Inspection Reports for Presbyterian Village
2000 EAST-WEST CONNECTOR, AUSTELL, GA, 30106
Back to Facility ProfileInspection Report Summary
The most recent inspections on May 22, 2025, substantiated complaints but did not result in any cited deficiencies. Earlier inspections showed a pattern of multiple deficiencies primarily related to resident care, medication management, infection control, and safety, including issues with supervision on the locked Dementia Care Unit, unsecured medications, and inadequate infection prevention practices. Immediate Jeopardy was identified and later removed during the December 2024 survey, which also cited numerous deficiencies in abuse policy implementation, staffing, care planning, and facility maintenance. Complaint investigations were mostly unsubstantiated, except for the recent substantiated complaints that did not lead to deficiencies. The facility appears to have corrected previously cited deficiencies by early 2025, indicating some improvement following earlier compliance challenges.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
62 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 0
Date: May 22, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Presbyterian Village to investigate complaint #GA00255097.
Complaint Details
Complaint #GA00255097 was substantiated with no deficiencies cited.
Findings
The complaint #GA00255097 was substantiated but no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 0
Date: May 22, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Presbyterian Village investigating complaint #GA00255097.
Complaint Details
Complaint #GA00255097 was substantiated with no deficiencies cited.
Findings
The complaint #GA00255097 was substantiated with no deficiencies cited.
Report Facts
Census: 62
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Date: May 22, 2025
Visit Reason
An abbreviated/partial extended survey was conducted at Presbyterian Village to investigate complaint #GA00255097.
Complaint Details
Complaint #GA00255097 was substantiated with no deficiencies cited.
Findings
The complaint #GA00255097 was substantiated with no deficiencies cited during the investigation.
Report Facts
Complaint number: 1
Census: 62
Inspection Report
Abbreviated Survey
Census: 61
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00254316.
Complaint Details
Complaint GA00254316 was substantiated.
Findings
The complaint GA00254316 was substantiated, but no regulatory violations were cited during the survey.
Inspection Report
Follow-Up
Census: 63
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
A second revisit was conducted at Presbyterian Village Austell from 2/25/2025 through 2/28/2025 to verify correction of deficiencies cited in the recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 2/7/2025.
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
A revisit was conducted at Presbyterian Village from 2/25/25 through 2/28/25 to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 2/7/25.
Report Facts
Facility census: 63
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
A revisit was conducted at Presbyterian Village beginning 2/25/25 through 2/28/25 to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 2/7/25.
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
A revisit was conducted at Presbyterian Village from 2/25/25 through 2/28/25 to verify correction of deficiencies cited in the recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 2/7/25.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Presbyterian Village, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
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
Follow-Up
Census: 63
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
A revisit was conducted at Presbyterian Village Austell from 2/25/2025 through 2/28/2027 to verify correction of previously cited deficiencies.
Findings
All deficiencies cited as a result of the FMS survey were found to be corrected by 2/7/2025.
Report Facts
Facility census: 63
Inspection Report
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Village, 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
Re-Inspection
Census: 66
Deficiencies: 1
Date: Dec 31, 2024
Visit Reason
A revisit survey was conducted on 12/30/2024 through 12/31/2024 following a recertification with complaint survey completed on 11/14/2024.
Findings
The facility was found to be back in compliance with all citations except for citation F761, which will be recited.
Deficiencies (1)
Citation F761 will be recited.
Report Facts
Facility census: 66
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 19
Date: Dec 19, 2024
Visit Reason
A Federal Health Comparative Survey was conducted by CMS from December 9-19, 2024, including complaint investigations and review of compliance with Medicare regulations.
Findings
The facility was found not in compliance with multiple requirements including abuse policy implementation, supervision on the locked Dementia Care Unit, resident care including incontinence and turning, privacy, maintenance, medication administration, physician visits, staffing, infection control, and quality assurance. Immediate Jeopardy was identified and later removed with corrective actions.
Deficiencies (19)
Failure to implement abuse policy by immediately suspending an alleged perpetrator and conducting a thorough investigation of verbal abuse.
Failure to provide sufficient staff to supervise residents on the locked Dementia Care Unit, resulting in residents being left unsupervised during mealtimes and in rooms.
Failure to provide person-centered baseline care plan for newly admitted resident addressing ADLs, wounds, rehabilitation, medication self-administration, and placement on locked unit.
Failure to develop individualized care plans with interventions for residents at risk for dehydration and for use of palm protectors.
Failure to provide incontinent care, turning and repositioning, and assistance with shaving for dependent residents, resulting in actual harm and resident distress.
Failure to develop criteria for admission to locked Dementia Care Unit, resulting in inappropriate placement of cognitively intact residents who felt trapped and hopeless.
Failure to ensure physician visits every 30 days for first 90 days and alternating visits with Nurse Practitioner every 60 days thereafter for sampled residents.
Failure to provide privacy during procedures for residents.
Failure to maintain facility environment in good repair including door frames, sheetrock, tiles, and cleanliness in resident rooms.
Failure to ensure medications and oxygen tanks were properly secured and expired medications removed.
Failure to provide thorough investigation of falls and implement interventions to prevent recurrence.
Failure to provide timely follow-up and treatment for resident complaints of urinary tract infection symptoms.
Failure to ensure proper cleaning and disinfection of shared medical equipment including blood pressure cuffs and blood glucose meters between uses.
Failure to ensure antibiotic stewardship program was in place and functioning to monitor antibiotic use and involve medical staff.
Failure of the Administrator to provide effective administration, oversight of staffing, physician services, and safety of residents.
Failure to develop a comprehensive Facility Assessment including required parties, staffing plans per unit and shift, recruitment and retention plans, contingency planning, and mandatory training topics.
Failure of Medical Director to actively participate in clinical oversight, policy development, resident care coordination, and regulatory compliance.
Failure to have a comprehensive QAPI program addressing all systems of care, including staffing, abuse/neglect, physician visits, infection control, and staff training.
Failure to provide mandatory training to all staff on resident rights, abuse/neglect, infection prevention and control, compliance and ethics, QAPI, behavioral health, and 12 hours annual CNA training.
Report Facts
Census: 70
Deficiencies cited: 23
Staffing ratio: 1
Staffing ratio: 1
Staffing ratio: 1
Staffing ratio: 1
Medication doses: 4
Medication doses: 2
Medication doses: 1
Antibiotic courses: 3
Training hours: 12
Training hours: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in multiple findings related to staffing, abuse investigation, falls, wound care, and medication oversight | |
| Infection Preventionist | Named in infection control and antibiotic stewardship findings | |
| Human Resources Training Coordinator | Named in findings related to staff training documentation and tracking | |
| Administrator | Named in findings related to facility administration, oversight, and QAPI | |
| Medical Director | Named in findings related to physician visits, medical oversight, and QAPI | |
| RN #2 | Registered Nurse | Named in abuse allegation investigation failure |
| RN #1 | Registered Nurse | Named in medication administration and infection control observations |
| LPN #1 | Licensed Practical Nurse | Named in medication administration and infection control observations |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and infection control observations |
| CNA #3 | Certified Nurse Aide | Named in neglect and incontinence care failure |
| CNA #7 | Certified Nurse Aide | Named in infection control PPE failure |
| CNA #5 | Certified Nurse Aide | Named in medication storage failure |
| LPN #4 | Licensed Practical Nurse | Named in medication administration and infection control observations |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 6
Date: Nov 14, 2024
Visit Reason
A State Licensure survey was conducted at Presbyterian Village-Austell from November 12, 2024, through November 14, 2024, to assess compliance with state health regulations and facility licensure requirements.
Findings
The inspection revealed multiple deficiencies including unsecured medications on medication carts, failure to implement stop dates for PRN psychotropic medications, inadequate infection control surveillance and signage, improper wound care procedures, unclean shared equipment, and insufficient activities of daily living care such as fingernail grooming for several residents.
Deficiencies (6)
Medications were left unsecured on one of two medication carts on Hall B, with multiple medication cards and pills left unattended.
Failure to implement a stop date for a PRN psychotropic medication for one resident (R53), with indefinite duration and no documented clinical rationale.
Facility failed to provide proper infection surveillance and monitoring for infections and communicable diseases for all residents, and failed to ensure Enhanced Barrier Precautions signs were posted on residents' doors.
Failure to provide wound care following appropriate technique to prevent spread of infection for one resident (R19), including improper handling of wound care supplies and lack of hand hygiene.
Shared equipment such as blood pressure machines were not properly cleaned between uses.
Failure to provide adequate activities of daily living care related to fingernail care and grooming for five residents, resulting in long, dirty fingernails and facial hair not being managed.
Report Facts
Facility census: 71
Residents reviewed for unnecessary medications: 5
Residents on Enhanced Barrier Precautions: 17
Residents with infection control deficiencies: 71
Residents with wound care deficiencies: 1
Residents with ADL care deficiencies: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Named in medication cart unsecured medication finding and infection control interviews |
| ADON | Assistant Director of Nursing | Provided statements on medication security, infection control expectations, and wound care |
| RN AA | Registered Nurse | Observed performing wound care and interviewed regarding wound care procedures |
| CNA BB | Certified Nursing Assistant | Assisted with wound care and interviewed regarding ADL care and fingernail grooming |
| CNA II | Certified Nursing Assistant | Interviewed regarding resident ADL care and hygiene |
| IP | Infection Preventionist | Interviewed regarding infection control surveillance and signage deficiencies |
| DON | Director of Nursing | Interviewed regarding infection control expectations and wound care |
| Executive Director | Interviewed regarding infection control signage expectations |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 6
Date: Nov 14, 2024
Visit Reason
A recertification survey was conducted at Presbyterian Village Austell from November 12 through November 14, 2024, including investigation of two complaint intake numbers which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00248060 and GA00248456 were investigated and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide adequate activities of daily living care, improper psychotropic medication management, unsecured medication carts, inadequate infection prevention and control practices, failure to maintain antibiotic stewardship monitoring, and lack of a certified Infection Preventionist.
Deficiencies (6)
Failure to ensure activities of daily living relating to fingernail care and grooming for five of 18 sampled residents.
Failure to implement a stop date for a PRN psychotropic medication for one resident.
Failure to ensure medications were secured on one medication cart, leaving medications unattended.
Failure to provide proper surveillance and monitoring for infections and communicable diseases for all residents, failure to ensure Enhanced Barrier Precautions signs on residents' doors, and failure to provide proper wound care and infection prevention techniques.
Failure to establish and maintain an antibiotic stewardship facility-wide monitoring system (line listing) for residents on antibiotics.
Failure to employ a certified Infection Preventionist and experienced a lapse in infection prevention leadership.
Report Facts
Residents on Enhanced Barrier Precautions: 17
Hours of Infection Preventionist Training: 19.75
Days without fully trained Infection Preventionist: 60
Facility census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Provided statements regarding nail care, medication cart security, infection control, and training of Infection Preventionist | |
| Certified Nursing Assistant (CNA) BB | Confirmed fingernail care practices and resident observations | |
| Licensed Practical Nurse (LPN) EE | Observed leaving medication cart unsecured and blood pressure cuff cleaning practices | |
| Registered Nurse (RN) AA | Performed wound care and described proper wound care procedures | |
| Infection Preventionist (IP) | Discussed infection control surveillance, training status, and antibiotic stewardship duties | |
| Director of Nursing (DON) | Discussed infection control and antibiotic stewardship expectations and training | |
| Executive Director | Provided expectations for infection control and antibiotic stewardship programs |
Inspection Report
Life Safety
Census: 71
Capacity: 107
Deficiencies: 3
Date: Nov 13, 2024
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to deficiencies in the emergency preparedness program, smoke compartment door integrity, and lack of documentation for the generator 4-hour load test. Specific issues included incomplete annual updates of the emergency preparedness plan, a resident room door with a gap allowing smoke passage, and missing generator load test documentation.
Deficiencies (3)
Emergency preparedness plan was not maintained with complete annual updates, lacking dates and signatures.
Resident room door had a gap at the top allowing smoke passage, failing to prevent smoke spread.
Facility failed to provide documentation of the required generator 4-hour load test for backup power assurance.
Report Facts
Census: 71
Total licensed beds: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, smoke door gap, and generator load test documentation |
Inspection Report
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Presbyterian Village, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Date: Sep 19, 2022
Visit Reason
A revisit was conducted at Presbyterian Village Austell on 9/19/22 to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 8/26/22.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 2, 2022
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 noted by the surveyor.
Inspection Report
Renewal
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
The inspection was a Licensure Survey conducted from July 12, 2022 through July 14, 2022 to assess compliance with licensure requirements for Presbyterian Village.
Findings
The facility failed to provide an ongoing program of activities based on resident input and preferences for four of 24 sampled residents. Group activities were largely suspended due to COVID-19 outbreak restrictions, resulting in resident frustration and boredom. The Activities Director was providing only one-on-one activities without documentation, and there was confusion among staff about resuming group activities despite CDC guidance allowing them under certain conditions.
Deficiencies (1)
Failure to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four of 24 sampled residents.
Report Facts
Sampled residents reviewed for activities: 24
BIMS score: 15
Date range of survey: Survey conducted from July 12, 2022 through July 14, 2022.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interviewed regarding activity program and COVID restrictions; confirmed no group activities since May; only one-on-one activities provided without documentation. | |
| Administrator | Provided direction to restrict group activities during outbreak; unaware group activities were allowed under CDC guidance. | |
| Director of Nurses (DON) | Discussed CDC guidance allowing group activities with precautions; confirmed no group activities since April except a 4th of July parade. | |
| BB | Certified Nursing Assistant (CNA) | Reported residents complaining about lack of activities due to COVID. |
| AA | Licensed Practical Nurse (LPN) | Reported facility not allowing group activities and residents requesting gatherings. |
| Social Worker | Reported residents bored and requesting activities; confirmed shift from small group to one-on-one activities due to COVID. |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 1
Date: Jul 14, 2022
Visit Reason
A standard survey was conducted from July 12, 2022 through July 14, 2022, including investigation of Complaint Intake Number GA00215746, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00215746 was investigated in conjunction with the standard survey. The complaint involved lack of group activities and resident dissatisfaction with activity programming during COVID-19 outbreak restrictions.
Findings
The facility failed to provide an ongoing program of activities based on resident input and preferences for four of 24 sampled residents. Group activities were largely suspended due to COVID-19 outbreak restrictions, resulting in resident boredom and dissatisfaction. The facility was not documenting activities provided, and key staff had differing understandings of CDC guidance regarding group activities during outbreaks.
Deficiencies (1)
Failure to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four sampled residents.
Report Facts
Resident census: 74
Sampled residents: 24
Residents with activity deficiencies: 4
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interviewed regarding activity programming and restrictions during COVID-19 outbreak | |
| Administrator | Interviewed regarding facility policies on group activities during outbreak and CDC guidance | |
| Director of Nurses (DON) | Interviewed regarding CDC guidance and resumption of group activities | |
| Social Worker | Interviewed regarding resident boredom and requests for activities | |
| BB | Certified Nursing Assistant (CNA) | Reported resident complaints about lack of activities |
| AA | Licensed Practical Nurse (LPN) | Reported residents requesting group gatherings |
Inspection Report
Life Safety
Census: 75
Capacity: 107
Deficiencies: 2
Date: Jul 13, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically regarding maintenance and testing of the sprinkler system and ensuring unobstructed access to electrical panels for shut off power. Deficiencies were observed in one of four smoke compartments.
Deficiencies (2)
Accumulated loading of components on the sprinkler head was evident in the laundry over the dryers, indicating failure to maintain the fire sprinkler system in optimum readiness.
Electrical panels in the kitchen were blocked by rolling food shelves, obstructing immediate access to shut off power.
Report Facts
Smoke Compartments affected: 1
Stories: 2
Construction Type: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler system and electrical panel obstructions during facility tour. |
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 0
Date: Feb 18, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 17, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 78
Deficiencies: 1
Date: Dec 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to place a resident (R#4) with known exposure to COVID-19 on transmission-based precautions, potentially exposing 13 other residents. Staff did not consistently use gowns and gloves when caring for the exposed resident, and facility policies lacked procedures for residents exposed to COVID-19 positive roommates.
Deficiencies (1)
Failure to ensure a resident with known exposure to COVID-19 was placed on transmission-based precautions to prevent spread of infection.
Report Facts
Census: 78
Residents exposed: 13
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator and Infection Preventionist | Interviewed regarding COVID-19 protocols and quarantine procedures for exposed residents |
| Director of Nursing | Director of Nursing and Infection Preventionist | Interviewed regarding infection control practices and quarantine procedures |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed about monitoring and care of exposed resident R#4 |
| Medical Director | Medical Director | Interviewed about COVID-19 precautions and resident monitoring |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Interviewed about direct care provided to exposed resident R#4 |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00205462.
Complaint Details
Complaint GA00205462 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess 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 for COVID-19.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on August 4-5, 2020 by Ascellon on behalf of the Georgia Department of Community Health.
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 to prepare for COVID-19.
Inspection Report
Routine
Census: 89
Deficiencies: 0
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess 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 to prepare for COVID-19.
Report Facts
Total census: 89
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on June 24, 2020 to assess compliance with emergency preparedness and infection control regulations 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 infection control regulations, and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 91
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 15, 2019
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 survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 1, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Presbyterian Village, indicating a regulatory inspection was conducted and corrective actions are planned.
Findings
No specific deficiencies or findings are detailed in the provided document; it primarily serves as a cover sheet for the plan of correction related to the inspection.
Inspection Report
Life Safety
Census: 100
Capacity: 107
Deficiencies: 4
Date: Feb 25, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and related NFPA standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-illuminated exit signage, missing sprinkler escutcheon plates, fire wall penetrations allowing smoke passage, and exposed electrical wiring posing shock hazards.
Deficiencies (4)
Exit sign in the kitchen means of egress was not illuminated as required.
Fire sprinkler escutcheon plates were missing in 4 locations within the kitchen area, potentially delaying sprinkler activation.
Fire wall penetrations in fire/smoke barriers above rated fire doors on A & D hallways would allow passage of smoke.
Electrical panel and an outlet in the kitchen area presented exposed wiring that could cause electrical shock.
Report Facts
Staff at risk: 6
Residents at risk: 50
Missing sprinkler escutcheon plates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2018
Visit Reason
A complaint survey was conducted to investigate complaint GA00192125 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00192125 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 4, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00190018.
Complaint Details
Complaint #GA00190018 was investigated and found to be unsubstantiated.
Findings
The complaint investigated during the survey was found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 11, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00188738 and GA00187725 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaints #GA00188738 and GA00187725 were investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A revisit survey was conducted on 3/30/18 for the Recertification survey of 1/29/18 through 2/2/18.
Findings
The revisit revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 3/30/18.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 23, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2018
Visit Reason
A complaint survey was conducted on 2018-03-04 and 2018-03-05 to investigate complaint #GA 00185782 by two Qualified Surveyors to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Investigation of complaint #GA 00185782; facility found out of compliance with regulations.
Findings
Based on the Federal and State Long Term Care Requirements, the facility remains out of compliance with the regulations.
Inspection Report
Life Safety
Census: 94
Capacity: 107
Deficiencies: 5
Date: Jan 29, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including failures in exit signage illumination, fire alarm system readiness, sprinkler system maintenance, corridor door latching, and electrical panel safety.
Deficiencies (5)
Exit directional sign was not internally or externally illuminated in the Basement/warehouse area.
Fire alarm panel presented a 'trouble' signal light due to a duct detector not working properly, indicating failure to assure constant readiness of the fire alarm system.
Loaded sprinkler heads found in Utility Closets on Main level and a missing sprinkler escutcheon plate in the front office closet could delay sprinkler activation.
Two resident doors would not latch to secure the door in the closed position, risking smoke spread.
A voided circuit space in electrical panel 'L-1' in the lower level breakroom area could cause accidental electrical shock.
Report Facts
Staff at risk due to exit signage deficiency: 6
Staff and residents at risk due to sprinkler system deficiency: 40
Staff and residents at risk due to door latching deficiency: 24
Staff at risk due to electrical panel deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 01/29/2018 |
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Jun 7, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/7/17 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 100
Capacity: 107
Deficiencies: 2
Date: Jan 17, 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) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to missing fire sprinkler escutcheon plates in dining rooms on both floors and unsealed penetrations in smoke barriers at three locations, potentially placing residents at risk in the event of fire.
Deficiencies (2)
Missing fire sprinkler escutcheon plates in dining rooms on both floors.
Unsealed penetrations or locations in smoke barriers at three locations allowing smoke encroachment.
Report Facts
Residents at risk due to sprinkler deficiency: 25
Residents at risk due to smoke barrier deficiency: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of missing sprinkler escutcheon plates and smoke barrier penetrations during facility tour |
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