Inspection Reports for
Powder Springs Center for Nursing & Healing

The facility was found to have cigarette butts improperly disposed of in the smoking area, emergency drinking water stored unsafely outside, and arbitration agreements lacking a specified venue for dispute resolution.

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.

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.

The facility failed to follow infection control protocols regarding the disposal and reuse of PPE in rooms with residents on Droplet Precautions. Observations and interviews revealed inconsistent PPE disposal practices and improper reuse of PPE contrary to facility policy.

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.

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.

The facility was found deficient in multiple areas including resident dignity and independence, grievance resolution, medication administration errors, fall supervision and documentation, catheter care leading to infection and resident death, medication storage and expired medications, laboratory services delays, food safety and sanitation, medical record accuracy, infection control program tracking, vaccination documentation, and call light functionality.

The facility had multiple deficiencies including failure to promote resident dignity, unresolved grievances, medication administration errors, inadequate fall supervision and documentation, failure to prevent catheter-associated urinary tract infections leading to resident death, medication storage issues, failure to provide timely lab services, food safety violations, inaccurate medical records, incomplete infection control tracking, incomplete pneumococcal vaccination documentation, and nonfunctional nursing call system in a resident's room.

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.

The facility was found deficient in multiple areas including failure to administer pain medication as ordered, inadequate respiratory care, malfunctioning nurse call system, medication errors exceeding 5%, incomplete COVID-19 staff and resident screening, lack of antibiotic stewardship monitoring, and failure to conduct timely and comprehensive COVID-19 outbreak testing.

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.

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.

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.

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.

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.

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.

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.

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.

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.