Inspection Reports for Parkside Post Acute and Rehabilitation Center
3000 Lenora Church Rd, Snellville, GA 30078, GA, 30078
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 5, 2025 found no deficiencies and determined the complaint investigated was unsubstantiated. Prior inspections show a history of deficiencies primarily related to resident care, including failure to notify physicians of significant changes, incomplete care plans, and environmental safety hazards such as improperly stored chemicals and electrical hazards. Complaint investigations have been mostly unsubstantiated, though some complaints were substantiated without resulting in cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, correcting previously cited deficiencies from earlier inspections.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
149 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to maintaining a safe, clean, and homelike environment and infection prevention and control practices at Parkside Post Acute and Rehabilitation.
Findings
The facility was found deficient in maintaining clean PTAC unit filters and grills in some resident rooms, which could affect resident comfort and infection control. Additionally, infection control deficiencies were identified including failure to use sterile procedures during tracheostomy care, improper storage of respiratory equipment, contamination risks during wound care, improper linen cart contents, and failure to adhere to contact precautions by staff.
Deficiencies (2)
Failed to ensure PTAC unit filters were free of debris in 2 of 48 rooms and PTAC unit grills were free of debris in 1 of 48 rooms.
Failed to maintain appropriate infection control practices including non-sterile procedure during tracheostomy care, improper storage of respiratory equipment, contamination risks during wound care, storing personal items on clean linen carts, and staff not adhering to contact precautions.
Report Facts
Rooms with PTAC filter debris: 2
Rooms with PTAC grill debris: 1
Sampled residents with infection control issues: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SS | Respiratory Therapist | Observed using non-sterile gloves during tracheostomy suctioning |
| GG | Registered Nurse | Observed placing hand sanitizer back into plastic bag without sanitizing outside during wound care |
| MM | Laundry Aide | Acknowledged storing personal cell phone inside linen cart |
| EE | Certified Nursing Assistant | Unaware of policy restricting items in linen carts |
| KK | Licensed Practical Nurse | Unsure about linen cart policy |
| BB | Licensed Practical Nurse | Entered isolation room without gown, violating contact precautions |
| DON | Director of Nursing | Confirmed expectations for PPE use and training responsibilities |
| SDC | Staff Development Coordinator | Responsible for training clinical staff on linen cart use and infection control |
| MD | Maintenance Director | Responsible for inspection and cleaning of PTAC units |
| Administrator | Provided information on PTAC filter cleaning schedule |
Inspection Report
Abbreviated Survey
Census: 149
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00254063.
Complaint Details
Complaint GA00254063 was investigated and found to be unsubstantiated.
Findings
The complaint GA00254063 was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 151
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaint GA00252317 was substantiated; other complaints investigated were unsubstantiated.
Findings
Complaint GA00252317 was substantiated, while complaints GA00253888, GA00252916, GA00253848, GA00246592, and GA00245458 were unsubstantiated. No deficiencies were cited.
Inspection Report
Deficiencies: 0
Date: May 20, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Parkside Post Acute and Rehabilitation facility, 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: 149
Deficiencies: 0
Date: May 20, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/24/2024 Recertification Survey.
Findings
All deficiencies cited as a result of the 3/24/2024 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 6, 2024
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Mar 24, 2024
Visit Reason
The inspection was a licensure survey conducted from March 22, 2024 through March 24, 2024 to assess compliance with state regulations for Parkside Post Acute and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to notify the physician and responsible party of a significant change in a resident's condition resulting in actual harm, failure to develop care plans for certain residents, and safety hazards such as an electrical power strip lying in a resident's bed and improperly stored cleaning chemicals. One resident (R660) experienced actual harm due to untreated urinary tract infection leading to hospitalization for sepsis and acute renal failure.
Deficiencies (5)
Failure to notify physician and responsible party of critical lab results for resident R660, resulting in hospitalization for urosepsis and acute renal failure.
Failure to develop care plans for residents R108 (PTSD), R116 (dementia), and R126 (smoking).
Failure to provide appropriate treatment and care for resident R660 with severe UTI.
Electrical power strip lying in resident R2's bed, creating a potential accident hazard.
Chemical spray bottle with cleaning solution left improperly stored in resident R82's room, posing risk of exposure.
Report Facts
Sample size: 44
Hospitalization duration: 11
Temperature readings: 101.7
Temperature readings: 101.4
BIMS score: 14
BIMS score: 15
BIMS score: 10
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Nurse Practitioner | Wrote progress notes regarding resident R660's UTI and treatment plan |
| PP | Licensed Practical Nurse | Documented resident R660's elevated temperature on 12/16/2023 |
| Licensed Practical Nurse | Documented resident R660's transfer to hospital on 12/17/2023 | |
| AA | Licensed Practical Nurse | Described notification process for lab results |
| NN | Certified Nursing Assistant | Provided care for resident R2 and aware of power strip hazard |
| BB | Licensed Practical Nurse Unit Manager | Removed cleaning solution from resident R82's room |
| KK | Certified Nursing Assistant | Observed leaving cleaning solution in resident R82's room |
| LL | Housekeeper | Left cleaning solution in resident R82's room by mistake |
| MM | Assistant Maintenance Director | Checked electronic maintenance system for work orders |
Inspection Report
Complaint Investigation
Census: 154
Deficiencies: 4
Date: Mar 24, 2024
Visit Reason
A standard survey was conducted from March 22-24, 2024, including investigation of multiple complaint intake numbers. Some complaints were substantiated with deficiencies, prompting the inspection.
Complaint Details
The investigation included multiple complaint intake numbers. Four complaints were unsubstantiated without deficiencies, while two complaints (GA00244384 and GA00242117) were substantiated with deficiencies related to failure to notify physician of lab results and failure to develop care plans.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to notify physician of critical lab results leading to actual harm, failure to develop comprehensive care plans for certain residents, environmental hazards such as unsafe use of electrical power strips and improperly stored chemicals, and failure to provide appropriate treatment for a resident with a severe urinary tract infection resulting in hospitalization.
Deficiencies (4)
Failure to notify physician and responsible party of critical urinalysis lab results for resident R660, resulting in hospitalization for urosepsis and acute renal failure.
Failure to develop comprehensive care plans for residents R108 (PTSD), R116 (dementia), and R126 (smoking).
Failure to ensure environment free from accident hazards: electrical power strip lying in resident R2's bed and improperly stored chemical spray bottle in resident R82's room.
Failure to provide appropriate treatment for resident R660's severe urinary tract infection, resulting in hospitalization for 11 days with sepsis and acute renal failure.
Report Facts
Census: 154
Sample size: 44
Hospitalization duration: 11
Temperature: 101.7
Lab result - Klebsiella pneumoniae: 100000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP GG | Nurse Practitioner | Ordered urinalysis for resident R660 and stated she would have given treatment orders if notified of abnormal lab results. |
| LPN PP | Licensed Practical Nurse | Documented resident R660's elevated temperature on 12/16/2023. |
| LPN QQ | Licensed Practical Nurse | Documented resident R660's transfer to hospital on 12/17/2023. |
| DON | Director of Nursing | Provided information on lab result notification process and confirmed lack of notification for R660's abnormal lab results. |
| CNA NN | Certified Nursing Assistant | Aware of power strip on resident R2's bed and entered a work order but did not notify supervisor. |
| ADON | Assistant Director of Nursing | Confirmed power strip should not be on resident's bed and should have been removed immediately. |
| MM | Assistant Maintenance Director | Verified no prior work orders related to power strip in resident's room. |
| CNA KK | Certified Nursing Assistant | Observed placing cleaning solution behind television in resident R82's room. |
| LPN UM BB | Licensed Practical Nurse Unit Manager | Removed cleaning solution from resident R82's room and stated it should not be there. |
| Housekeeper LL | Housekeeper | Left cleaning solution in resident R82's room by mistake. |
| Director of Environmental Services | Verified cleaning solution should not be left in resident rooms and staff are trained accordingly. | |
| Administrator | Stated cleaning chemicals should never be left unattended in resident rooms and power strips should not be in beds. | |
| Assistant MDS Coordinator | Acknowledged lack of comprehensive care plans for residents R108 and R116. | |
| Social Worker | Responsible for psych components of care plans; unaware of missing care plans for R108 and R116. | |
| MDS Coordinator | Confirmed no care plan developed for smoking for resident R126. | |
| Activities Director | Responsible for care plans related to smoking; confirmed no care plan for resident R126. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician and responsible party of a resident's change in condition and failure to provide appropriate treatment for a severe urinary tract infection.
Complaint Details
The complaint investigation focused on failure to notify the physician and responsible party of a resident's change in condition related to abnormal lab results and failure to provide appropriate treatment for a severe urinary tract infection, resulting in actual harm and hospitalization.
Findings
The facility failed to notify the physician and responsible party of critical lab results for one resident, resulting in actual harm and hospitalization. Additionally, the facility failed to develop care plans for certain residents and did not maintain a safe environment free from accident hazards.
Deficiencies (4)
Failure to notify physician and responsible party of critical urinalysis lab results for resident R660, resulting in hospitalization for urosepsis and acute renal failure.
Failure to develop care plans for residents R108 (PTSD), R116 (dementia), and R126 (smoking).
Failure to ensure environment was free from accident hazards, including electrical power strip lying in resident R2's bed and improperly stored chemical spray bottle in resident R82's room.
Failure to provide appropriate treatment and care for resident R660 with severe urinary tract infection, resulting in hospitalization for 11 days with acute renal failure.
Report Facts
Residents sampled: 44
Hospitalization duration: 11
Temperature readings: 101.7
Lab result: 100000
Medication dosage: 40
Care plan deficits: 3
Power strip cords: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Nurse Practitioner | Wrote progress notes regarding resident R660's UTI and treatment plan |
| PP | Licensed Practical Nurse | Documented resident R660's temperature and care on 12/16/2023 |
| AA | Licensed Practical Nurse | Described nurse responsibilities for notifying physician of lab results |
| NN | Certified Nursing Assistant | Provided care for resident R2 and aware of power strip hazard |
| KK | Certified Nursing Assistant | Observed placing cleaning solution behind television in resident R82's room |
| LL | Housekeeper | Admitted to leaving cleaning solution in resident R82's room by mistake |
| MM | Assistant Maintenance Director | Checked electronic maintenance system and confirmed no prior work order for power strip |
| DON | Director of Nursing | Provided multiple interviews regarding lab result notification and care plan deficiencies |
| ADON | Assistant Director of Nursing | Observed power strip in resident R2's bed during compliance rounds |
| SW | Social Worker | Responsible for behavioral and psych components of care plans |
| AD | Activities Director | Responsible for developing care plans related to smoking |
| Administrator | Provided statements on policies and facility practices | |
| Medical Director | Interviewed regarding notification of abnormal lab results |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician and responsible party of a resident's change in condition and failure to provide appropriate treatment for a severe urinary tract infection.
Complaint Details
The complaint investigation focused on failure to notify the physician and responsible party of a resident's change in condition and failure to provide appropriate treatment for a severe urinary tract infection, resulting in actual harm and hospitalization.
Findings
The facility failed to notify the physician and responsible party of critical lab results for one resident (R660), resulting in actual harm and hospitalization for urosepsis and acute renal failure. Additionally, the facility failed to develop care plans for three residents with specific needs and failed to maintain a safe environment by allowing electrical hazards and improperly storing cleaning chemicals.
Deficiencies (6)
Failed to notify physician and responsible party of critical urinalysis lab results for resident R660, resulting in actual harm and hospitalization.
Failed to develop a care plan for resident R126 related to smoking.
Failed to develop care plans for residents R108 for PTSD and R116 for dementia.
Electrical power strip was found lying in resident R2's bed, creating a potential fire hazard.
Cleaning chemical spray bottle was improperly stored in resident R82's room, posing a risk of chemical exposure.
Failed to provide appropriate treatment and care for resident R660 with severe urinary tract infection, resulting in hospitalization for 11 days.
Report Facts
Residents sampled: 44
Hospitalization duration: 11
Temperature readings: 101.7
Lab result: 100000
Medication dosage: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP GG | Nurse Practitioner | Wrote progress notes and ordered urinalysis for resident R660; interviewed regarding notification of lab results |
| LPN PP | Licensed Practical Nurse | Documented resident's elevated temperature and care on 12/16/2023 |
| DON | Director of Nursing | Interviewed regarding lab result notification process and facility policies |
| ADON | Assistant Director of Nursing | Interviewed regarding compliance rounds and power strip hazard |
| CNA NN | Certified Nursing Assistant | Provided care for resident R2 and aware of power strip hazard |
| MM | Assistant Maintenance Director | Interviewed regarding maintenance work orders and power strip issue |
| SW | Social Worker | Responsible for behavioral and psych components of care plans; interviewed about missing care plans |
| AD | Activities Director | Responsible for care plans related to smoking; interviewed about missing care plan for resident R126 |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed about care plan development responsibilities |
| CNA KK | Certified Nursing Assistant | Observed placing cleaning solution behind television in resident R82's room |
| Housekeeper LL | Housekeeper | Interviewed about cleaning solution left in resident room |
| Administrator | Facility Administrator | Interviewed about policies and incidents related to power strip and cleaning chemical hazards |
Inspection Report
Life Safety
Census: 153
Capacity: 167
Deficiencies: 7
Date: Mar 23, 2024
Visit Reason
The visit was a Life Safety Code Survey 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 several Life Safety Code requirements, including emergency lighting failure in the medicine room, damaged drywall in the boiler/hotwater room, fire alarm system panel trouble, missing sprinkler system components, door latch failures, lack of self-closers on hazard room doors, and unsealed smoke barrier penetrations above ceilings.
Deficiencies (7)
Failed to maintain emergency lighting in the medicine room.
Failed to repair drywall damage in boiler/hotwater room compromising smoke resistance.
Fire alarm system panel showing trouble at the Tamper vault needing repair.
Missing escutcheon plate on sprinkler head in kitchen and missing waterflow switch cap in riser room.
Failed to maintain latch on exterior NO EXIT door in Therapy room.
Failed to install self-closers on doors of environmental storage and central supply rooms.
Failed to maintain seal with U.L listed caulk of smoke compartments above ceiling at rooms A-5 and E-8.
Report Facts
Census: 153
Total Capacity: 167
Residents at risk: 2
Residents at risk: 20
Residents at risk: 167
Residents at risk: 5
Residents at risk: 30
Inspection Report
Abbreviated Survey
Census: 149
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey from November 13, 2023, through November 15, 2023, including complaint investigations.
Complaint Details
Complaint Intake Numbers GA00223647, GA00225850, GA00232051, GA00226562, GA00226703, GA00228843, GA00236542, GA00226753, GA00230120, GA00238403 were unsubstantiated. Complaint Intake Number GA00227918 was substantiated. No regulatory violations were cited.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Multiple complaint intake numbers were unsubstantiated except one which was substantiated, but no regulatory violations were cited.
Report Facts
Complaint Intake Numbers Unsubstantiated: 10
Complaint Intake Numbers Substantiated: 1
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 153
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00239099 and GA00239488.
Complaint Details
Complaint #GA00239488 was unsubstantiated. Complaint #GA00239099 was substantiated. No deficiencies were cited for either complaint.
Findings
Complaint #GA00239488 was unsubstantiated with no deficiencies cited. Complaint #GA00239099 was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 31, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00231897.
Complaint Details
Complaint #GA00231897 was unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00230976.
Complaint Details
Complaint #GA00230976 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint #GA00230976 was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Census: 152
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/10/22 Recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Census: 153
Deficiencies: 4
Date: Apr 1, 2022
Visit Reason
The inspection was a Licensure Survey conducted from March 29, 2022 through April 1, 2022 to assess compliance with state regulations and facility licensure requirements.
Findings
The facility was found deficient in multiple areas including failure to promptly notify physicians of significant resident health changes, improper management of psychotropic medications, failure to lock medication carts when unattended, inadequate provision of showers and personal hygiene for residents, and ineffective infection control practices including poor hand hygiene and improper glove use during care.
Deficiencies (4)
Failure to ensure physician was immediately notified when resident complained of pain following a fall.
Psychotropic medications were not ordered as needed beyond 14 days, lacked documentation of rationale and duration, and medication carts were left unlocked.
Failure to ensure showers were regularly provided and facial hair was removed as needed for a resident.
Failure to implement effective infection control program including failure to encourage hand hygiene for residents during meal delivery, failure of housekeeping staff to perform hand hygiene between rooms and glove changes, and failure of nursing staff to change gloves and perform hand hygiene during incontinent care.
Report Facts
Census: 153
Medication carts observed: 6
Residents reviewed for falls: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for ADLs: 3
Residents reviewed for incontinent care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN II | Licensed Practical Nurse | Mentioned in relation to failure to notify physician of resident pain and medication administration |
| RN KK | Registered Nurse | Notified physician of resident pain and ordered x-ray |
| LPN JJ | Licensed Practical Nurse | Found resident on floor and assessed, stated normal practice to wait for x-ray |
| MD HH | Medical Director | Discussed notification procedures following resident falls |
| DON | Director of Nursing | Provided expectations for notification and infection control practices |
| Administrator | Facility Administrator | Provided expectations for nursing staff notification and shower provision |
| LPN PP | Licensed Practical Nurse | Responsible for medication cart left unlocked |
| CNA GG | Certified Nursing Assistant | Observed providing incontinent care without changing gloves appropriately |
| Housekeeper DDD | Housekeeper | Observed failing to perform hand hygiene between glove changes |
Inspection Report
Routine
Census: 153
Deficiencies: 8
Date: Apr 1, 2022
Visit Reason
A standard survey was conducted by CertiSurv, LLC on behalf of the Georgia Department of Community Health at Parkside Post-Acute and Rehabilitation from March 29, 2022 through April 1, 2022, including investigations GA000218412 and GA000218231.
Findings
The survey revealed multiple deficiencies including failure to notify physicians promptly after resident falls, inadequate ADL care such as irregular showers and shaving, insufficient fall prevention interventions and documentation, failure to follow psychiatrist consultation orders, incomplete medication destruction documentation, unlocked medication carts, and lapses in infection control practices including hand hygiene and glove use.
Deficiencies (8)
Failure to ensure physician was immediately notified when resident complained of pain following a fall.
Failure to ensure showers were regularly provided and facial hair removed as needed for a dependent resident.
Failure to investigate and document causative factors for falls and implement consistent fall prevention interventions for a resident with multiple falls.
Failure to ensure psychiatric consultation was provided per physician order for a resident receiving unnecessary medications.
Failure to accurately document controlled substance destruction amounts on destruction forms.
Failure to follow pharmacist recommendations related to psychotropic medication orders including PRN duration and documentation of rationale.
Failure to ensure medication carts were locked when unattended.
Failure to implement effective infection control program including failure to offer hand hygiene to residents during meal delivery, improper glove use and hand hygiene by housekeeping and nursing staff during care activities.
Report Facts
Resident census: 153
Controlled substances with undocumented destruction amounts: 4
Medication administration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN PP | Licensed Practical Nurse | Responsible for medication cart found unlocked |
| LPN YY | Licensed Practical Nurse | Witnessed medication destruction and signed destruction form |
| LP EE | Licensed Pharmacist | Signed medication destruction form and reviewed medication regimen |
| CNA GG | Certified Nursing Assistant | Observed providing incontinent care without changing gloves or hand hygiene |
| DON | Director of Nursing | Provided multiple interviews regarding fall prevention, medication follow-up, and infection control |
| Administrator | Provided interviews regarding expectations for medication follow-up and infection control | |
| Social Worker LLL | Social Worker | Responsible for psychiatric consult referrals |
| LPN EE | Licensed Practical Nurse | Administered lorazepam PRN for anxiety |
| Licensed Pharmacist QQ | Licensed Pharmacist | Provided interview on expectations for PRN psychotropic medication orders |
Inspection Report
Complaint Investigation
Census: 153
Deficiencies: 9
Date: Apr 1, 2022
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to notify physicians of resident conditions, inadequate personal care, fall prevention, medication management, infection control, and other regulatory compliance issues.
Complaint Details
The investigation was complaint-driven, focusing on issues such as failure to notify physicians after falls, inadequate personal care, fall prevention, medication management, and infection control.
Findings
The facility failed to ensure timely physician notification after a resident fall, adequate personal hygiene care, proper fall prevention interventions, accurate medication destruction documentation, appropriate psychiatric consultation and medication management, secure medication storage, and effective infection control practices including hand hygiene and glove use during care.
Deficiencies (9)
Failure to ensure physician was immediately notified when resident complained of pain following a fall.
Failure to ensure showers were regularly provided and facial hair was removed as needed for a resident.
Failure to investigate and document causative factors for falls and implement consistent interventions for fall prevention.
Failure to ensure psychiatric consultation was provided in accordance with physician's order for a resident.
Failure to ensure controlled substances were accurately documented on destruction forms.
Failure to follow consultant pharmacist's recommendations related to an as-needed antianxiety medication order.
Failure to implement gradual dose reductions and non-pharmacological interventions prior to continuing psychotropic medications; PRN orders exceeded 14 days without documented rationale.
Failure to ensure medication carts were locked when not attended.
Failure to implement an effective infection control program including failure to offer hand hygiene to residents during meal delivery, failure of housekeeping staff to perform hand hygiene between rooms and glove changes, and failure of nursing staff to change gloves and perform hand hygiene during incontinent care.
Report Facts
Resident census: 153
Controlled substances reviewed: 59
Pharmacist recommendation date: Jan 14, 2022
Fall Risk Assessment score: 12
Fall Risk Assessment score: 14
Fall Risk Assessment score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN II | Licensed Practical Nurse | Named in failure to notify physician of resident pain after fall |
| RN KK | Registered Nurse | Named in assessment and notification of physician after resident fall |
| LPN JJ | Licensed Practical Nurse | Named in assessment of resident after fall |
| MD HH | Medical Director | Named in interview regarding fall notification and x-ray orders |
| DON | Director of Nursing | Named in multiple interviews regarding fall prevention, medication management, and infection control |
| Administrator | Facility Administrator | Named in interviews regarding facility expectations for nursing and infection control |
| LPN PP | Licensed Practical Nurse | Named in psychiatric consult order process |
| Social Worker LLL | Social Worker | Named in psychiatric consult referral process |
| Licensed Pharmacist EE | Licensed Pharmacist | Named in medication destruction and medication regimen review |
| CNA GG | Certified Nursing Assistant | Named in infection control and incontinent care observations |
Inspection Report
Life Safety
Census: 153
Capacity: 167
Deficiencies: 0
Date: Mar 28, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and related standards.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code edition.
Report Facts
Census: 153
Certified Beds: 167
Inspection Report
Re-Inspection
Census: 158
Deficiencies: 0
Date: Dec 16, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/22/21 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on 10/22/21; all deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited as a result of the 10/22/21 Complaint Survey were found to be corrected during the revisit survey.
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 2
Date: Oct 22, 2021
Visit Reason
A COVID-19 Focused Infection Control and Complaint Survey was conducted from October 19, 2021 through October 22, 2021, including investigation of multiple complaint intake numbers, with some substantiated with deficient practice.
Complaint Details
Complaint Intake Numbers GA00214056 and GA00214153 were substantiated with deficient practice related to failure to notify family and delayed treatment of Resident #1's vascular ulcer. Other complaint intake numbers were investigated and unsubstantiated without deficiencies.
Findings
The facility failed to notify the family of Resident #1 about skin discoloration noted on 4/22/21 and failed to timely assess and treat the resident's vascular ulcer until a week later. The wound was identified by the family member during an outdoor visit, but the previous Director of Nursing did not pass the information to the unit manager, delaying treatment.
Deficiencies (2)
Failure to notify family of Resident #1's skin discoloration on right lower leg noted on 4/22/21.
Failure to timely assess and treat Resident #1's vascular ulcer identified on 4/22/21 until a week later.
Report Facts
Resident census: 143
Wound size: 3.5
Wound size: 2.5
BIMS score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse Unit Manager | Named in relation to assessment and notification failures regarding Resident #1's wound |
| Director of Nursing | Mentioned as previous DON who failed to pass wound information to unit manager | |
| Administrator | Interviewed regarding wound notification and assessment failures |
Inspection Report
Abbreviated Survey
Census: 162
Deficiencies: 0
Date: Feb 4, 2021
Visit Reason
An Abbreviated Survey was conducted from February 2 to February 4, 2021, investigating multiple complaint allegations which were found to be unsubstantiated. Additionally, a COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations.
Complaint Details
Multiple complaints (GA00203090, GA00204761, GA00205037, GA00205263, GA00205596, GA00205598, GA00206221, GA00207628) were investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control. All investigated complaints were unsubstantiated.
Report Facts
Resident census: 162
Inspection Report
Routine
Census: 140
Deficiencies: 0
Date: Sep 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 141
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.83 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 137
Deficiencies: 0
Date: Jul 29, 2020
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 on July 28-29, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 145
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Report Facts
Total census: 145
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 20, 2020
Visit Reason
An abbreviated survey was conducted to investigate complaint number GA00202505.
Complaint Details
Complaint number GA00202505 was investigated and found to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 31, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00196561, GA00201340, and GA00201540.
Complaint Details
The survey investigated three complaints: GA00196561 and GA00201540 were substantiated with no deficiencies, while GA00201340 was unsubstantiated.
Findings
Complaint GA00201340 was unsubstantiated. Complaints GA00196561 and GA00201540 were substantiated with no deficiencies identified.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 16, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Re-Inspection
Census: 155
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
A revisit survey was conducted from 2/11/19 to 2/12/19 to verify correction of deficiencies cited in the 12/10/18-12/13/18 Standard Survey and to investigate Complaint Intake Number GA00194439.
Complaint Details
Complaint Intake Number GA00194439 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior standard survey were found to be corrected. The complaint investigation was unsubstantiated.
Inspection Report
Re-Inspection
Census: 155
Deficiencies: 0
Date: Feb 11, 2019
Visit Reason
A revisit survey was conducted on 2/11/19 to verify correction of deficiencies cited in the 12/10/18-12/13/18 Standard Survey. Additionally, a complaint investigation (GA00194439) was conducted in conjunction with this revisit.
Complaint Details
Complaint Intake Number GA00194439 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior standard survey were found to be corrected. The complaint investigation was unsubstantiated.
Report Facts
Facility census: 155
Inspection Report
Follow-Up
Deficiencies: 1
Date: Feb 1, 2019
Visit Reason
A Follow-Up/Revisit Survey was conducted to verify correction of previously cited deficiencies related to fire sprinkler coverage in the facility.
Findings
The facility failed to provide fire sprinkler coverage in the patient closets in the Long Term Care part of the facility and did not correct two fire sprinklers in the rehab room that were 11 feet 8 inches from the wall, placing 146 residents at risk in the event of a fire.
Deficiencies (1)
Failed to provide fire sprinkler coverage in patient closets in the Long Term Care area and did not correct two fire sprinklers in the rehab room that were improperly located.
Report Facts
Residents at risk: 146
Distance of fire sprinklers from wall: 11.67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings at time of discovery but no full name provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
A complaint survey was conducted on 1/15/2019 through 1/16/2019 to investigate complaints #GA00193924 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaints #GA00193924; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
Licensure survey conducted to determine compliance with State Long Term Care Requirements.
Findings
No deficiencies were cited during the licensure survey conducted from December 10 through December 13, 2018.
Inspection Report
Routine
Census: 179
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food quality and palatability standards, following resident complaints and council meeting concerns about food taste, temperature, and preparation.
Findings
The facility failed to ensure that food served to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents and resident council meetings reported dissatisfaction with food quality, including complaints of cold meals, overcooked or undercooked food, lack of condiments, and poor taste. Meal observations confirmed that food temperatures were often below the required 135°F, and food presentation was inadequate.
Deficiencies (1)
Food was not satisfactory in taste or temperature and condiments were not consistently served, creating potential for dissatisfaction and weight loss.
Report Facts
Residents prescribed regular texture diets: 94
Residents prescribed mechanical soft texture diets: 62
Residents prescribed pureed texture diets: 23
Residents eating in main dining room: 30
Food temperature: 110
Food temperature: 110.8
Food temperature: 102
Food temperature: 89
Food temperature: 115
Food temperature: 123
Number of residents sampled: 37
Number of residents with food palatability issues: 6
Number of meal carts: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding meal times, food delivery, and addressing residents' food concerns | |
| Registered Dietitian | Interviewed regarding kitchen audits and addressing residents' food concerns |
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 1
Date: Dec 13, 2018
Visit Reason
A standard survey was conducted in conjunction with a complaint intake investigation regarding food quality and palatability at Parkside Post Acute and Rehabilitation.
Complaint Details
Complaint Intake GA00191607670 was investigated in conjunction with the standard survey. The complaint involved resident dissatisfaction with food quality, temperature, and preparation.
Findings
The facility failed to ensure food was palatable, properly prepared, and served at appropriate temperatures, resulting in resident dissatisfaction. Multiple residents and the Ombudsman reported issues with cold meals, lack of condiments, overcooked or undercooked food, and poor food appearance. Meal observations confirmed food was often served lukewarm or cold, and condiments were inconsistently provided.
Deficiencies (1)
Food was not satisfactory in taste or temperature and condiments were not consistently served, creating potential for dissatisfaction and weight loss.
Report Facts
Resident census: 147
Residents prescribed regular texture diets: 94
Residents prescribed mechanical soft texture diets: 62
Residents prescribed pureed texture diets: 23
Residents sampled: 37
Residents with food issues: 6
Meal service times: Breakfast 7:00-8:30 a.m., Lunch 12:00-1:20 p.m., Dinner 5:00-6:30 p.m.
Food temperatures observed: 110
Food temperatures observed: 102
Food temperatures observed: 89
Food temperatures observed: 115
Food temperatures observed: 123
Meal carts: 6
Insulated food carts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding meal times, food preparation, and temperature issues | |
| Registered Dietitian | Interviewed regarding kitchen audits and addressing residents' food concerns |
Inspection Report
Life Safety
Census: 146
Capacity: 167
Deficiencies: 7
Date: Dec 11, 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 fire safety requirements including fire suppression system inspection, fire alarm system installation and maintenance, sprinkler system installation and maintenance, corridor door sealing and latching, and fire drill documentation.
Deficiencies (7)
Fire suppression system in the main kitchen was past due on test/inspection.
Fire alarm pull station in the front lobby was obstructed by furniture.
Facility failed to have a recent fire alarm sensitivity test/inspection document on site.
Patient room closets in the long term care side lacked fire sprinkler coverage; rehab room had sprinklers improperly located 11 ft. 8 in. from wall.
Fire sprinkler system had a yellow inspection tag indicating an intermediate problem; missing fire sprinkler trim rings in multiple rooms.
Public restroom door, multiple patient room doors, dining room door, and shower doors did not seal properly to prevent smoke; one patient room door did not latch properly.
Fire drills were not conducted in consecutive order; missing fire drills for several months and shifts.
Report Facts
Residents at risk due to fire suppression system issue: 10
Residents at risk due to obstructed fire alarm pull station: 10
Residents at risk due to missing fire alarm sensitivity document: 20
Residents at risk due to sprinkler coverage issues: 146
Residents at risk due to sprinkler system maintenance issues: 10
Residents at risk due to door sealing and latching issues: 20
Residents at risk due to fire drill deficiencies: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 12/11/18. | |
| Staff AM | Confirmed sprinkler system inspection tag and missing trim rings during facility tour on 12/11/18. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 17, 2018
Visit Reason
A complaint survey was conducted to investigate multiple complaints identified by their numbers to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey investigated complaints #GA00189879, #GA001904440, #GA00190221, GA00190724, #GA00190802, and GA00191288; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey conducted by Registered Nurse Surveyors.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 10, 2018
Visit Reason
A revisit survey was conducted on 7/9/18 through 7/10/18 for the complaint survey of 5/20/18 to determine if previously cited deficiencies had been corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 5/20/18; all deficiencies cited in that complaint survey were found to be corrected.
Findings
The revisit survey determined that all previously cited deficiencies from the complaint survey had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 20, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00189135 and GA00188977 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaints #GA00189135 and GA00188977 were investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2018
Visit Reason
A complaint survey was conducted on 3/21/18 through 3/22/18 to investigate complaint GA 00186559 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA 00186559 was investigated and found to have no deficiencies.
Findings
No deficiency was cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 10, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies at the facility.
Findings
The follow-up inspection found that all previously cited deficiencies had been corrected except for one related to the gap between corridor smoke doors on B Hall, which remained greater than 1/8 inch.
Deficiencies (1)
Gap between corridor smoke doors on B Hall is greater than 1/8 inch and has not been corrected.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M and Staff A were involved in confirming the deficiency and providing information about corrective actions. |
Inspection Report
Routine
Census: 158
Deficiencies: 0
Date: Nov 16, 2017
Visit Reason
A standard survey was conducted at Scepter Rehab and Healthcare from November 13, 2017 through November 16, 2017 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 156
Capacity: 167
Deficiencies: 13
Date: Nov 13, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including improper testing and maintenance of exit signs and emergency lighting, incomplete fire alarm system installation and maintenance, inadequate sprinkler system coverage and maintenance, improperly maintained fire extinguishers, corridor smoke door gaps exceeding limits, unprotected rated ceiling penetrations, improper use of extension cords, presence of unapproved space heaters, lack of emergency lighting in medication room, and failure to perform required generator load bank testing.
Deficiencies (13)
Failed to properly test facility exit and exit directional signs; exit light in main dining area not working.
Failed to properly test facility emergency lighting; emergency light in Rehab room not working.
Fire alarm system not installed according to code; no visual notification device in Library.
Failed to properly maintain fire alarm system; 12 smoke detectors, 1 pull station, 1 horn/strobe not working; device in room D 107 not tested; no sensitivity testing conducted.
Facility not fully protected by fire sprinkler system; combustible cover over egress from E hall not protected.
Failed to properly maintain fire sprinkler system; grease loaded sprinkler heads, missing escutcheon, no head wrench in head box.
Failed to properly maintain fire extinguishers; extinguishers mounted too high; generator area extinguisher not inspected annually.
Failed to properly maintain corridor smoke doors; gap greater than 1/8 inch on B Hall.
Failed to properly maintain smoke barrier construction; unprotected penetrations in rated ceilings; damaged attic opening.
Failed to properly maintain electrical systems; extension cord used as permanent wiring in Activity Storage Room.
Improperly rated portable space heater found in Charting Room (removed at inspection).
Failed to provide proper emergency lighting in Medication Room.
Failed to properly maintain facility generator; no annual load bank test performed.
Report Facts
Census: 156
Total Capacity: 167
Smoke detectors not working: 12
Pull stations not working: 1
Horn/strobe not working: 1
Fire sprinkler system load bank tests missed: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during observations and record reviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 4, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00180323 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00180323 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey conducted on 10/3-10/4/2017 at Scepter Rehab and Healthcare.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 29, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176347 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00176347 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 30, 2017
Visit Reason
The abbreviated survey was conducted to investigate a complaint (#GA00172497) and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00172497 was investigated; no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey conducted on 5/30/2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 31, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA 00171600 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00171600 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated following the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 30, 2016
Visit Reason
A Life Safety Code (LSC) Follow-Up Survey was conducted to verify correction of deficiencies cited in the Recertification Survey on 2016-10-07 and the Revisit survey on 2016-11-21.
Findings
It was determined that all previously cited survey tags have been corrected.
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