | |
| MDS Coordinator (MDSC) | Acknowledged oxygen use should be on care plan and stated it would be corrected immediately |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 4
Jan 31, 2025
Visit Reason
A recertification survey was conducted from January 28, 2025 through January 31, 2025, including investigation of three complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written transfer notices for emergent hospital transfers, incomplete comprehensive care plans regarding oxygen use, failure to ensure timely medication receipt and administration, and inadequate monitoring of antipsychotic medication effectiveness.
Complaint Details
Complaint Intake Numbers GA00252381, GA00249036, and GA00251242 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide written transfer notice containing all required information to three of five residents and/or their representatives for emergent hospital transfers. | SS= D |
| Failure to complete the comprehensive care plan to include the use of oxygen for one resident. | SS= D |
| Failure to ensure medications were received in a manner that allowed administration for one resident, resulting in delayed medication administration. | SS= D |
| Failure to identify target behaviors for monitoring effectiveness of antipsychotic medication for one resident. | SS= D |
Report Facts
Residents reviewed for emergent hospital transfer: 23
Residents with deficient transfer notice: 3
Resident census: 99
Residents reviewed for care planning: 23
Resident with incomplete oxygen care plan: 1
Residents reviewed for medication administration: 23
Resident with medication receipt failure: 1
Residents reviewed for unnecessary medications: 5
Resident with inadequate antipsychotic monitoring: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding transfer notices, care planning, medication administration, and antipsychotic monitoring. |
| Unit Manager 1 | Unit Manager | Interviewed regarding transfer documentation and discharge summaries. |
| Licensed Practical Nurse 8 | Licensed Practical Nurse | Interviewed regarding oxygen use on care plan. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding oxygen use on care plan. |
| Registered Nurse 4 | Registered Nurse | Interviewed regarding medication delivery and administration. |
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Interviewed regarding pharmacy delivery and medication administration. |
| Medical Director | Medical Director | Interviewed regarding expectations for medication administration and stat delivery. |
| Registered Nurse 3 | Registered Nurse | Interviewed regarding monitoring of antipsychotic medication effectiveness. |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding medication delivery to rehab unit. |
Inspection Report
Life Safety
Census: 99
Capacity: 100
Deficiencies: 5
Jan 31, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with patient sleeping room doors not closing properly, emergency lighting failure, sprinkler system maintenance deficiencies, improper smoke barrier construction, and unauthorized use of a portable space heater.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Door to patient room 162 failed to close and secure properly. | D |
| Emergency lighting at the front door failed to operate upon testing. | D |
| Sprinkler system maintenance deficiencies including a yellow tagged dry sprinkler system and missing escutcheon plates in shower facility. | D |
| Failure to maintain proper rating and construction properties of wall components and fire barriers; penetrations above fire doors and use of improper rating material (Great Stuff) in multiple rooms and ceilings. | D |
| Failure to provide proper documentation for use of a portable space heater located in a shower room. | D |
Report Facts
Census: 99
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 18, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Parkside Center for Nursing and Rehab at Ellijay, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 96
Deficiencies: 0
Apr 18, 2024
Visit Reason
A revisit was conducted at Parkside Center for Nursing and Rehabilitation to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of April 15, 2024.
Report Facts
Facility census: 96
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 2
Mar 7, 2024
Visit Reason
A State Licensure survey was conducted at Parkside Center for Nursing and Rehab at Ellijay from February 29, 2024 through March 7, 2024 to assess compliance with state health regulations.
Findings
The survey revealed deficiencies in dietary service related to improper food portioning that could affect 84 of 85 residents, and safety issues due to a malfunctioning dishwashing machine producing inadequate temperatures for the last 10 months, posing a risk of foodborne illness to 84 of 85 residents.
Deficiencies (2)
| Description |
|---|
| Facility failed to serve appropriate quantities of food according to prescribed dietary recipe, potentially affecting 84 of 85 residents receiving oral diets. |
| Facility failed to recognize malfunctioning dish machine producing temperatures too low to kill bacteria and germs for 10 months, risking foodborne illnesses for 84 of 85 residents. |
Report Facts
Residents affected by dietary deficiency: 84
Total residents present: 85
Residents affected by dish machine deficiency: 84
Dish machine wash temperature: 145
Dish machine final rinse temperature: 90
Required minimum wash temperature: 155
Required minimum rinse temperature: 180
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietician (RD) | Interviewed regarding dietary recipe compliance and serving sizes | |
| Dietary Cook | Observed serving food with incorrect ladle sizes and interviewed about recipe adherence | |
| Food Service Director | Interviewed regarding dish machine malfunction, temperature logs, and food safety | |
| Administrator | Interviewed and confirmed awareness of dish machine problems and planned in-services |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 5
Mar 7, 2024
Visit Reason
An abbreviated survey was conducted to investigate Complaint Intake Numbers GA00244169, GA00240290, and GA00240665. Two complaints were unsubstantiated, and one complaint was substantiated with federal deficiencies cited.
Findings
The facility failed to hire qualified dietary staff certified in safe food handling, failed to serve appropriate food quantities and palatable food at proper temperatures, did not honor resident food preferences and alternatives, and had a malfunctioning dishwashing machine producing inadequate temperatures for the last 10 months, risking foodborne illnesses affecting most residents.
Complaint Details
Complaint Intake Numbers GA00244169 and GA00240290 were unsubstantiated. Complaint Intake Number GA00240665 was substantiated with federal deficiencies cited.
Severity Breakdown
F: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to hire qualified dietary staff certified to serve food in a clean, safe and sanitary manner. | F |
| Facility failed to serve appropriate quantities of food according to prescribed dietary recipes, risking malnutrition. | F |
| Facility failed to serve food that is palatable, attractive, and at required temperatures. | F |
| Facility failed to serve residents their preferences and alternative meals. | F |
| Facility failed to recognize malfunctioning dish machine producing temperatures too low to kill bacteria and germs for 10 months. | F |
Report Facts
Residents affected: 84
Residents census: 93
Dish machine malfunction duration: 10
Serving ladle sizes: 3
Serving ladle sizes: 4
Required serving ladle size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed multiple times; lacked Certified Dietary Manager certification and knowledge of safe food handling and dish machine temperatures. | |
| Registered Dietician | Interviewed regarding dietary recipe adherence and plans to serve fresh fruit. | |
| Human Resource Director | Interviewed confirming Food Service Director lacked CDM certification. | |
| Administrator | Interviewed regarding food service garnishments, dish machine issues, and corrective actions. | |
| Dietary Cook | Interviewed regarding serving sizes and food preparation. |
Inspection Report
Deficiencies: 0
Jul 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Parkside Center for Nursing and Rehab at Ellijay, indicating a regulatory inspection was completed.
Findings
No specific deficiencies or findings are detailed in the provided document.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Jul 7, 2023
Visit Reason
A Revisit Survey was conducted from July 5, 2023, through July 7, 2023, to verify correction of deficiencies cited in the standard survey concluded on April 30, 2023.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Jul 5, 2023
Visit Reason
A revisit survey was initiated on July 5, 2023, by a Qualified Survey Team to investigate Complaint Intake Number GA00236341 in conjunction with the revisit survey.
Findings
The complaint investigation found Complaint Number GA00236341 to be unsubstantiated. The facility census on the date of the visit was 90 residents.
Complaint Details
Complaint Intake Number GA00236341 was investigated and found to be unsubstantiated.
Report Facts
Resident census: 90
Inspection Report
Follow-Up
Deficiencies: 0
Jun 23, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Renewal
Deficiencies: 5
Apr 30, 2023
Visit Reason
A Licensure Survey was conducted from 4/28/23 through 4/30/23 to assess compliance with licensure requirements and facility regulations.
Findings
The facility failed to complete timely comprehensive nutritional assessments for nine residents, failed to follow puree food recipes, failed to implement stop dates for PRN psychotropic medications, failed to ensure proper infection control during wound care, failed to wear PPE appropriately, lacked an updated water management plan, failed to monitor dialysis access sites properly, had communication issues with a resident, and had multiple dietary and sanitation deficiencies including grease build-up, improper food storage, unclean equipment, unlabeled food, and open dumpsters.
Deficiencies (5)
| Description |
|---|
| Failed to complete comprehensive nutritional assessments for nine residents and failed to follow puree food recipes. |
| Failed to ensure a stop date was implemented for PRN psychotropic medications for one resident. |
| Failed to ensure proper infection control during wound care for two residents, failed to wear PPE for residents on transmission-based precautions, and failed to develop an updated water management plan. |
| Failed to provide care according to plan for three residents related to pain management, dialysis access site monitoring, and communication. |
| Failed to maintain kitchen and dietary sanitation including grease build-up on fire suppression pipes, wet pans stored, improper food storage and labeling, unclean equipment, food spills on walls, dietary staff not wearing hair restraints, and open dumpsters with trash debris. |
Report Facts
Residents missing comprehensive nutritional assessments: 9
Residents receiving puree consistency: 6
Residents reviewed for unnecessary medications: 5
Residents on transmission-based precautions: 3
Residents affected by water management plan deficiency: 91
Residents sampled for care plan compliance: 45
Residents with communication issues: 1
Residents receiving oral diet: 90
Dumpster count: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook AA | Confirmed not following puree recipes and adding unmeasured broth. | |
| Director of Nursing | DON | Interviewed multiple times regarding nutritional assessments, wound care expectations, PPE use, dialysis monitoring, and communication issues. |
| Registered Dietician | RD | Acknowledged missing nutritional assessments and described assessment process. |
| Interim Dietary Manager | IDM | Confirmed dietary sanitation issues and grease build-up. |
| Wound Care Nurse | WCN | Observed failing to follow infection control during wound care. |
| Licensed Practical Nurse JJ | LPN | Observed failing to follow infection control during wound care. |
| Licensed Practical Nurse II | LPN | Described dialysis access site monitoring practices. |
| Licensed Practical Nurse EE | LPN | Described resident condition and PPE use issues. |
| Corporate Rehab Director | Discussed speech therapy and communication issues for resident. | |
| Regional Rehab Director | Discussed speech therapy and communication issues for resident. | |
| Dietary Aide CC | Observed not wearing hair restraint in kitchen. | |
| Maintenance Director | Responsible for dumpster area and grease build-up issues. |
Inspection Report
Routine
Census: 91
Deficiencies: 11
Apr 30, 2023
Visit Reason
A standard survey was conducted at Parkside Center for Nursing and Rehab from April 28, 2023 through April 30, 2023 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop baseline care plans within 48 hours for multiple residents, inadequate pain management during wound care, failure to assess dialysis access sites, ineffective communication plans for a resident, incomplete nutritional assessments, improper infection control practices during wound care, and issues with kitchen cleanliness and food safety.
Severity Breakdown
E: 2
G: 3
F: 4
D: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to develop a 48-hour baseline care plan for 16 of 45 sampled residents. | E |
| Failed to implement appropriate interventions on care plans related to pain management and dialysis access site assessment for two residents. | G |
| Failed to develop and implement effective communication goals for one resident resulting in psychosocial harm. | G |
| Failed to complete comprehensive nutritional assessments for nine residents. | E |
| Failed to stop and address verbal expression of pain during wound care for one resident. | G |
| Failed to follow puree recipes to conserve nutrient value for six residents. | F |
| Failed to ensure fire suppression system pipes were clean and free from grease build-up; failed to ensure proper kitchen sanitation and food safety practices. | F |
| Failed to ensure dialysis access site was assessed and documented daily and after dialysis treatments and failed to ensure communication between facility and dialysis center. | D |
| Failed to ensure stop date was implemented for PRN psychotropic medication for one resident. | D |
| Failed to ensure proper infection control practices during wound care for two residents; failed to ensure staff wore PPE in transmission based precaution rooms and appropriate signage was missing; failed to develop updated water management program for Legionella prevention. | F |
| Failed to ensure dumpsters doors/lids were closed and area surrounding dumpsters was free from trash debris. | F |
Report Facts
Resident census: 91
Residents without baseline care plan: 16
Residents reviewed for nutritional assessment: 9
Weight loss: 11.46
Weight gain: 12.99
PRN Klonopin administrations: 34
Date of last exhaust hood cleaning: Mar 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Performed wound care for resident R#86 with infection control deficiencies |
| Wound Care Nurse | Performed wound care for resident R#39 with pain management deficiencies | |
| Director of Nursing | DON | Provided multiple interviews confirming expectations and deficiencies |
| LPN II | Licensed Practical Nurse | Reported dialysis access site assessment practices |
| Dietary Cook AA | Dietary Cook | Observed not following puree recipes |
| Interim Dietary Manager | IDM | Confirmed kitchen sanitation and food safety deficiencies |
| Maintenance Director | Confirmed grease build-up on fire suppression pipes and dumpster area issues | |
| CNA GG | Certified Nursing Assistant | Entered isolation room without PPE |
Inspection Report
Life Safety
Census: 91
Capacity: 100
Deficiencies: 6
Apr 29, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with egress door locking, hazardous area door closures, sprinkler system installation and maintenance, corridor door functionality, and electrical safety.
Severity Breakdown
E: 3
D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure staff could readily unlock all exit doors at all times due to Wander Guard System preventing door opening. | E |
| Failed to ensure all hazardous room doors were self-closing and latched in the closed position. | E |
| Failed to provide complete sprinkler coverage throughout the facility, including a small closet adjacent to room #117, a portion of the annex patio, and the North Wing riser room. | E |
| Failed to maintain proper clearance from sprinkler coverage; storage was placed within eighteen inches of sprinkler deflectors in the East Wing clean linen storage closet and activity director's office/storage area. | D |
| Resident room doors #130 and #118 failed to close properly and latch in the closed position. | D |
| Open electrical junction box noted above the ceiling in mechanical room #5 near the front exit. | D |
Report Facts
Census: 91
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and observations |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 13, 2023
Visit Reason
An abbreviated/partial extended survey was conducted from 4/11/2023 to 4/13/2023 to investigate multiple complaints against the facility.
Findings
Complaints GA00226454 and GA00219533 were substantiated, while all other complaints were unsubstantiated. No deficiencies were cited during the survey.
Complaint Details
Multiple complaints were investigated; most were unsubstantiated except for GA00226454 and GA00219533 which were substantiated. No deficiencies were cited.
Report Facts
Complaint investigations: 18
Inspection Report
Renewal
Deficiencies: 0
Dec 16, 2021
Visit Reason
The inspection was conducted as a Licensure Survey from 12/14/2021 through 12/16/2021 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey conducted from 12/14/2021 through 12/16/2021.
Inspection Report
Routine
Census: 73
Deficiencies: 0
Dec 16, 2021
Visit Reason
A standard survey was conducted at Parkside Center for Nursing and Rehabilitation at Ellijay from December 14, 2021 through December 16, 2021. Additionally, three complaint intake numbers were investigated in conjunction with this standard survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. Two complaints were unsubstantiated, and one was substantiated without deficiencies.
Complaint Details
Complaint Intake Numbers GA00215118 and GA00217884 were unsubstantiated. Complaint Intake Number GA00217301 was substantiated without deficiencies.
Report Facts
Resident Census: 73
Inspection Report
Life Safety
Census: 73
Capacity: 100
Deficiencies: 0
Dec 15, 2021
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 Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Inspection Report
Deficiencies: 0
Sep 27, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Parkside Center for Nursing and Rehab at Ellijay, 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
Deficiencies: 3
Jul 23, 2021
Visit Reason
The inspection was conducted as an abbreviated survey from 7/20/21 through 7/23/21 to identify licensure deficiencies related to nursing care and compliance with care plans.
Findings
The facility failed to ensure a person-centered, comprehensive care plan was implemented for four of 20 sampled residents, specifically regarding activities of daily living such as nail care and incontinence management. Deficiencies included failure to provide nail care for residents #1 and #3, and lack of comprehensive care plans addressing incontinence and bladder/bowel retraining for residents #10 and #16. The facility lacked a formal bowel and bladder program and did not assess residents for potential continence improvement.
Deficiencies (3)
| Description |
|---|
| Failure to provide activities of daily living services as directed in the care plan for Resident #1 related to nail care. |
| Resident #3 was not provided with nail care as directed in the care plan. |
| Residents #16 and #10 were not provided with a comprehensive care plan to address incontinence status and potential for bladder and/or bowel retraining. |
Report Facts
Sampled residents: 20
Residents with care plan deficiencies: 4
BIMS score: 4
BIMS score: 3
BIMS score: 12
BIMS score: 9
BIMS score: 15
Date of admission: Oct 18, 2017
Date of admission: Jul 4, 2019
Date of admission: Apr 3, 2017
Date of admission: Mar 19, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HH | Activities Director and Certified Nursing Assistant | Observed assisting Resident #1 with bathing and hair styling; stated staff were supposed to clean residents' fingernails during bathing |
| DD | Licensed Practical Nurse | Charge nurse on unit where Resident #1 resided; stated CNAs should provide nail care during bathing |
| BB | Certified Nursing Assistant | Assigned to Resident #3; stated she did not clean or trim Resident #3's fingernails |
| CC | Licensed Practical Nurse and Unit Manager | Unit manager where Resident #10 resided; participated in interview regarding incontinence care |
| FF | Certified Nursing Assistant | Provided bath to Resident #3; did not clean or cut fingernails or toenails |
| EE | Licensed Practical Nurse | Second shift nurse; noted Resident #3's long nails but did not report for podiatry |
| HN | Hospice Nurse | Reported Resident #3's need for podiatry and nail care; trimmed fingernails but not toenails |
| MDSC | Minimum Data Set Coordinator | Reported facility had no formal bowel and bladder program or assessments |
| Administrator | Facility Administrator | Acknowledged lack of bowel and bladder assessments and programs; stated facility working on issues |
| DON | Director of Nursing | Stated CNAs provide nail care during showers or baths; discussed staffing issues affecting nail care |
| LPN OO | Licensed Practical Nurse | Reported Resident #16 could communicate toileting needs; no discussion of continence improvement in team meetings |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 3
Jul 23, 2021
Visit Reason
An abbreviated complaint survey and a COVID-19 Focused Infection Control survey were conducted due to multiple complaint intake numbers, some substantiated with deficiency.
Findings
The facility was found not in compliance with Medicare/Medicaid regulations related to comprehensive care plans, ADL care, and incontinence management. Specific deficiencies included failure to provide nail care and personal hygiene for residents #1 and #3, and failure to provide comprehensive care plans addressing incontinence for residents #10 and #16. The facility lacked a formal bowel and bladder program and did not assess residents for potential continence improvement.
Complaint Details
Complaint Intake Numbers GA00212671, GA00213709, GA00214179, and GA00214409 were unsubstantiated. GA00214415, GA00214452, GA00214571, and GA00214761 were substantiated with deficiency.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement a person-centered comprehensive care plan for residents #1, #3, #10, and #16, including nail care and incontinence management. | D |
| Failure to provide necessary ADL care related to personal hygiene, including nail care for residents #1 and #3. | D |
| Failure to provide appropriate bowel and bladder incontinence care and assessment for residents #10 and #16. | D |
Report Facts
Resident census: 89
Number of sampled residents with care plan deficiencies: 4
Number of sampled residents with ADL care deficiencies: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HH | Activities Director / Certified Nursing Assistant | Observed assisting Resident #1 with hair styling and reported nail care responsibilities |
| DD | Licensed Practical Nurse | Charge nurse on unit of Resident #1, discussed nail care expectations |
| CC | Licensed Practical Nurse / Assistant Director of Nursing | Present during interview regarding nail care and care plan deficiencies |
| BB | Certified Nursing Assistant | Assigned to Resident #3, did not provide nail care or report toenail issues |
| FF | Certified Nursing Assistant | Provided bath to Resident #3, did not provide nail care or report toenail issues |
| EE | Licensed Practical Nurse | Second shift nurse on 7/20/21, did not report Resident #3's toenail issues |
| DON | Director of Nursing | Discussed nail care procedures and staffing |
| HN | Hospice Nurse | Reported Resident #3's toenail issues and family requests to facility |
| SSD | Social Service Director | Discussed podiatry scheduling and resident placement on podiatry list |
| AA | Certified Nursing Assistant | Assisted Resident #10 with toileting |
| MM | Certified Nursing Assistant | Present during interview regarding Resident #10's incontinence care |
| OO | Licensed Practical Nurse | Discussed Resident #16's continence status and care |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 13, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00215882.
Findings
The complaint was substantiated, but no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00215882 was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00214824.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00214824 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 84
Deficiencies: 0
Feb 17, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control. Complaint investigations related to COVID-19 were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00211740 and GA00208533 were investigated in conjunction with the COVID-19 Focused Infection Control Survey and were found to be unsubstantiated.
Report Facts
Resident Census: 84
Inspection Report
Follow-Up
Deficiencies: 0
Dec 18, 2020
Visit Reason
A follow-up to the COVID-19 Focused Infection Control survey conducted on October 14, 2020, to verify correction of previously identified deficiencies.
Findings
The follow-up survey conducted on November 18, 2020, revealed that all deficiencies were corrected and the facility was in substantial compliance as of November 11, 2020.
Report Facts
Survey dates: Oct 14, 2020
Survey dates: Nov 18, 2020
Compliance date: Nov 11, 2020
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 1
Oct 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and CMS/CDC recommended practices related to COVID-19.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to have procedures for addressing residents who refuse COVID-19 testing or are unable to be tested during an outbreak.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure procedures for addressing residents who refuse COVID-19 testing or are unable to be tested. | SS= D |
Report Facts
COVID-19 positive residents: 44
Total census: 88
Resident testing refusal: 1
Days between tests for Resident #4: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding COVID-19 testing procedures and refusal | |
| Director of Nursing (DON) | Interviewed regarding COVID-19 testing procedures and refusal | |
| Assistant Director of Nursing (ADON) | Interviewed regarding COVID-19 testing procedures and refusal |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 24, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00205892 and #GA00204086.
Findings
Complaint #GA00205892 was substantiated with no regulatory violations found. Complaint #GA00204086 was unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaint #GA00205892 was substantiated with no regulatory violations. Complaint #GA00204086 was unsubstantiated with no regulatory violations cited.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Jul 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted. Additionally, a complaint investigation was conducted but found unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Complaint Details
Complaint GA 00206172 was investigated and found to be unsubstantiated.
Report Facts
Census: 86
Inspection Report
Routine
Census: 86
Deficiencies: 0
Jul 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted, along with an investigation of a complaint which was unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
Complaint GA 00206172 was investigated and found to be unsubstantiated.
Report Facts
Total census: 86
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 5, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00199512, GA00199543, and GA00199633.
Findings
No deficiencies were identified during the survey and the complaints were not substantiated.
Complaint Details
Complaints GA00199512, GA00199543, and GA00199633 were investigated and found to be not substantiated.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Feb 5, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the November 29, 2018 standard survey.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 17, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 100
Deficiencies: 8
Nov 29, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and other federal requirements for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including advance directives documentation, safe and homelike environment maintenance, vision care follow-up, water temperature safety, dietary staffing and sanitation practices, infection control, and resident room size requirements.
Severity Breakdown
SS= D: 4
SS= E: 2
SS= F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to obtain and clarify advance directives for one resident since admission. | SS= D |
| Failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms and common areas. | SS= D |
| Failed to ensure corrective lenses were obtained for one resident after eye exam and prescription. | SS= D |
| Failed to ensure water temperatures in resident rooms and common areas were maintained at safe levels to prevent burns. | SS= E |
| Failed to ensure dietary staff had appropriate competencies and skill sets and failed to maintain proper sanitizing chemical levels and training documentation. | SS= F |
| Failed to procure, store, prepare, distribute and serve food in accordance with professional food safety standards including failure to sanitize food processor equipment between pureed food items and improper food holding temperatures. | SS= F |
| Failed to maintain an effective infection prevention and control program including failure to disinfect glucometers properly between residents and failure to maintain surveillance data. | SS= E |
| Failed to provide at least 80 square feet of living space per resident in a multiple resident bedroom. | SS= D |
Report Facts
Resident census: 100
Resident sample size: 49
Water temperature: 128.5
Water temperature: 135
Room size: 74.8
Dishwasher sanitizer concentration: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Named in infection control deficiency related to glucometer disinfection |
| LPN BB | Licensed Practical Nurse | Named in infection control deficiency related to glucometer disinfection |
| Dietary Manager JJ | Dietary Manager | Named in dietary staffing and sanitation deficiencies |
| Dietary Aide LL | Dietary Aide | Named in dietary sanitation deficiencies |
| Dietary Aide MM | Dietary Aide | Named in dietary sanitation deficiencies |
| LPN DD | Licensed Practical Nurse | Named in advance directives and infection control deficiencies |
| Social Services Director | Named in advance directives deficiency | |
| Director of Nursing | Named in advance directives and infection control deficiencies | |
| Maintenance Supervisor | Named in room size and water temperature deficiencies | |
| Maintenance Tech HH | Named in water temperature deficiency | |
| Housekeeping Supervisor | Named in environment cleanliness deficiency |
Inspection Report
Routine
Deficiencies: 4
Nov 29, 2018
Visit Reason
The inspection was conducted as a routine survey to assess compliance with infection control, safety, environmental sanitation, physical plant standards, and other regulatory requirements at Parkside Center for Nursing and Rehab at Ellijay.
Findings
The facility was found deficient in infection control practices, including improper disinfection of glucometers and incomplete infection surveillance data. Water temperatures in resident areas exceeded safe limits, posing a scald risk. Environmental sanitation issues included dust buildup, damaged walls, cracked floor tiles, stained ceiling tiles, and housekeeping deficiencies. Resident rooms were found to be undersized, with one resident reporting insufficient space for personal belongings.
Deficiencies (4)
| Description |
|---|
| Failure to properly disinfect reusable equipment (glucometers) and incomplete infection surveillance data. |
| Water temperatures in resident areas exceeded the maximum allowable temperature of 110°F, with readings up to 128.5°F. |
| Environmental sanitation deficiencies including dust buildup on personal fans, damaged flooring, cracked tiles, stained ceiling tiles, and missing ceiling tiles with exposed insulation. |
| Resident rooms did not meet minimum size requirements; one room measured 74.8 square feet, less than the required 80 square feet per bed in multibed rooms. |
Report Facts
Water temperature: 128.5
Water temperature: 124.7
Water temperature: 121
Water temperature: 120.5
Water temperature: 120.2
Water temperature: 115.9
Water temperature: 114
Room size: 74.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Named in findings related to improper glucometer disinfection |
| LPN BB | Licensed Practical Nurse | Named in findings related to improper glucometer disinfection |
| DD | Licensed Practical Nurse | In charge of Infection Control program, interviewed about missing surveillance documentation |
| CC | Employee Health/Education Coordinator | Interviewed regarding staff education on glucometer disinfection |
| FF | Certified Nursing Assistant | Interviewed regarding water temperature observations |
| GG | Certified Nursing Assistant | Interviewed regarding water temperature observations |
| HH | Maintenance Technician | Interviewed and performed water temperature measurements |
| NN | Housekeeper | Interviewed about cleaning responsibilities and dust buildup |
| Maintenance Supervisor | Verified environmental and maintenance concerns during walking rounds | |
| Social Worker | Interviewed about room assignments and resident requests | |
| RA | Resident | Interviewed about room size and personal belongings storage |
Inspection Report
Life Safety
Census: 98
Capacity: 100
Deficiencies: 16
Nov 27, 2018
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 multiple Life Safety Code requirements including exit discharge obstructions, inadequate emergency lighting, improper installation of hand sanitizer dispensers, fire alarm pull stations at incorrect heights, missing sensitivity test documentation for smoke detectors, insufficient sprinkler coverage and maintenance, improperly installed fire extinguishers, corridor doors not smoke tight, unsealed penetrations in fire rated walls, open electrical boxes without covers, missing fire drill documentation, prohibited portable space heater usage, missing generator annunciators and emergency lighting, improper use of surge protectors, and lack of proper signage for oxygen tank storage.
Severity Breakdown
D: 6
E: 6
F: 3
Deficiencies (16)
| Description | Severity |
|---|---|
| Walkway from staff emergency exit to public-way obstructed by foliage. | D |
| Facility failed to have proper exterior emergency lighting; missing emergency lights along west side and northwest exit. | E |
| Hand sanitizer improperly installed over electrical light switch in telephone room office space. | D |
| Fire alarm pull stations installed at improper height (55-59 inches instead of 42-48 inches). | F |
| No recent test/inspection documentation for sensitivity test of smoke detectors. | F |
| Improper fire sprinkler coverage in clean linen closet by room 113 due to top shelf obstruction. | D |
| Fire sprinkler system yellow tagged requiring hydro test, internal pipe inspection, full trip test, and painted head replacements. | E |
| Fire extinguishers installed at 68 inches from floor to activating handle, exceeding maximum allowed height of 60 inches. | E |
| Patient room doors (158, 144, 135) and utility room door in west wing not closing or latching properly, preventing smoke tight seal. | F |
| Penetrations through fire rated walls above ceilings in smoke compartments not properly sealed with fire rated caulk. | F |
| Open electrical boxes without covers found above ceilings at all smoke compartments. | E |
| Fire drill documentation missing 3rd shift for June, July, August quarter and drills not in proper order. | D |
| Portable space heater found underneath desk in Director of Housekeeping's office without proper documentation. | D |
| Facility lacks generator annunciator for each generator in nursing station or viewable location and lacks battery back-up two lens emergency lights in mechanical rooms with generator transfer switches. | E |
| Surge protectors improperly placed on the floor in Director of Housekeeping and telephone room office space. | D |
| Oxygen tanks stored at all nursing stations without proper signage. | E |
Report Facts
Residents at risk due to walkway obstruction: 20
Residents at risk due to lack of emergency lighting: 25
Residents and staff at risk due to improper hand sanitizer installation: 5
Residents at risk due to fire alarm pull station height: 98
Residents at risk due to missing smoke detector sensitivity test: 98
Residents at risk due to sprinkler coverage obstruction: 5
Residents at risk due to sprinkler system maintenance issues: 10
Residents at risk due to fire extinguisher installation height: 25
Residents at risk due to door smoke seal issues: 20
Residents at risk due to unsealed fire rated wall penetrations: 98
Residents at risk due to open electrical boxes: 20
Residents at risk due to missing fire drills: 10
Staff and residents at risk due to portable space heater: 5
Residents at risk due to missing generator annunciators and emergency lighting: 50
Staff and residents at risk due to surge protector placement: 10
Staff and residents at risk due to missing oxygen tank signage: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2018
Visit Reason
The inspection was conducted to investigate complaint GA00191140 and determine compliance with State Long Term Care Requirements.
Findings
No State health deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA00191140 was investigated and found to have no cited deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 18, 2018
Visit Reason
A revisit survey was conducted on 9/18/18 to verify correction of deficiencies cited in the 8/16/18 Complaint Survey. Additionally, Complaint Intake Number GA00191140 was investigated in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 8/16/18 Complaint Survey were found to be corrected. The complaint investigation for GA00191140 was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00191140 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 18, 2018
Visit Reason
A revisit survey was conducted on 9/18/18 to investigate Complaint Intake Number GA00191140 in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 6/13/18 through 7/2/18 Complaint Survey were found to be corrected. The complaint investigation found GA00191140 was unsubstantiated.
Complaint Details
Complaint Intake Number GA00191140 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Aug 16, 2018
Visit Reason
A complaint survey was conducted on 8/15/18 through 8/16/18 to investigate complaints GA00190663 and GA00190333 to determine compliance with Federal and State Long Term Care Requirements.
Findings
The facility failed to provide care for a skin excoriation on one resident (R#1) according to professional standards and the comprehensive care plan. The resident's leaking PEG tube caused a skin burn that was treated without physician or nurse practitioner orders for several days, delaying appropriate burn treatment.
Complaint Details
The complaint investigation was triggered by complaints GA00190663 and GA00190333. The facility was found noncompliant for failing to notify the physician or nurse practitioner timely about the resident's skin excoriation and for treating the excoriation without orders until 7/30/18. The medical director and nurse practitioner confirmed delayed notification and treatment.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide care for a skin excoriation according to professional standards and the comprehensive care plan for one resident. | SS= D |
Report Facts
Facility census: 89
Excoriation size: 12
Excoriation size: 4
Dates of treatment orders: Jul 30, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director | Medical Director | Interviewed regarding notification of resident's leaking PEG tube and skin excoriation |
| Director of Nurses | Director of Nurses (DON) | Confirmed RN and LPN treated excoriation without orders and acknowledged notification requirements |
| Nurse Practitioner | Nurse Practitioner (NP) | Ordered Silvadene cream after being notified of excoriation; confirmed burn diagnosis and treatment progress |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 23, 2018
Visit Reason
A complaint survey was conducted on 7/23/18 to investigate complaints #GA00190173 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00190173 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00189648 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00189648 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Jul 2, 2018
Visit Reason
A complaint survey was conducted from 2018-06-13 through 2018-07-02 to investigate complaints GA00189279 and GA00188170 regarding compliance with Federal and State Long Term Care Requirements.
Findings
The facility failed to follow Physician's orders for sliding scale insulin administration for two residents, resulting in incomplete documentation of fingerstick blood sugar (FSBS) results and insulin administration. The Quality Assurance and Performance Improvement Committee failed to effectively identify, develop, implement, and monitor corrective actions related to these documentation omissions.
Complaint Details
The complaint investigation was triggered by complaints GA00189279 and GA00188170. The investigation found noncompliance related to insulin administration and documentation, with no actual harm but potential for more than minimal harm.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow Physician's orders for sliding scale insulin administration for two residents, resulting in incomplete documentation of FSBS results and insulin administration. | SS=E |
| Failure of the Quality Assurance and Performance Improvement Committee to effectively identify, develop, implement, and monitor corrective action plans related to documentation omissions for FSBS results and sliding scale insulin administration. | SS=E |
Report Facts
Facility census: 96
Dates of missing documentation: 20
Units of insulin not documented: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding documentation omissions and monitoring; acknowledged missing documentation and lack of monitoring system. | |
| Consultant Pharmacist | Reported ongoing issues with EMAR system causing incomplete documentation and discussed concerns with former Administrator and DON. | |
| Administrator | New Administrator as of 6/18/18, unable to find documentation of corrective actions or disciplinary measures related to the deficiencies. |
Inspection Report
Routine
Deficiencies: 3
Jul 2, 2018
Visit Reason
The inspection was conducted to evaluate compliance with nursing care requirements, specifically focusing on the administration and documentation of sliding scale insulin for residents with diabetes.
Findings
The facility failed to consistently document fingerstick blood sugar (FSBS) results and the administration of sliding scale insulin for residents with diabetes, resulting in missing records and potential noncompliance with physician orders. The Director of Nurses acknowledged gaps in documentation and monitoring practices.
Deficiencies (3)
| Description |
|---|
| Failure to document FSBS results and sliding scale insulin administration for Resident #1 on multiple dates from March through May 2018. |
| Failure to document FSBS results and sliding scale insulin administration for Resident #2 on multiple dates in May 2018. |
| Lack of monitoring and follow-up on missing documentation of FSBS and insulin administration by nursing staff and previous Director of Nurses. |
Report Facts
Units of Novolog insulin: 11
Units of Humalog insulin: 7
Number of licensed nursing staff: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed on 6/13/18 regarding documentation and monitoring of FSBS and insulin administration; acknowledged documentation gaps |
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 9, 2018
Visit Reason
A Revisit survey was conducted on 3/8-9/2018 for the Recertification survey of 1/12/2018.
Findings
The Revisit survey reveals that all previously cited deficiencies have been corrected and the facility is found to be in substantial compliance as of 2/25/2018.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 5, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during this Follow-Up Survey.
Inspection Report
Life Safety
Census: 86
Capacity: 100
Deficiencies: 4
Jan 9, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and emergency preparedness standards.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and Life Safety Code standards, including deficiencies in the emergency preparedness plan, slip resistance of exterior ramps, lack of approved handrails, and corridor doors failing to resist smoke passage.
Severity Breakdown
F: 1
D: 2
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan was not complete, up to date, and referenced the facility by a former name, missing required elements per Appendix Z. | F |
| Exterior exit discharge ramp from the Annex Hall was not properly maintained to be slip resistant. | D |
| Approved handrails were not provided at the exit discharge ramp from the Annex Hall. | D |
| Several corridor doors were warped and failed to resist the passage of smoke, with gaps exceeding 1/2 inch, including doors to resident room #162, Director of Nursing office, and storage room next to the DON's office. | E |
Report Facts
Census: 86
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, exterior ramp, handrails, and corridor doors | |
| Staff A | Confirmed findings related to emergency preparedness plan |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 17, 2017
Visit Reason
A revisit to the abated immediate jeopardy survey of 9/26/17 was conducted from 11/16/17 through 11/17/17 to verify correction of previous deficiencies.
Findings
The revisit revealed that all deficiencies were corrected and the facility was in substantial compliance as of 10/18/17.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 4
Sep 8, 2017
Visit Reason
An abbreviated and extended survey was conducted to investigate Complaint #GA00179083 regarding resident safety and wandering/elopement behaviors at Gilmer County Nursing Home.
Findings
The facility failed to ensure residents with wandering and exit-seeking behaviors were properly assessed, care planned, and monitored, resulting in a resident (R#1) eloping and dying from injuries sustained in a fall. The fire alarm system was malfunctioning due to a lightning strike and was not properly managed or repaired in a timely manner. The facility's Quality Assurance Performance Improvement (QAPI) committee failed to address these issues adequately.
Complaint Details
Complaint #GA00179083 was substantiated. The complaint involved resident elopement and safety issues related to wandering behaviors and a malfunctioning fire alarm system.
Severity Breakdown
Level J: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop and implement comprehensive care plans addressing wandering and elopement risks for residents, including R#1, R#2, and R#3. | Level J |
| Failure to maintain a safe environment free from accident hazards, including malfunctioning fire alarm system and inadequate supervision to prevent resident elopement. | Level J |
| Failure of the facility administration and governing body to ensure timely repair of the fire alarm system after lightning strike and to address resident safety concerns. | Level J |
| Failure of the Quality Assessment and Assurance Committee to identify, develop, and implement corrective action plans related to resident elopement and fire alarm system deficiencies. | Level J |
Report Facts
Resident census: 81
Resident sample size: 7
Date of lightning strike: 2017
Date of resident elopement: 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Named in medication administration and resident supervision during elopement incident |
| CNA EE | Certified Nursing Assistant | Provided statement regarding resident wandering and elopement |
| CNA RR | Certified Nursing Assistant | Involved in resident supervision and wandering behavior |
| Director of Nursing | Director of Nursing | Responsible for care planning and QAPI committee |
| Social Service Director | Social Service Director | Responsible for coding MDS and care planning for wandering behaviors |
| Previous Administrator | Administrator | Responsible for facility management and communication regarding fire alarm issues |
| Medical Director | Medical Director | Interviewed regarding facility safety and resident care |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 23, 2017
Visit Reason
A revisit to a Standard Survey was conducted to verify correction of previous deficiencies.
Findings
The revisit found that all previous deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 20, 2017
Visit Reason
A Follow-Up Survey was conducted at Gilmer Nursing Home to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 3
Jan 4, 2017
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 due to inadequate emergency lighting at exit discharge points and failure to properly seal penetrations in fire rated and smoke barrier walls, including improperly sealed wiring and unsealed pipe penetrations.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Emergency lighting was not provided throughout the entire means of egress, including the exit discharge near the dining room and annex hall near room #205. | SS= D |
| Penetrations in fire rated and smoke barrier walls near room #156 were improperly sealed, including unsecured sleeves for low voltage wires and an unsealed opening. | SS= D |
| A four inch PVC pipe passed through the one hour fire rated/smoke barrier without proper sealing or a fire collar. | SS= D |
Report Facts
Census: 92
Total Capacity: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting and fire barrier penetrations |
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