Inspection Reports for
Presbyterian Village Athens
1400 Live Oak Ln, Athens, GA 30606, United States, GA, 30606
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
110% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Presbyterian Village - Athens.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 30, 2025
Visit Reason
The purpose of this survey was to investigate complaint #GA50002152 and conduct a compliance inspection.
Complaint Details
Investigation of complaint #GA50002152; no rule violations were found.
Findings
The survey was completed on 5/30/25 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
The purpose of this visit was to investigate intakes GA00251688, GA0000819, and GA00252908.
Complaint Details
Investigation of intakes GA00251688, GA0000819, and GA00252908 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Routine
Deficiencies: 8
Date: Sep 17, 2024
Visit Reason
Routine inspection of Presbyterian Village - Athens nursing facility to assess compliance with federal and state regulations including resident care, abuse investigations, bed hold policies, care planning, pain management, medication administration, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide dignified podiatry care in a common area, incomplete abuse investigation, failure to notify residents or representatives about bed hold policies, inadequate monitoring and documentation of meal intake, failure to provide ordered snacks, inadequate pain management, medication errors, and poor infection control practices related to hand hygiene.
Deficiencies (8)
F 0557: The facility failed to ensure the podiatrist provided care with respect and dignity by performing foot care in a common area causing resident distress and pain.
F 0610: The facility failed to conduct a complete investigation of an abuse allegation involving a resident and a CNA, lacking written statements from involved parties.
F 0625: The facility failed to provide written notification of the bed-hold policy and return to the resident or representative upon hospital transfer.
F 0656: The facility failed to follow care plans for three residents related to monitoring and recording meal intake and snack provision.
F 0684: The facility failed to follow physician orders to offer snacks between meals for one resident.
F 0697: The facility failed to provide appropriate pain management for a resident during podiatry care, ignoring resident's pain complaints and not administering pain medication as ordered.
F 0759: The facility had a medication error rate of 8%, including failure to check vital signs before administering medications and failure to administer a prescribed medication.
F 0880: The facility failed to ensure proper infection control practices as a nurse did not perform hand hygiene before and after medication administration for three residents.
Report Facts
Medication opportunities observed: 25
Medication errors: 2
BIMS score: 11
BIMS score: 13
BIMS score: 6
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Podiatrist | Named in findings related to failure to provide dignified care and pain management |
| FF | Licensed Practical Nurse | Named in medication administration errors and failure to perform hand hygiene |
| EE | Certified Nursing Assistant | Named in abuse allegation investigation |
| John Smith | Director of Nursing | Interviewed regarding multiple deficiencies including podiatry care, abuse investigation, bed hold policy, meal intake monitoring, pain management, and medication administration |
| Jane Doe | Assistant Director of Nursing | Interviewed regarding meal intake documentation and snack provision |
| Mary Johnson | Dietary Manager | Interviewed regarding snack availability and provision |
| Social Services Director | Interviewed regarding bed hold notification process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00247938.
Complaint Details
Investigation of complaint #GA00247938 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Deficiencies: 7
Date: Jul 22, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations related to nursing home operations, resident care, medication management, staffing, and food and nutrition services.
Findings
The facility was found deficient in multiple areas including failure to ensure employee background screening prior to hiring, failure to provide written notice of bed-hold policy to residents or representatives, failure to develop and implement comprehensive care plans for multiple residents, failure to provide adequate activities of daily living (ADL) care, a significant medication error resulting in actual harm to a resident, and lack of certified dietary management staff.
Deficiencies (7)
F 0606: The facility failed to ensure employee screening including a criminal background check was received prior to hiring one of 11 employees (Dietary Manager).
F 0625: The facility failed to notify the resident or representative in writing about the bed-hold policy upon hospital transfer for one of two residents reviewed.
F 0656: The facility failed to develop and implement comprehensive care plans addressing key health issues for five of 20 sampled residents, placing them at risk for unmet care needs.
F 0677: The facility failed to ensure activities of daily living care was provided for two of five dependent residents, as evidenced by untrimmed facial hair.
F 0755: The facility failed to provide pharmaceutical services that dispensed the correct dosage of lamotrigine for one resident, resulting in a grand mal seizure due to subtherapeutic dosing over 13 days.
F 0760: The facility failed to ensure one resident was free from a significant medication error related to incorrect administration of lamotrigine, causing actual harm.
F 0801: The facility failed to employ a certified dietary manager or equivalent qualified staff to oversee food and nutrition services.
Report Facts
Days medication error persisted: 13
Residents affected: 25
Residents sampled: 20
Residents reviewed for background screening: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Failed to have criminal background check prior to hire; not certified as dietary manager. | |
| Director of Human Resources | Confirmed some employees hired prior to receiving background screening. | |
| Director of Nursing (DON) | Director of Nursing | Provided multiple interviews regarding care plan deficiencies, medication error, and ADL care. |
| Social Services Director (SSD) | Social Services Director | Interviewed regarding failure to provide bed-hold notice. |
| Pharmacy Director BB | Pharmacy Director | Discussed medication dispensing error and pharmacy procedures. |
| Previous Pharmacy Director AA | Pharmacy Director | Worked briefly and described pharmacy order processing. |
| Pharmacist CC | Pharmacist | Confirmed medication dispensing error on bubble pack. |
| Certified Nursing Assistant (CNA) MM | Certified Nursing Assistant | Interviewed about ADL care for resident R5. |
| Certified Nursing Assistant (CNA) NN | Certified Nursing Assistant | Interviewed about ADL care for resident R15. |
| Registered Nurse (RN) DD | Registered Nurse | Witnessed seizure event and acknowledged medication administration error. |
| Licensed Practical Nurse (LPN) FF | Licensed Practical Nurse | Interviewed about medication administration education and access. |
| Licensed Practical Nurse (LPN) EE | Licensed Practical Nurse | Acknowledged failure to check medication bubble pack against MAR. |
| Executive Director | Executive Director | Acknowledged dietary manager certification status and pharmacy audit procedures. |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 22, 2024
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding employee screening, resident care plans, activities of daily living, medication administration, dietary services, and other regulatory requirements in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to ensure employee criminal background checks prior to hiring, failure to provide written bed-hold notices to residents or representatives, incomplete and non-person-centered care plans for multiple residents, inadequate assistance with activities of daily living, a significant medication error involving incorrect dosage of lamotrigine resulting in a grand mal seizure, and lack of certification for the Dietary Manager.
Deficiencies (7)
F 0606: The facility failed to ensure employee screening including a criminal background check was received prior to hiring one of 11 employees (Dietary Manager).
F 0625: The facility failed to notify the resident or representative in writing about bed-hold policies upon transfer to hospital for one of two residents reviewed.
F 0656: The facility failed to develop and implement comprehensive, person-centered care plans for five of 20 sampled residents, missing key focus areas such as pressure ulcer risk, psychotropic drug use, and dementia care.
F 0677: The facility failed to provide adequate assistance with activities of daily living for two dependent residents, including failure to shave facial hair as requested or needed.
F 0755: The facility failed to provide pharmaceutical services that dispensed the correct dosage of lamotrigine for one resident, resulting in a grand mal seizure due to subtherapeutic dosing for 13 days.
F 0760: The facility failed to ensure residents were free from significant medication errors, specifically administering lamotrigine 25 mg instead of the prescribed 250 mg ER, causing harm to one resident.
F 0801: The facility failed to employ a certified Dietary Manager or qualified food service manager to oversee food and nutrition services.
Report Facts
Residents affected: 11
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 1
Days medication error persisted: 13
Residents affected: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Named in medication error finding related to lamotrigine dosage |
| Pharmacy Director BB | Pharmacy Director | Named in medication error finding and pharmacy process |
| LPN FF | Licensed Practical Nurse | Named in medication error finding regarding medication administration |
| LPN EE | Licensed Practical Nurse | Named in medication error finding regarding medication administration |
| Dietary Manager | Named in employee screening and certification deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 13, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00244213 during an onsite visit on 3/13/24.
Complaint Details
Investigation of complaint #GA00244213 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Deficiencies: 14
Date: Apr 16, 2023
Visit Reason
Routine recertification survey and complaint investigation of Presbyterian Village - Athens nursing home to assess compliance with regulatory requirements.
Findings
The facility failed to ensure resident participation in care planning, develop baseline and discharge care plans, update care plans after falls, follow physician orders for wound care, maintain adequate fall prevention measures, ensure sufficient nurse staffing including RN coverage, maintain proper food safety and hygiene practices, implement an effective infection control program including antibiotic stewardship, designate a qualified infection preventionist, and properly offer and document influenza and pneumonia vaccinations.
Deficiencies (14)
F 0553: Facility failed to ensure residents and their representatives participated in care planning for three sampled residents, with no care plan meetings documented after mid-2022.
F 0655: Facility failed to develop a baseline care plan within 48 hours of admission for one resident, lacking goals and interventions for immediate care needs.
F 0657: Facility failed to update the care plan after a resident's fall with injury, missing new interventions and documentation.
F 0660: Facility failed to develop and document a discharge plan for one resident, with no evidence of discharge planning or communication.
F 0661: Facility failed to provide a discharge summary including recapitulation of stay and post-discharge plan for one resident.
F 0684: Facility failed to follow physician orders for wound care treatment for one resident, with missed dressing application and no system to track treatments.
F 0689: Facility failed to ensure fall prevention measures including bed and chair alarms were consistently applied and documented neuro-checks post-fall were incomplete for one resident with history of falls.
F 0725: Facility failed to ensure sufficient nurse staffing 24/7, including RN coverage for at least 8 consecutive hours daily, and failed to ensure resident participation in care planning and wound care treatment compliance.
F 0727: Facility failed to have a registered nurse on duty for at least 8 consecutive hours daily for 7 days a week, with documented days lacking RN coverage.
F 0812: Facility failed to ensure food items were properly labeled and dated, and staff wore proper hair restraints in food service areas, risking food safety for 26 residents.
F 0880: Facility failed to maintain an effective infection prevention and control program, lacking surveillance data and documentation for the past 12 months.
F 0881: Facility failed to implement an antibiotic stewardship program to monitor antibiotic use, with no documentation or tracking available.
F 0882: Facility failed to designate a qualified infection preventionist with required training and certification to oversee the infection control program.
F 0883: Facility failed to offer and/or administer influenza and pneumonia vaccines to four of five residents reviewed, with no documented education or vaccination campaigns.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 26
Days without RN coverage: 3
Residents reviewed for vaccines: 5
Residents not offered vaccines: 4
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Apr 16, 2023
Visit Reason
The inspection was conducted as part of a recertification survey to assess compliance with regulatory requirements including care planning, fall prevention, staffing, wound care, and infection control.
Findings
The facility was found deficient in updating care plans after resident falls, ensuring use of bed and chair alarms, completing neuro-check documentation post-fall, maintaining adequate RN staffing coverage, following physician orders for wound care, and maintaining infection control surveillance data.
Deficiencies (4)
F 0657: The facility failed to revise the care plan for a resident after a fall on 4/5/2023, despite policy requiring updates following significant changes.
F 0689: The facility failed to apply bed and chair alarms as ordered for a resident at risk for falls and did not complete neuro-check documentation after a fall on 4/5/2023.
F 0725: The facility failed to ensure sufficient nurse staffing 24/7, did not hold care plan meetings quarterly for some residents, and failed to follow physician orders for wound care for one resident.
F 0727: The facility did not have a Registered Nurse on duty for at least 8 consecutive hours a day for 7 days a week as required.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Days without RN coverage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Assigned to Resident #4; confirmed bed and chair alarms were not in use as ordered and missed wound care treatment for Resident #27 |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan updates, fall prevention documentation, wound care system, and staffing issues |
| Administrator | Facility Administrator | Provided information on RN staffing coverage and facility leadership |
| Human Resources Staff II | Human Resources Staff | Interviewed about Payroll Based Journal staffing data reporting |
| MDS/Care Plan Coordinator | MDS/Care Plan Coordinator | Responsible for updating care plans; acknowledged missing care plan updates due to workload |
| CNA DD | Certified Nursing Assistant | Reported lack of fall training at facility |
| LPN EE | Licensed Practical Nurse | Described fall assessment and documentation procedures |
| LPN HH | Licensed Practical Nurse | Reported wound care treatment missed for Resident #27 |
| Social Worker | Social Worker | Reported lack of care plan meetings for several residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 9, 2023
Visit Reason
The purpose of this visit was to investigate complaint #GA00229543.
Complaint Details
Investigation of complaint #GA00229543; finding substantiated by observation and interview.
Findings
The facility failed to ensure the memory care center operated with a valid certificate. During the tour on 3/9/23, no memory care certification was observed in the memory care unit, and Staff A was aware of this finding.
Deficiencies (1)
Facility failed to ensure the memory care center would not operate without a certificate.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Aware of the findings regarding lack of memory care certification. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
The purpose of this visit was to investigate complaint # GA00216640.
Complaint Details
Investigation of complaint # GA00216640 resulted in no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 1, 2021
Visit Reason
The purpose of this survey was to conduct an initial inspection of the facility.
Findings
The inspection was completed with no rule violations cited as a result of this inspection.
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