Inspection Reports for Presbyterian Village – Athens
1400 LIVE OAK LN BLDG 100, ATHENS, GA, 30606
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 29, 2025, was an abbreviated survey to investigate complaints and did not cite any deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to medication errors, infection control, pain management, care planning, and failure to provide written notice of the bed-hold policy upon hospital transfer. Complaint investigations in 2024 were substantiated with issues including dignified care, abuse investigation, and medication administration errors, but enforcement actions such as fines or license suspensions were not listed in the available reports. Prior surveys also noted fire safety deficiencies and staffing concerns, which were later corrected. The facility demonstrated improvement by November 14, 2024, when all previously cited deficiencies were found to be corrected.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
135% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
33 residents
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 33
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00241057 and GA00251724.
Complaint Details
Investigation of complaints GA00241057 and GA00251724.
Findings
The survey was initiated on January 28, 2025 and concluded on January 29, 2025. The facility census was 33 residents at the time of the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction report for Presbyterian Village - Athens, summarizing deficiencies identified during the inspection completed on 11/14/2024.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous 9/17/2024 survey.
Findings
All deficiencies cited as a result of the 9/17/2024 revisit survey were found to be corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Presbyterian Village - Athens following a survey completed on 11/14/2024.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior 9/17/2024 survey.
Findings
All deficiencies cited as a result of the 9/17/2024 Revisit Survey were found to be corrected.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Sep 17, 2024
Visit Reason
The inspection was a Licensure Survey conducted from September 16, 2024 through September 17, 2024 to assess compliance with licensure requirements for Presbyterian Village - Athens.
Findings
The facility was found deficient in multiple areas including failure to provide written notification of bed-hold policy upon hospital transfer, inadequate infection control practices during medication administration, medication errors exceeding acceptable rates, failure to provide adequate pain management during podiatry care, and failure to properly monitor and document meal intake for residents.
Deficiencies (5)
Failure to provide evidence that notice of the bed-hold policy and return was provided to the resident or residents' representative upon transfer to the hospital.
Failure to ensure staff practiced acceptable infection control practices by not performing hand hygiene during medication administration.
Failure to ensure medication error rate was below five percent; observed medication error rate was 8%.
Failure to provide adequate pain management; podiatrist did not stop or assess resident's pain during procedure causing actual harm.
Failure to follow plan of care related to monitoring and recording meal intake for three residents.
Report Facts
Medication opportunities observed: 25
Medication errors: 2
Medication error rate: 8
Sample size for infection control observation: 9
Sample size for pain management review: 9
Residents reviewed for meal intake monitoring: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Observed failing to perform hand hygiene during medication administration and involved in medication errors. |
| Podiatrist GG | Podiatrist | Failed to stop and assess resident's pain during podiatry procedure causing actual harm. |
| Social Services Director | Responsible for bed-hold letter process; confirmed lack of signed bed-hold notifications. | |
| Director of Nursing | Director of Nursing | Confirmed responsibility assignments and expectations related to bed-hold letters, medication administration, and care plan adherence. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided information about CNA responsibilities for documenting meal intake. |
| Certified Nursing Assistant II | Certified Nursing Assistant | Reported procedures for pain reporting and identification. |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 2
Date: Sep 17, 2024
Visit Reason
A revisit survey was conducted on September 17, 2024, in conjunction with Complaint Intake Number GA00249830. The revisit survey was to assess compliance following the July 22, 2024 Recertification Survey and to investigate the complaint.
Complaint Details
Complaint Intake Number GA00249830 was investigated and found substantiated with deficiencies related to bed hold policy notification and care plan implementation.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Actual harm was identified related to failure to assess a resident in pain during podiatry care. The complaint investigation was substantiated with deficiencies including failure to provide written notice of bed hold policy upon hospital transfer and failure to follow comprehensive care plans related to monitoring and recording meal intake for three sampled residents.
Deficiencies (2)
Failure to provide evidence that notice of the bed-hold policy and return was provided to the resident or resident's representative upon transfer to the hospital for one sampled resident (R6).
Failure to follow the plan of care for three sampled residents (R1, R2, and R22) related to monitoring and recording meal intake.
Report Facts
Census: 31
Deficiencies cited: 2
BIMS scores: 6
BIMS scores: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding bed hold policy notification process and documentation | |
| Director of Nursing | Interviewed regarding responsibility for bed hold letters and care plan compliance | |
| Assistant Director of Nursing | Interviewed regarding CNA documentation of meal intake |
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 8
Date: Sep 17, 2024
Visit Reason
A revisit survey was conducted on September 17, 2024, in conjunction with Complaint Intake Number GA00249830, to investigate the facility's compliance with Medicare/Medicaid regulations following a July 22, 2024 Recertification Survey.
Complaint Details
Complaint Intake Number GA00249830 was substantiated with deficiencies related to dignified care, abuse investigation, and other compliance issues.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide dignified podiatry care in a common area, incomplete abuse investigation, failure to notify residents of bed-hold policy, failure to follow care plans for meal intake monitoring, failure to provide ordered snacks, inadequate pain management during podiatry care, medication administration errors, and failure to perform proper hand hygiene during medication administration.
Deficiencies (8)
Failure to ensure podiatrist provided care in a dignified manner for resident R4 in a common area.
Failure to provide a complete and thorough investigation of an allegation of abuse for resident R13.
Failure to provide evidence that notice of the bed-hold policy was provided to resident R6 or representative upon hospital transfer.
Failure to follow the plan of care for residents R1, R2, and R22 related to monitoring and recording meal intake.
Failure to follow physician orders to offer snacks between meals for resident R1.
Failure to ensure pain management was provided to resident R4 during podiatry care; actual harm identified.
Failure to ensure medications were given as ordered, resulting in a medication error rate of 8% for residents R5 and R16.
Failure to ensure proper hand hygiene was performed by nurse during medication administration for residents R5, R3, and R16.
Report Facts
Census: 31
Medication error rate: 8
BIMS score: 11
BIMS score: 13
BIMS score: 6
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Podiatrist GG | Podiatrist | Named in findings related to undignified care and failure to assess pain |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding podiatry care, abuse investigation, bed-hold policy, pain management, and medication administration |
| CNA EE | Certified Nursing Assistant | Named in abuse allegation and provided written statement |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding bed-hold policy notification |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding care plan adherence and snack provision |
| Licensed Practical Nurse FF | Licensed Practical Nurse (LPN) | Observed and interviewed regarding medication administration errors and hand hygiene failures |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding snack availability |
| Certified Nursing Assistant CC | Certified Nursing Assistant (CNA) | Interviewed regarding snack provision |
| Certified Nursing Assistant DD | Certified Nursing Assistant (CNA) | Interviewed regarding snack provision |
Inspection Report
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Village - Athens, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 6, 2024
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.
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 7
Date: Jul 22, 2024
Visit Reason
A standard survey was conducted from July 20 through July 22, 2024, including investigation of Complaint Intake Number GA00248634. The complaint was substantiated with deficiencies related to medication errors and care planning.
Complaint Details
Complaint Intake Number GA00248634 was investigated in conjunction with the standard survey and was substantiated with deficiencies including medication errors and care planning failures.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure proper employee background screening, failure to provide written bed-hold notice, failure to develop comprehensive care plans for multiple residents, failure to provide adequate ADL care, failure to provide correct medication dosage resulting in harm, and failure to have a certified dietary manager.
Deficiencies (7)
Failure to ensure employee screening including criminal background check prior to hiring one of 11 employees (Dietary Manager).
Failure to provide written notice of bed-hold policy to resident or representative upon hospital transfer for one of two residents.
Failure to develop and implement comprehensive person-centered care plans for five of 20 sampled residents.
Failure to provide activities of daily living (ADL) care for two of five dependent residents.
Failure to provide pharmaceutical services that dispensed the correct dosage of physician ordered medication for one resident, resulting in a grand mal seizure due to subtherapeutic dosage for 13 days.
Failure to ensure one resident was free from a significant medication error related to incorrect administration of lamotrigine dosage.
Failure to ensure dietary department had a designated certified dietary or food service manager.
Report Facts
Residents present during inspection: 25
Days incorrect medication administered: 13
Residents reviewed for background screening: 11
Residents sampled for care plan review: 20
Dependent residents reviewed for ADL care: 5
Residents with deficient care plans: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Named in medication error finding; confirmed medication administration error and failure to follow five rights |
| Pharmacy Director BB | Pharmacy Director | Discussed pharmacy procedures and medication error |
| Pharmacist CC | Pharmacist | Confirmed filling of incorrect medication dosage |
| Previous Pharmacy Director AA | Pharmacy Director (former) | Described pharmacy order processing and lack of notification of medication error |
| Dietary Manager | Dietary Manager | Failed to have required certification or degree |
| Director of Nursing (DON) | Director of Nursing | Provided multiple interviews regarding medication error, care plan issues, and staff education |
| Executive Director | Administrator | Discussed pharmacy audits and dietary manager certification status |
Inspection Report
Renewal
Deficiencies: 3
Date: Jul 22, 2024
Visit Reason
A Licensure Survey was conducted from 7/20/2024 through 7/22/2024 to assess compliance with state regulations and licensing requirements for Presbyterian Village - Athens.
Findings
The facility failed to provide correct pharmaceutical services resulting in a medication error causing harm to a resident. Additionally, the facility did not develop comprehensive care plans for six sampled residents addressing their specific medical and psychological needs. The facility also failed to ensure criminal background checks were completed prior to hiring one employee.
Deficiencies (3)
Incorrect dosage of lamotrigine was administered to resident R77 for 13 days, resulting in a grand mal seizure.
Failure to develop and/or implement person-centered comprehensive care plans for six residents (R5, R15, R19, R20, R12) addressing various medical and psychological needs.
Failure to ensure employee screening including criminal background check was received prior to hiring one employee (Dietary Manager).
Report Facts
Number of residents sampled for medication error: 20
Number of residents with deficient care plans: 6
Number of employees reviewed for background screening: 11
Duration of medication error: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Pharmacy Director | Provided information about medication error and pharmacy procedures |
| AA | Previous Pharmacy Director | Provided information about pharmacy technician roles and medication order process |
| CC | Pharmacist | Confirmed filling of medication bubble pack for R77 |
| Director of Nursing | Director of Nursing (DON) | Confirmed medication error and resident admission details |
| Director of Health Services | Administrator | Discussed medication audit processes and internal reports |
| MDS Coordinator | MDS Coordinator | Confirmed lack of comprehensive care plans for multiple residents |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Discussed EMR system migration and care plan documentation issues |
| Licensed Practical Nurse FF | Licensed Practical Nurse (LPN) | Confirmed lack of access to old EMR system for resident care plans |
| Director of Human Resources | Director of Human Resources (DHR) | Confirmed hiring prior to receipt of criminal background check |
Inspection Report
Life Safety
Census: 20
Capacity: 40
Deficiencies: 3
Date: Jul 20, 2024
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 Edition requirements for fire safety and related standards.
Findings
The facility was found not in substantial compliance due to failure to maintain the fire alarm panel which showed a trouble circuit, failure to maintain smoke barriers with multiple penetrations above ceilings, and failure to replace multiple junction box covers above ceilings near the main nurse's station, potentially placing residents at risk.
Deficiencies (3)
Fire alarm panel was notifying a trouble circuit instead of 'All systems normal', risking notification failure for all 40 residents.
Failed to maintain three smoke compartments above ceiling at rear activity area and two compartments near main nurse's station, risking smoke migration.
Failed to replace multiple junction box covers above ceiling at two smoke compartments near main nurse's station, risking smoke from hot wires affecting patient areas.
Report Facts
Certified Beds: 40
Census: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00241630.
Complaint Details
Complaint GA00241630 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Jun 30, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted at Presbyterian Village - Athens.
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: Jun 30, 2023
Visit Reason
A revisit survey was conducted on June 30, 2023, in conjunction with an investigation of Complaint Intake Number GA00230445.
Complaint Details
Complaint Intake Number GA00230445 was investigated and found to be unsubstantiated without deficiencies.
Findings
All deficiencies cited during the April 16, 2023 Standard Survey were found to be corrected. The complaint investigation was unsubstantiated without deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 30, 2023
Visit Reason
A revisit survey was conducted on June 30, 2023, in conjunction with an investigation of Complaint Intake Number GA00230445.
Complaint Details
Complaint Intake Number GA00230445 was investigated and found to be unsubstantiated without deficiencies.
Findings
All deficiencies cited in the April 16, 2023 Standard Survey were found to be corrected. The complaint investigation was unsubstantiated without deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
A follow-up survey was conducted to verify correction of previous deficiencies.
Findings
All previous citations were found to be corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 16, 2023
Visit Reason
A State Licensure survey was conducted from 4/14/2023 through 4/16/2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in following physician orders for wound care, ensuring proper food labeling and staff hair restraints in food service areas, and offering/administering pneumonia and influenza vaccines to residents.
Deficiencies (3)
Failed to follow physician orders related to treatment for a skin tear for one resident.
Failed to ensure food items were properly dated and labeled, and staff wore proper hair restraints in food service area.
Failed to offer and/or administer pneumonia and influenza vaccines to four residents.
Report Facts
Residents reviewed for vaccines: 5
Residents affected by wound care deficiency: 1
Residents affected by food safety deficiency: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse (LPN) | Interviewed regarding missed wound care treatment. |
| FF | Licensed Practical Nurse (LPN) | Responsible for wound care treatments on day of inspection; missed treatment for resident. |
| BB | Head Hot Cook | Interviewed about hair net use in food preparation area. |
| EE | Licensed Practical Nurse (LPN) | Interviewed about vaccine administration procedures. |
| Director of Nursing (DON) | Director of Nursing | Interviewed about wound care tracking and vaccine administration policies. |
| Administrator | Administrator | Interviewed about food safety and vaccine administration responsibilities. |
Inspection Report
Annual Inspection
Census: 26
Deficiencies: 13
Date: Apr 16, 2023
Visit Reason
A standard survey was conducted from April 14 through April 16, 2023, including investigation of Complaint Intake Number GA00228148, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00228148 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to ensure resident and representative participation in care planning, incomplete baseline care plans, failure to revise care plans after falls, lack of discharge planning and summaries, failure to follow physician orders for wound care, inadequate fall prevention measures, insufficient nurse staffing including lack of RN coverage for multiple days, improper food handling and labeling, ineffective infection control program and surveillance, lack of antibiotic stewardship program, absence of a qualified infection control preventionist, and failure to offer or administer influenza and pneumonia vaccines to several residents.
Deficiencies (13)
Failed to ensure residents and representatives participated in care planning for 3 of 14 sampled residents.
Failed to develop baseline care plan including goals and interventions for one resident.
Failed to revise care plan after fall for one resident.
Failed to ensure discharge plan was developed and documented for one resident.
Failed to complete discharge summary for one resident.
Failed to follow physician orders related to treatment of skin tear for one resident.
Failed to assure safety of resident with history of falls by not applying bed and chair alarms and incomplete neuro-check documentation.
Failed to ensure sufficient nurse staffing including RN coverage for at least 8 consecutive hours daily for 7 days a week.
Failed to ensure food items were properly dated and labeled and staff wore proper hair restraints in food service area.
Failed to maintain effective infection prevention and control program with ongoing surveillance and control of infections.
Failed to develop and implement an Antibiotic Stewardship Program including antibiotic use protocols and monitoring.
Failed to designate a qualified Infection Control Preventionist with specialized training responsible for infection prevention and control program.
Failed to offer and/or administer pneumonia and influenza vaccines to four of five residents reviewed.
Report Facts
Residents present: 26
Days with no RN coverage: 3
Residents reviewed for vaccines: 5
Residents not offered vaccines: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Named in wound care treatment deficiency for missing dressing on resident's skin tear |
| LPN FF | Licensed Practical Nurse | Named in wound care treatment deficiency for missing dressing and treatment |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including care planning, infection control, staffing, and vaccine administration |
| Administrator | Facility Administrator | Named in staffing and infection control deficiencies |
| Human Resources Staff II | Human Resources Staff | Interviewed regarding Payroll Based Journal staffing data |
| Social Worker | Named in care planning deficiency regarding lack of care plan meetings | |
| MDS Coordinator | Named in care planning deficiency regarding lack of care plan meetings | |
| Head Hot cook BB | Head Cook | Named in food service hair restraint deficiency |
| Dish washer CC | Dishwasher | Named in food service hair restraint deficiency |
| LPN EE | Licensed Practical Nurse | Named in vaccine administration interview |
Inspection Report
Life Safety
Census: 28
Capacity: 40
Deficiencies: 2
Date: Apr 15, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including improper installation and maintenance of the fire alarm system and failure to maintain smoke barrier/fire barrier walls. These deficiencies could potentially affect all residents.
Deficiencies (2)
Fire alarm system was not properly installed and maintained, including unmarked breaker, unidentified fire alarm circuit breaker location, and improperly marked batteries.
Smoke barrier/fire barrier walls were not properly maintained, with numerous penetrations observed in the North and South smoke barrier/fire barrier walls.
Report Facts
Census: 28
Total Capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and confirmed findings during the inspection |
Inspection Report
Original Licensing
Census: 6
Deficiencies: 0
Date: Sep 15, 2021
Visit Reason
An Initial Certification survey was conducted at Presbyterian Village Athens from September 13, 2021, through September 15, 2021.
Findings
The Standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 6
Capacity: 40
Deficiencies: 0
Date: Sep 13, 2021
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 in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 9, 2021
Visit Reason
An initial walk-through licensure survey was conducted at Presbyterian Village-Athens on June 9, 2021.
Findings
The facility was found to be in compliance with state requirements.
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