Inspection Report
Plan of Correction
Deficiencies: 0
Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility following an inspection completed on June 10, 2025.
Findings
The report contains initial comments but does not provide specific details about deficiencies or findings.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 0
Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/24/2025 Recertification Survey with attached complaint.
Findings
All deficiencies cited in the prior 4/24/2025 Recertification Survey with attached complaint were found to be corrected.
Complaint Details
The revisit survey was related to a complaint attached to the 4/24/2025 Recertification Survey; deficiencies were corrected.
Report Facts
Census: 24
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility, indicating it is related to addressing previously identified deficiencies.
Findings
The document contains initial comments but does not provide specific findings or details of deficiencies.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 0
Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/24/2025 Recertification Survey with attached complaint.
Findings
All deficiencies cited as a result of the 4/24/2025 Recertification Survey with attached complaint were found to be corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 10, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 24
Deficiencies: 0
Jun 10, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 4/24/2025 Recertification Survey with attached complaint.
Findings
All deficiencies cited in the prior 4/24/2025 Recertification Survey with attached complaint were found to be corrected.
Inspection Report
Life Safety
Census: 22
Capacity: 25
Deficiencies: 0
May 1, 2025
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 standards.
Report Facts
Certified Beds: 25
Census: 22
Inspection Report
Annual Inspection
Deficiencies: 3
Apr 24, 2025
Visit Reason
A State Licensure survey was conducted at The Terraces at Peachtree Hills Place from April 22, 2025, through April 24, 2025, to assess compliance with state health and safety regulations.
Findings
The survey identified deficiencies including failure to develop a care plan for a resident at risk of wandering, unsafe food storage and handling practices risking foodborne illness, and failure to offer pneumococcal vaccines to four of five residents reviewed, increasing their risk of pneumonia.
Deficiencies (3)
| Description |
|---|
| Failure to ensure a care plan was developed for a resident reviewed for wandering. |
| Failure to ensure food was stored, labeled, dated, and discarded properly; improper hand hygiene and glove use by dietary staff risking cross contamination. |
| Failure to offer pneumococcal vaccines to four of five residents reviewed per CDC guidelines. |
Report Facts
Residents reviewed for wandering: 13
Residents reviewed for pneumococcal vaccines: 13
Residents not offered pneumococcal vaccine: 4
Residents reviewed for pneumococcal vaccines offered vaccine: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook3 | Cook | Observed handling food with contaminated gloves and improper hand hygiene |
| Cook1 | Lead Cook | Provided oversight and acknowledged observation of Cook3's improper glove use |
| Assistant Director of Nursing | ADON | Confirmed lack of care plan for wandering resident and vaccination deficiencies |
| MDS Coordinator | MDSC | Confirmed failure to code resident as wanderer triggering care plan development |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 4
Apr 24, 2025
Visit Reason
A standard survey was conducted from April 22 through April 24, 2025, including investigation of Complaint Intake Number GA00248248, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations due to deficiencies including inaccurate resident assessment for wandering, failure to develop a care plan for wandering, unsafe food storage and handling practices, and failure to offer pneumococcal vaccines to eligible residents per CDC guidelines.
Complaint Details
Complaint Intake Number GA00248248 was investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 2
SS= E: 1
SS= F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure an accurate assessment for Resident 13 regarding wandering behavior. | SS= D |
| Failed to develop a care plan addressing wandering for Resident 13. | SS= D |
| Failed to ensure food was stored, labeled, dated, and discarded properly; improper hand hygiene and glove use by dietary staff leading to risk of food borne illness. | SS= F |
| Failed to ensure four of five residents reviewed were offered pneumococcal vaccines per CDC guidelines, increasing risk of pneumonia. | SS= E |
Report Facts
Resident census: 23
Residents reviewed for wandering: 13
Residents reviewed for pneumococcal vaccines: 13
Residents not offered pneumococcal vaccine: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Confirmed Resident 13 wandering behavior and lack of updated care plan; confirmed vaccination deficiencies. | |
| MDS Coordinator (MDSC) | Confirmed Resident 13 was not coded as a wanderer on admission MDS. | |
| Cook3 | Dietary Staff | Observed handling food with contaminated gloves, improper hand hygiene. |
| Cook1 | Lead Cook | Provided oversight and confirmed observations of improper food handling by Cook3. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 30, 2024
Visit Reason
The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 data to the NHSN between 01/22/2024 and 01/28/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 26, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the facility, indicating a regulatory inspection was conducted to identify deficiencies and outline corrective actions.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection, but no specific deficiencies or severity levels are detailed on the provided page.
Inspection Report
Follow-Up
Census: 22
Deficiencies: 0
Jan 26, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the December 3, 2023 Standard Survey.
Findings
All deficiencies cited in the prior December 3, 2023 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 22, 2024
Visit Reason
The facility was reviewed for compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the NHSN between 01/15/2024 and 01/21/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's NHSN during a required seven-day period. | F |
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Jan 18, 2024
Visit Reason
A follow-up Life Safety Code revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Deficiencies: 1
Dec 3, 2023
Visit Reason
A State Licensure survey was conducted at The Terraces at Peachtree Hills Place from December 1, 2023 through December 3, 2023 to assess compliance with state health regulations.
Findings
The facility failed to ensure that two of 13 sampled residents were properly assessed for safe self-administration of medications, lacked physician orders for self-administration, and had unsecured medications in resident rooms, posing potential risks for medication errors and unauthorized access.
Deficiencies (1)
| Description |
|---|
| Failure to assess two residents for safe self-administration of medications, obtain physician orders, and secure medications properly. |
Report Facts
Sampled residents: 13
Residents with deficient practice: 2
BIMS score: 13
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Stated no resident was deemed safe to self-medicate and described medication storage procedures | |
| Licensed Practical Nurse (LPN) BB | Confirmed no residents self-medicate and described assessment requirements | |
| Administrator | Verified unsecured medications in resident rooms and lack of self-medication assessments or orders |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Dec 3, 2023
Visit Reason
A standard survey was conducted from December 1 through December 3, 2023, in conjunction with Complaint Intake Number GA00237040 to investigate compliance with Medicare/Medicaid regulations at a long-term care facility.
Findings
The facility failed to ensure that two of 13 sampled residents were properly assessed for safe self-administration of medications, lacked physician orders for self-administration, and had unsecured medications in resident rooms, contrary to facility policy and regulatory requirements.
Complaint Details
Complaint Intake Number GA00237040 was investigated in conjunction with the standard survey. The complaint involved concerns about medication self-administration and medication security.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess two residents for safe self-administration of medications, obtain physician orders, and secure medications properly. | SS= D |
Report Facts
Resident census: 20
Sampled residents: 13
Residents with deficiencies: 2
BIMS score: 13
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Interviewed regarding medication administration and facility policy on self-medication |
| LPN BB | Licensed Practical Nurse | Interviewed regarding medication administration and assessment requirements for self-medication |
| Administrator | Interviewed and conducted walking rounds verifying unsecured medications and lack of self-medication assessments |
Inspection Report
Life Safety
Census: 22
Capacity: 25
Deficiencies: 7
Dec 2, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including fire safety and emergency training.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and life safety codes. Deficiencies included lack of updated emergency preparedness plan documentation, missing staff training records, failure to maintain hazardous areas and smoke compartments, missing documentation of fire alarm system maintenance, and failure to conduct required fire drills.
Severity Breakdown
SS= D: 5
SS= F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Emergency Preparedness Program was not in substantial compliance; no updated plan including staff contact and vendor information for fire alarm and sprinkler system. | SS= D |
| No documentation of staff training for emergency preparedness since 2020 plan was written. | SS= D |
| Failed to maintain hazardous areas; obstructions preventing housekeeping storage closet doors from closing and latching. | SS= F |
| Failed to maintain fire alarm and smoke detection; no documentation of replacement of faulty smoke detector in room 4305 after annual inspection. | SS= D |
| Failed to maintain smoke compartments; penetrations above ceiling at corridor doors #1 and #3 not sealed. | SS= D |
| Failed to ensure smoke barrier; corridor door #1 did not close when released. | SS= D |
| Failed to maintain fire drill schedule; required number of fire drills not performed. | SS= F |
Report Facts
Census: 22
Total Capacity: 25
Stories: 4
Construction Year: 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, hazardous areas, fire alarm system, smoke compartments, and fire drills |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 24, 2023
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 07/17/2023 and 07/23/2023 as required, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 17, 2023
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 07/10/2023 and 07/16/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Dec 20, 2022
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 during the follow-up survey.
Inspection Report
Life Safety
Census: 12
Capacity: 25
Deficiencies: 1
Nov 1, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to maintain the fire alarm system at optimum readiness, including a fire alarm panel in trouble and missing fire alarm sensitivity testing records within the last two years.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Fire alarm system was in trouble and lacked fire alarm sensitivity testing records within the last 2 years. | SS=F |
Report Facts
Census: 12
Certified beds: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm system during facility tour |
Inspection Report
Renewal
Deficiencies: 0
Oct 23, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 10/21/22 through 10/23/22 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from 10/21/22 through 10/23/22.
Inspection Report
Routine
Census: 11
Deficiencies: 0
Oct 23, 2022
Visit Reason
A standard survey was conducted at The Terraces at Peachtree Hills Place from October 21, 2022, through October 23, 2022, to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 43, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Original Licensing
Capacity: 25
Deficiencies: 0
Oct 17, 2022
Visit Reason
A walk-through licensure survey was conducted to assess compliance for nine additional beds at The Terraces at Peachtree Hills Place.
Findings
The nine additional beds were found to be in compliance with State requirements, and the facility is approved for a total of 25 beds.
Report Facts
Total licensed beds: 25
Additional beds surveyed: 9
Inspection Report
Original Licensing
Census: 5
Deficiencies: 0
Feb 25, 2021
Visit Reason
An initial certification survey was conducted at Terraces at Peachtree Hills Place between February 22, 2021 and February 25, 2021 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 4
Capacity: 7
Deficiencies: 0
Feb 22, 2021
Visit Reason
The 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 in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR &483.73.
Inspection Report
Original Licensing
Deficiencies: 0
Nov 17, 2020
Visit Reason
An initial walk-through licensure survey was conducted at Terraces at Peachtree Hills Place on November 17, 2020.
Findings
The facility was found to be in compliance with state requirements.
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