Inspection Reports for Presbyterian Home, Quitman, in
1901 WEST SCREVEN STREET, QUITMAN, GA, 31643
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 24, 2025 cited deficiencies related to failure to timely report an allegation of abuse and failure to protect a resident from alleged abuse by staff during the investigation. Earlier inspections showed a mixed pattern, with prior deficiencies involving medication management, care plan follow-through, infection control, emergency preparedness, and life safety code compliance. Complaint investigations were mostly unsubstantiated, except for substantiated abuse and care plan-related complaints, including delayed physician notification and improper wound care. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows ongoing challenges with regulatory compliance, particularly in abuse reporting and resident care, with no clear trend toward overall improvement or worsening.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
140 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 24, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Hospital Authority of Brooks County, Georgia from June 16, 2025 through June 24, 2025, to determine compliance with the State Long Term Care Requirements.
Complaint Details
The complaint involved an allegation of simple assault by a Certified Nursing Assistant against Resident 1. The facility initially reported the incident as rough handling on 1/28/2025 for an event occurring on 1/27/2025, but it was later determined to be abuse after intervention by the Ombudsman. Law enforcement was involved at the resident's request.
Findings
The facility failed to report an allegation of abuse to the State Survey Agency within the required time frame for one of nine sampled residents. The incident involved a resident alleging rough handling by a Certified Nursing Assistant, which was initially reported as rough handling but later identified as abuse requiring timely reporting.
Deficiencies (1)
Failure to report an allegation of abuse to the State Survey Agency within the required time frame for one resident.
Report Facts
Number of sampled residents: 9
Incident date: Jan 27, 2025
Incident report date: Jan 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR | Licensed Practical Nurse | Called into the room during the incident |
| MM | Certified Nursing Assistant | Alleged to have shoved the resident's pillow behind her head |
| Director of Nursing | Director of Nursing | Responsible for state reportable incidents and interviewed about the abuse reporting |
| Administrator | Administrator | Interviewed regarding the incident and law enforcement involvement |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 2
Date: Jun 24, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake Numbers GA00253650 and GA00253681, which were substantiated with deficiencies cited.
Complaint Details
The investigation was initiated based on Complaint Intake Numbers GA00253650 and GA00253681. The complaints were substantiated with deficiencies cited related to abuse allegations involving resident R1. The facility failed to suspend the accused staff member during the investigation and failed to timely report the abuse allegation to the State Survey Agency.
Findings
The facility failed to ensure that a resident (R1) was protected from alleged abuse by staff, as the staff member continued to provide care during the investigation and was not suspended. Additionally, the facility failed to report the allegation of abuse to the State Survey Agency within the required timeframe.
Deficiencies (2)
Failure to ensure that one of nine sampled residents was protected from alleged abuse by staff, as the staff continued to provide care and was not suspended during the investigation.
Failure to report an allegation of abuse to the State Survey Agency within the required timeframe for one of nine sampled residents.
Report Facts
Complaint Intake Numbers: 2
Resident census: 140
Dates of incident and reporting: Incident on 2025-01-27, reported on 2025-01-28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA MM | Certified Nurse Aide | Named in abuse allegation involving resident R1 |
| CNA NN | Certified Nurse Aide | Witness and involved in care of resident R1 during investigation |
| RR | Licensed Practical Nurse | Called into room during incident involving resident R1 |
| Director of Nursing | Director of Nursing (DON) | Responsible for state reportable and questioned about staff assignment |
| Administrator | Facility Administrator | Provided statements regarding incident and reporting |
Inspection Report
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Home, Quitman, IN, related to a regulatory inspection completed on 06/05/2024.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Jun 5, 2024
Visit Reason
A revisit survey was conducted on June 5, 2024 to verify correction of deficiencies cited during the 3/28/2024 Recertification and Complaint Survey.
Findings
All deficiencies cited as a result of the 3/28/2024 Recertification and Complaint Survey were found to be corrected.
Inspection Report
Life Safety
Deficiencies: 0
Date: May 13, 2024
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Life Safety Code revisit.
Inspection Report
Life Safety
Census: 143
Capacity: 188
Deficiencies: 6
Date: Apr 3, 2024
Visit Reason
The inspection was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey to assess compliance with federal regulations and NFPA standards.
Findings
The facility was found not in substantial compliance with emergency preparedness communication requirements and multiple Life Safety Code standards including interior wall and ceiling finishes, sprinkler system maintenance, smoke barrier integrity, flame retardant requirements for draperies, and portable space heater usage.
Deficiencies (6)
Emergency preparedness communication plan did not include policies and procedures for family notification.
Interior wall and ceiling finishes did not meet flame spread rating requirements; cardboard was secured to the ceiling in certain areas.
Fire sprinkler system was not properly inspected, tested, and maintained; sprinkler heads were loaded with dust/lint and cover plates for concealed sprinkler heads were missing.
Smoke and fire barriers were not maintained properly; penetrations in ceiling/roof assembly were not sealed.
Privacy curtains in GNH Hall Room #35 lacked labels showing compliance with flame propagation performance criteria of NFPA 701.
Portable space heater was found in B&C Nurse's Station without thermostatic documentation, violating requirements.
Report Facts
Census: 143
Total Capacity: 188
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Census: 142
Deficiencies: 9
Date: Mar 28, 2024
Visit Reason
A standard survey was conducted from March 25 through March 28, 2024, including investigation of Complaint Intake Number GA00243157, which was found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00243157 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure safe self-administration of medications, improper issuance of Medicare non-coverage notices, failure to notify ombudsman of hospital transfers, lack of bed hold notices, incomplete care plans, inadequate respiratory equipment cleaning, incomplete nurse staffing postings, medication errors exceeding 5%, and improper infection control practices.
Deficiencies (9)
Failed to ensure a resident (R72) did not have unsecured nystatin powder on bedside table without interdisciplinary team approval for self-administration.
Failed to correctly issue Medicare Part A beneficiary notices for three residents (R61, R130, R394).
Failed to notify ombudsman after emergent hospital transfers for two residents (R70, R124).
Failed to provide written bed hold notices after hospital transfers for two residents (R70, R124).
Failed to implement comprehensive care plan regarding hand roll and splint for one resident (R72).
Failed to clean respiratory equipment properly for two residents (R115, R83).
Failed to ensure daily nurse staffing information was complete and posted in readable format.
Medication error rate exceeded 5% with three errors out of 26 opportunities for two residents (R93, R133).
Failed to ensure proper contact time after cleaning glucose meter with hydrogen peroxide wipes for one resident (R67).
Report Facts
Residents present: 142
Medication error rate: 11.54
BIMS score: 5
BIMS score: 15
Contact time: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Involved in medication administration errors for residents R93 and R133 |
| RN1 | Registered Nurse | Observed cleaning glucose meter improperly for resident R67 |
| LPN3 | Licensed Practical Nurse | Confirmed dirty oxygen concentrator filters for residents R115 and R83 |
| Director of Nursing | Director of Nursing | Confirmed no parameters for holding blood pressure medication and proper medication administration procedures |
| Administrator | Administrator | Unaware of failure to notify ombudsman and bed hold notifications |
| Director of Social Services | Director of Social Services | Acknowledged failure to notify ombudsman of hospital transfers |
| Licensed Practical Nurse Quality Assurance | Licensed Practical Nurse Quality Assurance | Stated dry time for hydrogen peroxide wipe is one minute |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 28, 2024
Visit Reason
A State Licensure survey was conducted at Presbyterian Home Quitman from March 25, 2024 through March 28, 2024 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to correctly issue Medicare beneficiary notices, failure to notify ombudsman of hospital transfers, failure to provide bed hold notices, medication errors exceeding acceptable rates, improper self-administration of medication, lack of comprehensive care plans for certain residents, and improper cleaning procedures for medical equipment.
Deficiencies (7)
Facility failed to correctly issue Medicare Part A beneficiary notices (CMS 10123 NOMNC and CMS-10055 SNFABN) for three residents.
Facility failed to notify the ombudsman after emergent hospital transfers for two residents.
Facility failed to provide written bed hold notices after hospital transfers for two residents.
Medication error rate exceeded five percent for two of five residents, with three errors out of 26 opportunities (11.54%).
Facility failed to ensure appropriate determination for resident self-administration of medication; nystatin powder was unsecured on bedside table.
Facility failed to implement a comprehensive care plan regarding use of hand roll and splint for one resident.
Facility failed to ensure proper contact time after cleaning glucose meter; glucometer was stored immediately after wiping without drying.
Report Facts
Medication error rate: 11.54
Medication errors: 3
Residents reviewed for medication errors: 5
Residents with medication errors: 2
BIMS score: 5
Hydrogen peroxide wipe contact time: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Involved in medication administration observations and interviews regarding medication holding and administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration policies and deficiencies |
| Administrative Assistant 1 | Administrative Assistant | Interviewed regarding Medicare beneficiary notice procedures |
| Director of Social Services | Director of Social Services (DSS) | Interviewed regarding ombudsman notification practices |
| Administrator | Facility Administrator | Interviewed regarding ombudsman notification and bed hold policies |
| LPN1 | Licensed Practical Nurse | Interviewed regarding medication storage and administration |
| RN1 | Registered Nurse | Observed and interviewed regarding glucometer cleaning procedures |
| Licensed Practical Nurse Quality Assurance 1 | Licensed Practical Nurse Quality Assurance (QA) | Interviewed regarding proper contact time for disinfecting glucometer |
| Certified Nursing Assistant 2 | Certified Nursing Assistant (CNA) | Interviewed regarding care plan implementation for resident R72 |
Inspection Report
Abbreviated Survey
Census: 141
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00237453, GA00238954, GA00239426, and GA00241672.
Complaint Details
Complaints GA00237453, GA00238954, GA00239426, and GA00241672 were substantiated with no regulatory violations cited.
Findings
The complaints were substantiated but no regulatory violations were cited during the survey.
Report Facts
Complaints investigated: 4
Facility census: 141
Inspection Report
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Home, Quitman, IN, related to a regulatory inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/14/2022 Standard Survey.
Findings
All deficiencies cited as a result of the 7/14/2022 Standard Survey were found to be corrected on 8/28/2022, as alleged in the facility's Plan of Correction.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 30, 2022
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 survey tags have been corrected during the follow-up visit.
Inspection Report
Renewal
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
The inspection was conducted as a Licensure survey from July 12, 2022 through July 14, 2022 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to store patient care equipment such as wash basins, bed pans, and urinals in a sanitary manner in residents' bathrooms on one unit (E hall), which could cause an infection control problem. Multiple bathrooms had unlabeled and uncovered wash basins, bed pans, and urinals.
Deficiencies (1)
Failure to store patient care equipment (wash basins, bed pans, and urinals) in a sanitary manner in residents' bathrooms on one unit (E hall).
Report Facts
Number of rooms with unlabeled or uncovered patient care equipment: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed concerns related to storage of bed pans, wash basins, and urinals causing infection control problem. |
| Maintenance Director | Maintenance Director | Confirmed concerns related to storage of bed pans, wash basins, and urinals causing infection control problem. |
| Administrator | Administrator | Reported awareness of the problem with storage of wash basins, bed pans, and urinals and stated they should be stored correctly. |
Inspection Report
Routine
Census: 141
Deficiencies: 2
Date: Jul 14, 2022
Visit Reason
A standard survey was conducted at Presbyterian Home of Quitman from July 12, 2022, through July 15, 2022, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including unsafe and unclean environment due to peeling wallpaper and broken furniture, and infection control issues related to improper storage of patient care equipment such as wash basins, bed pans, and urinals.
Deficiencies (2)
Resident furniture was not in good and functional condition, including peeling wallpaper, missing, loose, and broken drawer handles and drawers that would not open.
Failure to establish and maintain an infection prevention and control program, specifically improper storage of patient care equipment (wash basins, bed pans, urinals) in residents' bathrooms, risking spread of infection.
Report Facts
Resident census: 141
Units observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to furniture deficiencies and infection control observations | |
| Assistant Director of Nursing | ADON | Named in relation to furniture deficiencies and infection control observations |
| Administrator | Interviewed regarding awareness of furniture and infection control issues |
Inspection Report
Life Safety
Census: 141
Capacity: 188
Deficiencies: 3
Date: Jul 12, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including sprinkler system maintenance, smoke barrier doors, and arrangements with other facilities for patient transportation.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements due to lack of documented agreements for transportation to other facilities. Additionally, life safety code deficiencies included missing escutcheon rings on sprinkler heads, and smoke barrier doors that failed to properly seal.
Deficiencies (3)
Failed to ensure letters of agreements for transportation to other facilities.
Sprinkler heads missing escutcheon ring in room 36.
Smoke barrier doors in the facility failed to properly seal.
Report Facts
Census: 141
Total Capacity: 188
Stories: 2
Construction Type: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to transportation agreements, sprinkler escutcheon ring, and smoke door sealing during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00219504.
Complaint Details
Complaint #GA00219504 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00216675.
Complaint Details
Complaint #GA00216675 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the investigation.
Inspection Report
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 160
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
A revisit survey was conducted at Presbyterian Home Quitman on 10/15/2021 to verify correction of deficiencies cited during the complaint survey of 7/28/2021.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 7/28/2021; all cited deficiencies were corrected by 9/11/2021.
Findings
All deficiencies cited as a result of the complaint survey of 7/28/2021 were found to be corrected as of 9/11/2021.
Report Facts
Facility census: 160
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate a complaint (GA00216132) initiated on 2021-07-21 and concluded on 2021-07-28. The purpose was to determine compliance with care plan and physician orders related to skin conditions of residents.
Complaint Details
Complaint GA00216132 was substantiated based on findings related to failure to follow care plans and physician orders for skin conditions in two residents.
Findings
The facility failed to follow the care plan for two of six sampled residents regarding notifying the physician of changes in skin condition for Resident #1 and following physician's orders for Resident #6. Deficiencies included lack of physician notification for bleeding and inappropriate continuation of wound dressing after physician's order was discontinued.
Deficiencies (2)
Failure to notify physician of changes in skin condition for Resident #1 with a pressure ulcer and skin cancer.
Failure to follow physician's orders for Resident #6 regarding discontinuation of wound care dressing for diabetic ulcer on right great toe.
Report Facts
Number of sampled residents with deficiencies: 2
Dates related to wound care order: Jul 13, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse (RN) Minimum Data Set (MDS) Coordinator | Interviewed regarding awareness and removal of discontinued dressing on Resident #6. |
| FF | Licensed Practical Nurse (LPN) wound care nurse | Interviewed regarding placement of dressing on Resident #6 after physician's order was discontinued. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 28, 2021
Visit Reason
An abbreviated/partial extended survey was conducted from 7/21/2021 to 7/28/2021 investigating a substantiated complaint (GA00216132) regarding failure to follow care plans and physician orders for two sampled residents.
Complaint Details
The complaint was substantiated with deficiencies related to failure to follow care plans and physician orders for two residents, including failure to notify physician of skin condition changes and failure to discontinue wound care orders.
Findings
The facility failed to notify the physician of changes in skin condition for Resident #1, resulting in maggot infestation in the right ear, and failed to discontinue a wound care dressing for Resident #6 after the physician's order ended. Multiple staff interviews and record reviews confirmed inadequate skin assessments, delayed physician notification, and improper wound care management.
Deficiencies (2)
Failure to follow care plan for notifying physician of changes in skin condition for Resident #1, resulting in maggot infestation in the right ear.
Failure to follow physician's wound care orders for Resident #6, including continuing dressing after order discontinuation.
Report Facts
Dates of wound care orders and discontinuations: 7
Dates of maggot discovery: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Responsible for wound care and dressing changes; last changed Resident #1's ear dressing on 7/13/2021; unaware of maggot infestation until 7/16/2021 |
| RN VV | Registered Nurse, MDS Coordinator | Removed discontinued dressing from Resident #6 on 7/23/2021; aware of wound care orders |
| LPN FF | Wound Care Nurse/Infection Preventionist/Quality Assurance | Performed wound care treatments on Mondays; unaware of maggot infestation until called; reported wound care procedures |
| LPN HH | Assistant Director of Nursing | Assisted with flushing Resident #1's ear and notified hospice |
| CNA CC | Certified Nurse Aide | Discovered maggots in Resident #1's ear during bathing on 7/16/2021 |
| RN KK | Hospice Nurse Manager | Ordered transfer of Resident #1 to hospital after maggot discovery |
| Director of Nursing | Director of Nursing | Conducted investigation after maggot discovery; identified issues with skin assessments and education |
| Administrator | Facility Administrator | Oversaw investigation and confirmed wound care nurse should have followed orders |
Inspection Report
Re-Inspection
Census: 162
Deficiencies: 0
Date: Jun 24, 2021
Visit Reason
A revisit survey was conducted on June 24, 2021 to verify correction of deficiencies cited during the April 21, 2021 complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on April 21, 2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the April 21, 2021 complaint survey were found to be corrected.
Report Facts
Census: 162
Inspection Report
Deficiencies: 0
Date: Jun 24, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted by the State of Georgia Healthcare Facility Regulation Division.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection. Specific deficiencies or severity levels are not detailed in the provided page.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 21, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake number GA00213356, initiated on 2021-04-07 and concluded on 2021-04-22.
Complaint Details
Complaint Intake number GA00213356 was substantiated. The investigation found the facility did not timely notify the physician of abnormal lab results obtained on 3/5/21 for resident R#1, leading to delayed treatment.
Findings
The facility failed to notify the physician in a timely manner of abnormal high laboratory results for one resident (R#1) reviewed for dehydration, resulting in delayed medical intervention and hospital admission for kidney failure, hyperkalemia, and severe dehydration.
Deficiencies (1)
Failure to promptly notify the physician of abnormal high laboratory results for resident R#1.
Report Facts
Lab result - Blood Urea Nitrogen (BUN): 69
Lab result - Creatinine: 2
Date of hospital admission: Feb 18, 2021
Date of nursing home admission: Feb 26, 2021
Date of physician rounds: Mar 4, 2021
Date labs collected: Mar 5, 2021
Date physician notified: Mar 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility physician #1 | Physician who ordered labs and was not timely notified of abnormal results. | |
| Director of Nursing | DON | Reviewed fax issues and contacted physician about lab results delay. |
| Nursing Scheduler | CNA | Responsible for faxing lab results to physicians; did not keep fax confirmation sheets. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 21, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake number GA00213356, which was substantiated with cited deficiencies.
Complaint Details
Complaint Intake number GA00213356 was substantiated based on failure to timely notify the physician of abnormal lab results for resident R#1, leading to delayed treatment and hospital admission.
Findings
The facility failed to notify the physician in a timely manner of an abnormal high laboratory result for one resident (R#1) reviewed for dehydration, resulting in delayed medical intervention and subsequent hospital admission for kidney failure, hyperkalemia, and severe dehydration.
Deficiencies (2)
Failed to notify the physician of an abnormal high laboratory result in a timely manner for one resident reviewed for dehydration.
Failed to provide or obtain laboratory services only when ordered and promptly notify the ordering physician of abnormal lab results.
Report Facts
BUN lab value: 69
Creatinine lab value: 2
BUN lab value: 55
Creatinine lab value: 1.6
BUN lab value: 46
Creatinine lab value: 1.5
Blood sugar: 164
Vital signs: Blood pressure 138/69, heart rate 82, respiratory rate 20, temperature 97.5, oxygen saturation 98% on room air on 3/12/21 for resident R#1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Facility physician #1 | Physician who ordered labs and was not timely notified of abnormal lab results for resident R#1. | |
| Director of Nursing | DON | Reported reviewing fax issues and implemented new process to track lab results notification. |
| Nurse Scheduler | CNA | Responsible for faxing lab results to physicians; did not keep fax confirmation sheets at time of incident. |
Inspection Report
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Presbyterian Home in Quitman, GA, 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 on the page provided.
Inspection Report
Re-Inspection
Census: 161
Deficiencies: 0
Date: Mar 9, 2021
Visit Reason
A revisit survey was conducted on March 9, 2021 to verify correction of deficiencies cited during the January 11, 2021 complaint survey.
Complaint Details
This was a follow-up to a complaint survey conducted on January 11, 2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the January 11, 2021 complaint survey were found to be corrected.
Report Facts
Census: 161
Inspection Report
Renewal
Deficiencies: 2
Date: Jan 11, 2021
Visit Reason
A Licensure Survey was conducted from January 6, 2021 through January 11, 2021 to assess compliance with state and federal regulations for facility licensure renewal.
Findings
The facility failed to ensure medications were secured and stored properly on one of seven units, and failed to change and replace a resident's gastrostomy tube as ordered and timely, resulting in the resident being sent to the emergency room.
Deficiencies (2)
Medications were found unsecured and improperly stored on Unit A nursing station without staff present.
Failure to change and replace the gastrostomy tube as ordered for one resident, leading to complications requiring emergency room visit.
Report Facts
Units with medication storage issues: 1
Residents sampled for gastrostomy tube care: 5
Date range of licensure survey: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Mentioned in relation to medication delivery and gastrostomy tube care. |
| LPN GG | Licensed Practical Nurse | Mentioned in relation to medication storage observation. |
| LPN CC | Licensed Practical Nurse | Provided information about gastrostomy tube replacement criteria. |
| Director of Nursing | Director of Nursing (DON) | Involved in medication storage issue and gastrostomy tube care oversight. |
| Director of Social Work | Director of Social Work | Observed unsecured medications and notified DON. |
| Pharmacy Technician NN | Pharmacy Technician | Delivered medications to Unit A. |
| Medical Director | Medical Director | Provided information about resident's gastrostomy tube management and orders. |
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 4
Date: Jan 11, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate a complaint (GA00210880) regarding care plan deficiencies and tube feeding management at Presbyterian Home, Quitman, IN.
Complaint Details
The complaint was substantiated with deficiencies related to care plan timing and revision, nutrition/hydration status maintenance, tube feeding management, and medication storage.
Findings
The facility was found to have substantiated deficiencies related to failure to update care plans for gastrostomy tube management, failure to ensure adequate nutrition and hydration for a resident with a feeding tube, failure to timely replace a dislodged gastrostomy tube, and failure to properly secure medications on one unit.
Deficiencies (4)
Failed to update the care plan to reflect the frequency of changing the gastrostomy tube for one resident and failed to revise dietary orders related to bolus feedings for another resident.
Failed to ensure one resident received adequate nutrition related to tube feedings.
Failed to change the gastrostomy tube as ordered and failed to replace the gastrostomy tube timely for one resident.
Failed to ensure medications were secured and stored properly on one of seven units.
Report Facts
Census: 159
G-tube replacement frequency: 3
Feeding formula rate: 50
Bolus feeding times: 4
Water flush volume: 70
G-tube size: 20
G-tube smaller size used: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Registered Nurse (RN), MDS Coordinator | Interviewed regarding care plan updates for gastrostomy tube. |
| Certified Dietary Manager | Interviewed regarding care plan for residents with G-tube and feeding tolerance. | |
| AA | Registered Nurse (RN) | Interviewed about resident #1's G-tube placement and hospital transfer. |
| DD | Certified Nurse Assistant (CNA) | Interviewed about resident #1's status on 12/30/2020. |
| CC | Licensed Practical Nurse (LPN) | Interviewed about notification and hospital transfer of resident #1's dislodged G-tube. |
| DON | Director of Nursing | Interviewed about G-tube replacement policy and medication security. |
| Medical Director | Interviewed about decision to delay G-tube replacement due to COVID-19 concerns. | |
| BB | Licensed Practical Nurse (LPN) | Interviewed about awareness of G-tube replacement orders and medication handling. |
| NN | Pharmacy Technician | Interviewed about medication delivery and storage on Unit A. |
| GG | Licensed Practical Nurse (LPN) | Interviewed about medication delivery and storage on Unit A. |
Inspection Report
Routine
Census: 159
Deficiencies: 0
Date: Jan 6, 2021
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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 21, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00207130.
Complaint Details
Complaint #GA00207130 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the investigation.
Inspection Report
Routine
Census: 156
Deficiencies: 0
Date: Aug 28, 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 preparedness and infection control.
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 for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00202451.
Complaint Details
Complaint GA00202451 was unsubstantiated.
Findings
The complaint #GA00202451 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 160
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on August 4-5, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with COVID-19 related regulations.
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 for COVID-19 preparation.
Report Facts
Total census: 160
Inspection Report
Routine
Census: 182
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Presbyterian Home on 7/14/2020 through 7/15/2020 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 §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Home, Quitman, IN, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 13, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint intake number GA00198364.
Complaint Details
Investigation of complaint intake number GA00198364; no deficiencies were found.
Findings
No State Health Deficiencies were cited during the investigation.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 6, 2019
Visit Reason
A revisit survey was conducted on May 6, 2019 to verify correction of deficiencies cited during the March 14, 2019 Standard Survey.
Findings
All deficiencies cited as a result of the March 14, 2019 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 2, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 178
Capacity: 188
Deficiencies: 4
Date: Mar 13, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess the facility's compliance with fire safety regulations and the National Fire Protection Association (NFPA) 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including missing sprinkler heads and escutcheon rings, sprinkler heads not free from dirt and rust, missing proper signage for fire extinguishers, and a patient room door obstructed from closing properly. These deficiencies could place residents at risk in the event of an emergency.
Deficiencies (4)
Facility failed to ensure full sprinkler coverage and proper placement of escutcheon rings on sprinkler heads.
Sprinkler heads were not free from dirt, dust, debris, and rust.
Fire extinguishers lacked proper signage throughout the facility.
Patient room door (room 87) was obstructed and would not close properly.
Report Facts
Census: 178
Total Capacity: 188
Percentage of residents at risk: 50
Percentage of residents at risk: 30
Percentage of residents at risk: 100
Percentage of residents at risk: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and confirmed findings related to sprinkler heads, fire extinguisher signage, and door obstruction |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 24, 2018
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 of the follow-up survey date.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00187065 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00187065 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Annual Inspection
Census: 181
Deficiencies: 0
Date: Mar 8, 2018
Visit Reason
A standard survey was conducted at Presbyterian Nursing Home, Quitman from March 5, 2018, through March 8, 2018, to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 180
Capacity: 188
Deficiencies: 9
Date: Mar 6, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including corridor width maintenance, emergency lighting, hazardous area door maintenance, fire alarm system maintenance, sprinkler system installation and supervision, corridor door maintenance, smoke barrier maintenance, electrical system maintenance, and smoking regulations.
Deficiencies (9)
Facility failed to maintain exit corridor width, patient chairs blocked corridors leaving less than 60 inches clear width.
Facility failed to provide emergency lighting at exterior exit discharge locations.
Doors to hazardous areas did not close and latch properly, including kitchen storage and biohazard rooms.
Fire alarm system components not properly secured; heat detectors and control panel hanging by wiring.
Sprinkler system deficiencies including missing ceiling tiles affecting activation and unsupervised sprinkler control valves.
Corridor doors failed to close and latch properly, including wedged doors in resident rooms.
Facility failed to maintain 3 of 7 smoke barriers properly, including incomplete fire barrier at dining hall and unsealed basement barrier.
Electrical system deficiencies including uncovered junction boxes, unsecured wiring, and unlabeled circuit breakers.
Smoking area lacked noncombustible ashtrays and metal containers with self-closing covers for ashtray disposal.
Report Facts
Census: 180
Total Capacity: 188
Residents at risk: 45
Residents at risk: 161
Residents at risk: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 27, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 6, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, with all prior issues corrected except for a smoke barrier deficiency.
Findings
The facility failed to ensure that smoke barriers in the pavilion hallway and cafeteria hallway were smoke tight and maintained a 1/2 hour fire resistance rating, with tape and mud used improperly to seal penetrations, placing 100% of residents at risk in an emergency.
Deficiencies (1)
Smoke barriers in the pavilion hallway and cafeteria hallway were not smoke tight and maintained 1/2 hour fire resistance rating.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 3, 2017
Visit Reason
A follow-up visit was conducted on 7/3/17 to verify correction of deficiencies identified in the prior recertification survey.
Findings
All deficiencies identified in the previous recertification survey had been corrected at the time of this follow-up visit.
Inspection Report
Routine
Census: 177
Deficiencies: 8
Date: May 4, 2017
Visit Reason
A standard survey was conducted at Presbyterian Home from 5/1/17 through 5/4/17 to assess compliance with Medicare/Medicaid regulations and facility standards.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide timely Medicare therapy termination notices, inadequate dining experience with use of Styrofoam dishware, incomplete care plans for residents with depression and anxiety, failure to revise care plans after significant weight loss, failure to monitor nutritional supplement intake, unnecessary psychotropic medication use without adequate rationale or gradual dose reduction, failure to maintain infection control precautions, and incomplete meal intake documentation.
Deficiencies (8)
Failure to ensure Medicare residents received a notice within 2 days prior to therapy services ending.
Failure to provide a home-like dining experience; use of Styrofoam plates and cups for meals and desserts in multiple dining units.
Failure to develop a comprehensive care plan addressing depression, anxiety, and agitation for a resident.
Failure to revise care plan after significant weight loss of 10.49% in 60 days.
Failure to maintain nutritional status including failure to monitor supplement intake and evaluate effectiveness of interventions.
Failure to ensure psychotropic drug regimen was free from unnecessary drugs and failure to attempt gradual dose reduction for hospice resident.
Failure to maintain effective infection control program; staff did not wear gowns and gloves when caring for resident on contact precautions.
Failure to maintain complete, accurate, and accessible medical records including inconsistent and incomplete documentation of meal intake for multiple residents.
Report Facts
Resident census: 177
Weight loss percentage: 10.49
Meal intake missing documentation: 59
Meal intake missing documentation: 10
Boost supplement cartons: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BD | Licensed Practical Nurse | Reported resident #76 rarely exhibited behaviors and was drowsy most of the time |
| LPN BG | Licensed Practical Nurse | Nurse on resident #38's unit, responsible for infection control education |
| CNA CC | Certified Nursing Assistant | Reported resident #122 refused Boost supplement at breakfast |
| Director of Nursing | Interviewed regarding care plan revisions and infection control | |
| Registered Dietitian | Interviewed regarding nutritional monitoring and weight loss | |
| Pharmacist | Provided recommendations for gradual dose reduction of psychotropic medications |
Inspection Report
Life Safety
Census: 177
Capacity: 188
Deficiencies: 6
Date: May 2, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including blocked means of egress, lack of sprinkler coverage in certain areas, smoke barriers not maintaining required fire resistance, use of extension cords, and failure to conduct required fire drills quarterly on each shift.
Deficiencies (6)
Facility failed to ensure all aisles, passageways, and corridors leading to exits were free of debris and obstructions.
Electrical room was not sprinkled and walls above smoke doors in the cafeteria had unprotected wood in concealed spaces not sprinkled.
Smoke barriers throughout the facility were not smoke tight and did not maintain the required 1/2 hour fire resistance rating.
Facility failed to ensure no flexible cords or extension cords were used throughout the facility.
An extension cord was spliced and used to supply power to the outside courtyard from the main building.
Facility failed to ensure that all fire drills were conducted quarterly on each shift.
Report Facts
Census: 177
Total Capacity: 188
Percentage of residents at risk: 40
Percentage of residents at risk: 30
Percentage of residents at risk: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to blocked exits, sprinkler issues, smoke barriers, extension cords, and fire drills |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA 001710904 and GA 00161577 at Presbyterian Home Quitman to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint investigation for complaints #GA 001710904 and GA 00161577; no deficiencies found.
Findings
No deficiencies were cited during the complaint survey conducted by a Registered Nurse on 02/08/2017.
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