Inspection Reports for Powder Springs Center for Nursing & Healing
3460 POWDER SPRINGS ROAD, POWDER SPRINGS, GA, 30127
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 3, 2025, found no deficiencies and the complaint investigated was unsubstantiated. Prior inspections showed a pattern of deficiencies primarily related to infection control practices, medication administration, resident care planning, and facility cleanliness, including a substantiated complaint in April 2024 that involved immediate jeopardy due to delayed laboratory services causing resident harm and death. Earlier complaint investigations were mostly unsubstantiated or found deficiencies that were subsequently corrected, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has addressed previous deficiencies through revisit surveys that confirmed corrections, indicating some improvement over time. However, the recurrence of infection control issues in mid-2024 suggests ongoing challenges in maintaining consistent compliance.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
195 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Abbreviated Survey
Census: 195
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Intake Number GA00254034 at Powder Springs Center Nursing and Rehab.
Complaint Details
Complaint Intake Number GA00254034 was investigated and found unsubstantiated.
Findings
The complaint intake was found unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Powder Springs Center for Nursing & Healing following a survey completed on August 15, 2024.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 181
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the June 27, 2024 Recertification and State Licensure survey.
Findings
All deficiencies cited in the prior June 27, 2024 survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 182
Capacity: 208
Deficiencies: 0
Date: Jul 3, 2024
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 to be in substantial compliance with the emergency preparedness program requirements and Life Safety Code standards.
Inspection Report
Annual Inspection
Census: 183
Deficiencies: 1
Date: Jun 27, 2024
Visit Reason
A State Licensure survey was conducted at Powder Springs Center for Nursing and Healing from June 25, 2024, through June 27, 2024, to assess compliance with state health regulations.
Findings
The facility failed to follow infection control protocols related to the disposal of personal protective equipment (PPE) in two out of five rooms with residents on Droplet Precautions, risking the spread of respiratory infections.
Deficiencies (1)
Failure to follow infection control protocol related to disposal of PPE in two out of five rooms with residents on Droplet Precautions.
Report Facts
Census: 183
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director BB | Activities Director | Observed improperly discarding PPE and interviewed regarding PPE use |
| Registered Nurse AA | Registered Nurse | Interviewed about staff PPE use and education |
| Certified Nursing Assistant CNA | Certified Nursing Assistant | Interviewed about PPE use and disposal |
| Licensed Practical Nurse DD | Licensed Practical Nurse | Interviewed about PPE use and disposal |
| Housekeeper FF | Housekeeper | Observed improperly discarding PPE |
| Central Supply EE | Central Supply | Interviewed about PPE availability and replenishment |
| Director of Nursing DON | Director of Nursing | Interviewed about PPE protocols and confirmed improper PPE disposal was unacceptable |
Inspection Report
Annual Inspection
Census: 183
Deficiencies: 1
Date: Jun 27, 2024
Visit Reason
A recertification survey was conducted at Powder Springs Center for Nursing and Healing from June 25, 2024, through June 27, 2024, to assess compliance with Medicare/Medicaid regulations for long-term care facilities.
Findings
The facility was found not in substantial compliance due to failure to follow infection control protocols related to disposal of personal protective equipment (PPE) in rooms with residents on Droplet Precautions. Observations and interviews revealed inconsistent PPE disposal practices among staff.
Deficiencies (1)
Failure to properly dispose of PPE in two out of five rooms with residents on Droplet Precautions, including staff removing gowns and gloves outside the room instead of inside.
Report Facts
Census: 183
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director BB | Activities Director | Observed improperly disposing PPE and interviewed regarding PPE use |
| Registered Nurse AA | Registered Nurse | Taught COVID-19 in-service and interviewed about PPE protocols |
| Certified Nursing Assistant CNA | Certified Nursing Assistant | Interviewed about PPE use and disposal practices |
| Licensed Practical Nurse DD | Licensed Practical Nurse | Interviewed about PPE use and disposal practices |
| Central Supply EE | Central Supply | Interviewed about PPE availability and replenishment |
| Director of Nursing DON | Director of Nursing | Interviewed about PPE protocols and confirmed proper disposal requirements |
| Housekeeper FF | Housekeeper | Observed failing to properly discard PPE inside resident room |
Inspection Report
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Powder Springs Center for Nursing & Healing, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 182
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies identified during a complaint survey and focused infection control survey on 2024-04-15.
Complaint Details
The visit was a result of a complaint survey conducted on 2024-04-15; deficiencies from that survey were corrected.
Findings
The deficiencies identified in the prior complaint and infection control survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 182
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
A revisit survey was conducted in conjunction with a complaint investigation to verify correction of previous deficiencies and to investigate complaints.
Complaint Details
The revisit survey was conducted in conjunction with complaint investigations GA00246735 and GA246860; no deficiencies related to the complaints were identified.
Findings
No deficient practice was identified related to the complaints, and the deficiencies from the original survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 178
Deficiencies: 13
Date: Apr 15, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted investigating multiple complaints from March 12, 2024 to April 15, 2024, including substantiated complaints related to resident care and facility compliance.
Complaint Details
The survey was initiated due to multiple complaints (GA00242286, GA00228762, GA00229683, and others) which were substantiated with cited deficiencies including Immediate Jeopardy related to failure to provide timely laboratory services causing serious harm and death.
Findings
The facility was found to be in Immediate Jeopardy related to failure to provide timely laboratory services causing resident harm and death. Additional deficiencies included failure to promote resident dignity, unresolved grievances, incomplete care plans, medication administration errors, inadequate fall supervision and documentation, improper medication storage, unsanitary food service conditions, improper garbage disposal, inaccurate resident records, deficient infection control tracking, failure to ensure pneumococcal vaccinations were offered or documented, and a nonfunctional resident call system.
Deficiencies (13)
Failure to provide timely laboratory services resulting in resident sepsis and death (Immediate Jeopardy).
Failure to promote dignity and independence related to incontinence supplies.
Failure to resolve resident grievance related to missing glasses.
Failure to develop and implement comprehensive care plans for residents with indwelling catheters.
Failure to follow physician orders for medication administration, including holding medications based on vital signs.
Failure to ensure supervision, documentation, and neuro checks after resident falls.
Failure to securely store medications and discard expired medications appropriately.
Failure to maintain sanitary food preparation areas, including dirty vents, unclean fan, frozen food on freezer floor, and staff not wearing hair nets.
Failure to keep outside garbage disposal area free from trash and debris.
Failure to maintain accurate resident medical records, including incorrect documentation of resident death and hospitalizations.
Failure to maintain tracking and trending of infection control program data accurately and timely.
Failure to ensure residents were offered and/or consented to pneumococcal vaccination and proper documentation of refusals or offers.
Failure to ensure resident call system was functional, resulting in a resident's call light not working and staff not being alerted.
Report Facts
Complaints substantiated: 34
Resident census: 178
Medication errors: 7
Fall incidents: 4
Expired medications: 2
Pneumococcal vaccination refusals: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | West Wing Unit Manager | Notified responsible party about missing glasses but did not file grievance |
| LPN HH | Documented resident R17 deceased erroneously | |
| LPN JJJJ | Documented resident R17 deceased erroneously | |
| LPN DD | Licensed Practical Nurse | Observed leaving medication packets unattended on medication cart |
| CNA GGGG | Certified Nursing Assistant | Reported resident R37 call light was not working |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, medication administration, infection control, and call light issues |
| Administrator | Provided interviews regarding facility policies and resident records |
Inspection Report
Renewal
Census: 178
Deficiencies: 6
Date: Apr 15, 2024
Visit Reason
A Licensure Survey was conducted from 3/12/2024 through 4/15/2024 to assess compliance with state licensure requirements and regulations for Powder Springs Center for Nursing & Healing.
Findings
The survey identified multiple deficiencies including failure to promptly resolve resident grievances, improper medication storage and administration practices, failure to maintain infection control tracking and trending, inadequate care planning and medication administration errors for sampled residents, unsanitary kitchen and dumpster conditions, and failure to ensure residents were offered or consented to pneumococcal vaccinations.
Deficiencies (6)
Failure to promptly resolve a grievance related to missing glasses for one resident.
Medications left unattended on medication cart during administration and expired medications found in the medication room.
Failure to maintain tracking and trending of the Infection Control Program with discrepancies in infection documentation.
Failure to develop and implement comprehensive care plans for residents, including catheter care and medication administration per physician orders.
Unsanitary kitchen conditions including dirty vents and fan, food stored on freezer floor, and staff not wearing hair nets; outside garbage area not kept clean.
Failure to ensure residents were offered and/or consented to pneumococcal vaccination with lack of documentation of offers or refusals for three residents.
Report Facts
Census: 178
Medication errors: 2
Medication administration errors: 2
Infection tracking discrepancies: 6
Residents reviewed for immunizations: 6
Residents with vaccination deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse, West Wing Unit Manager | Named in grievance related to missing glasses for resident R17 |
| LPN DD | Licensed Practical Nurse | Observed leaving medications unattended on medication cart |
| LPN EE | Licensed Practical Nurse | Interviewed regarding medication storage policies |
| Director of Nursing (DON) | Director of Nursing | Provided multiple interviews regarding medication administration, infection control, and vaccination responsibilities |
| LPN PP | Licensed Practical Nurse | Interviewed about expired medications |
| LPN BB | Licensed Practical Nurse | Interviewed about catheter care planning |
| LPN KKK | Licensed Practical Nurse | Interviewed about catheter care planning |
| Nurse Practitioner CC | Nurse Practitioner | Documented chief complaint and ordered tests for resident R10; refused to answer questions related to R10 |
| Physician PPPP | Physician | Medical Director at time of resident R10's hospitalization and death; commented on catheter care |
| Dietary Manager | Dietary Manager | Observed not wearing hair net and confirmed unsanitary kitchen conditions |
| Cook KKKK | Morning Cook | Interviewed about kitchen fan cleaning |
Inspection Report
Deficiencies: 0
Date: Jun 27, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Powder Springs Center for Nursing & Healing, 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
Follow-Up
Deficiencies: 0
Date: Jun 15, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as of the follow-up survey date.
Inspection Report
Renewal
Deficiencies: 3
Date: Apr 20, 2022
Visit Reason
A Licensure Survey was conducted from 4/19/2022 through 4/22/2022 to assess compliance with state regulations and licensing requirements for Powder Springs Center for Nursing & Healing.
Findings
The survey identified multiple deficiencies including a non-functional nurse call system in one wing, failure to properly screen staff and residents for COVID-19 symptoms, and a medication error rate exceeding 5% with specific medication administration errors documented.
Deficiencies (3)
Nurse call system was not fully functional in the West Wing, with call lights not illuminating to indicate resident needs.
Failure to ensure all staff and residents were screened daily for COVID-19 symptoms, with multiple missed screenings documented.
Medication error rate exceeded 5%, including borrowing medication from another resident, breaking extended-release tablets, and missed doses of intravenous antibiotics.
Report Facts
Medication opportunities observed: 27
Medication errors: 3
Medication error rate: 11.11
Staff not screened on 4/19/22: 58
Staff not screened on 4/20/22: 18
Staff not screened on 4/21/22: 37
Staff not screened on 4/22/22: 40
Residents with missed COVID-19 screenings: 5
Missed doses of Vancomycin: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Administered medications including borrowing medication from another resident; involved in medication error findings |
| LPN CC | Licensed Practical Nurse | Administered medications including breaking extended-release tablets; involved in medication error findings |
| LPN MM | Licensed Practical Nurse | Confirmed nurse call light system was not functional |
| LPN KK | Licensed Practical Nurse | Administered intravenous antibiotic medication; involved in missed dose findings |
| NP DD | Nurse Practitioner | Provided clinical guidance on medication administration and antibiotic therapy; interviewed regarding missed doses |
| NP EE | Nurse Practitioner | Interviewed regarding missed doses of Vancomycin and PICC line issues |
| Administrator | Confirmed nurse call system issues and maintenance protocol failures | |
| Director of Nursing | Director of Nursing | Provided information on medication administration policies and staff training |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Interviewed about COVID-19 screening procedures |
| Certified Nursing Assistant NN | Certified Nursing Assistant | Confirmed nurse call light was not functional |
Inspection Report
Life Safety
Census: 187
Capacity: 208
Deficiencies: 1
Date: Apr 19, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and building rehabilitation standards.
Findings
The facility was found not in substantial compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition due to failure to document daily inspections of areas undergoing construction or alterations to ensure means of egress in case of emergency. Specifically, a temporary plastic wall barrier near room 338 was not inspected daily as required.
Deficiencies (1)
Failure to document a means of egress for daily inspection of areas undergoing construction, alterations, repair, or additions to ensure emergency egress capability.
Report Facts
Smoke Compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding lack of documentation of daily inspections of the temporary plastic wall barrier near room 338 | |
| Staff M | Confirmed findings during tour and observation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 21, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (#GA00220743, #GA00220532, #GA00220242, #GA00219468, #GA00218498, #GA00218477, #GA00218305, #GA00218047, #GA00217658, and #GA00217525).
Complaint Details
Complaint #GA00220743 was substantiated with no regulatory violations cited. Complaints #GA00220532, #GA00220242, #GA00219468, #GA00218498, #GA00218477, #GA00218305, #GA00218047, #GA00217658, and #GA00217525 were unsubstantiated with no regulatory violations cited.
Findings
Complaint #GA00220743 was substantiated with no regulatory violations cited. All other complaints investigated were unsubstantiated with no regulatory violations cited.
Inspection Report
Re-Inspection
Census: 180
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on September 30, 2021.
Complaint Details
The visit was a follow-up to a complaint survey conducted on September 30, 2021, verifying correction of cited deficiencies.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 180
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint survey on September 30, 2021.
Complaint Details
The revisit survey was conducted following a complaint survey on September 30, 2021. All cited deficiencies were corrected.
Findings
All deficiencies cited during the complaint survey on September 30, 2021 were found to be corrected during the revisit survey on November 16, 2021.
Report Facts
Facility census: 180
Inspection Report
Renewal
Census: 25
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
Licensure Survey conducted from September 28, 2021 through September 30, 2021 to assess compliance with nursing care requirements.
Findings
The facility failed to implement a care plan for every two-hour monitoring for one resident following elopement from the facility. There was no evidence that the ordered two-hour monitoring had been completed as required.
Deficiencies (1)
Failure to implement a care plan for every two-hour monitoring for one resident following elopement.
Report Facts
Sample size: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 9/29/2021 confirming lack of documentation for two-hour monitoring. |
Inspection Report
Complaint Investigation
Census: 181
Deficiencies: 3
Date: Sep 30, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint intake numbers related to resident care and safety concerns.
Complaint Details
The investigation was initiated based on multiple complaint intake numbers. Some complaints were unsubstantiated without deficiency, some substantiated without deficiency, and two complaints substantiated with deficiencies related to resident monitoring and supervision.
Findings
The facility failed to implement a comprehensive care plan and follow physician orders for two-hour monitoring of a resident (R#3) after elopement. Additionally, the facility failed to adequately supervise the resident to prevent elopement from a secured unit, resulting in the resident leaving through a window and being found at a nearby gas station. The facility lacked policies on monitoring residents as a nursing standard and did not have a wander guard or identification bracelet system for residents at risk of elopement.
Deficiencies (3)
Failed to implement a care plan for every two-hour monitoring for resident following elopement.
Failed to ensure physician's orders for every two-hour monitoring were followed.
Failed to ensure adequate supervision to prevent elopement from secured unit.
Report Facts
Resident census: 181
Sample size: 28
Date of elopement incident: Apr 24, 2021
Time resident reported missing: 1830
Time resident found: 2045
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN OO | In-house Supervisor | Reported the resident was missing and described the search and window audit after elopement. |
| Administrator | Provided information about the elopement incident, notification to family and police, and facility response. | |
| DON | Director of Nursing | Confirmed physician orders for monitoring were not followed and stated the facility lacked a policy on monitoring residents as a nursing standard. |
| RN EE | Registered Nurse | Participated in search for resident and described circumstances of elopement. |
| LPN DD | Licensed Practical Nurse | Worked the evening of the elopement and described finding the window open and search efforts. |
| Lieutenant FF | Local County Police Lieutenant | Responded to the call at the gas station where the resident was found and described interactions with facility staff. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00212422.
Complaint Details
Complaint #GA00212422 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 20, 2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on January 20, 2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the January 20, 2021 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the January 20, 2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on January 20, 2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the January 20, 2021 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 168
Deficiencies: 0
Date: Feb 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaint numbers GA00211513 and GA00211478.
Complaint Details
Complaints GA00211513 and GA00211478 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended practices for COVID-19. The complaints were unsubstantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 1
Date: Jan 12, 2021
Visit Reason
The inspection was conducted as a licensure survey investigating multiple complaints (GA00210262, GA00210483, GA00210640, and GA00211225) regarding water temperature issues and other concerns at the facility.
Complaint Details
The investigation included complaints GA00210262, GA00210483, GA00210640, and GA00211225. Complaints GA00210626, GA00210483, and GA00211225 were unsubstantiated with no deficiencies cited. Complaint GA00210640 was partially substantiated with deficiencies cited.
Findings
The facility failed to maintain adequate hot water temperatures on one of three halls in the East Wing, resulting in cold water in resident rooms. Some complaints were partially substantiated with deficiencies cited, while others were unsubstantiated. The facility took corrective actions including replacing the mixing valve and circulating pump to improve water temperatures.
Deficiencies (1)
Facility failed to maintain comfortable and documented water temperatures on one of three halls on the East Wing, resulting in cold water temperatures in resident rooms.
Report Facts
Water temperature measurements: 58
Water temperature measurements: 110
Facility census: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practice Nurse (LPN) | Reported noticing cold water issues on the Memory Unit around late December 2020 and improvement since then. |
| CC | Certified Nursing Assistant (CNA) | Reported no problems with cold water on East Wing/A-Hall but noted staff had to let water run for 20 minutes before warm. |
| DD | Certified Nursing Assistant (CNA) | Reported experiencing cold water issues about two weeks prior and reported to Maintenance Director. |
| Maintenance Director | Conducted water temperature measurements, reported on facility hot water system, and coordinated repairs. | |
| Director of Nursing | Director of Nursing (DON) | Reported staff concerns about cold water in Memory Unit and communicated with Maintenance Director. |
| Administrator | Administrator | Directed Maintenance Director to hire plumber and address water temperature issues. |
Inspection Report
Complaint Investigation
Census: 171
Deficiencies: 1
Date: Jan 12, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00210262, GA00210483, GA00210640, and GA00211225. Three complaints were unsubstantiated, and one was partially substantiated with deficiencies cited.
Complaint Details
Complaint numbers GA00210262, GA00210483, GA00210640, and GA00211225 were investigated. GA00210626, GA00210483, and GA00211225 were unsubstantiated with no deficiencies cited. GA00210640 was partially substantiated with deficiencies cited related to cold water temperatures.
Findings
The facility failed to maintain comfortable and document water temperatures on one of three halls on the East Wing, resulting in cold water temperatures in resident rooms. Water temperatures were measured as low as 58-70 degrees Fahrenheit in resident rooms on the East Wing/C-Hall. The mixing valve was set at 110°F but showers running caused cold water in resident rooms until showers were completed. The issue was partially resolved after replacing the circulating pump and mixing valve, with improved water temperatures and fewer complaints by the end of the survey.
Deficiencies (1)
Failed to maintain comfortable and document water temperatures on one of three halls on the East Wing resulting in cold water temperatures in resident rooms.
Report Facts
Census: 171
Water temperature: 58
Water temperature: 70
Water temperature: 110
Water temperature: 110
Water temperature: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Measured water temperatures, reported on repairs and maintenance issues related to water temperature | |
| Licensed Practice Nurse (LPN) BB | Reported noticing cold water problem on Memory Unit and improvement after repairs | |
| Certified Nursing Assistant (CNA) CC | Reported no problems with water temperature on East Wing/A-Hall but relayed night shift staff concerns | |
| Certified Nursing Assistant (CNA) DD | Reported cold water temperature issue and notifying Maintenance Director | |
| Director of Nursing (DON) | Reported staff concerns about cold water on Memory Unit and communication with Maintenance Director | |
| Administrator | Directed Maintenance Director to hire plumber and follow up on water temperature issues |
Inspection Report
Routine
Census: 168
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
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.
Report Facts
Total census: 168
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