Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Life Safety
Census: 73
Capacity: 82
Deficiencies: 0
May 28, 2025
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 Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Census: 73
Total Capacity: 82
Inspection Report
Annual Inspection
Deficiencies: 6
May 22, 2025
Visit Reason
A State Licensure survey was conducted at Pruitthealth Fairburn from May 20, 2025, through May 22, 2025, to assess compliance with state health and safety regulations.
Findings
The survey identified multiple deficiencies including failure to meet professional standards in intravenous antibiotic therapy, improper preparation of puree diets, inadequate infection control practices, failure to document wound measurements, medication safety issues, and physical plant sanitation concerns.
Deficiencies (6)
| Description |
|---|
| Failure to provide care meeting professional standards for intravenous antibiotic therapy for one resident (R124), including improper flushing and antiseptic cap use on PICC line. |
| Failure to follow recipe and use measurement devices when preparing puree food for three residents, risking inconsistent texture and nutritional imbalance. |
| Failure to ensure appropriate infection control practices for one resident (R40), including inadequate hand hygiene and improper cleaning of reusable medical equipment. |
| Failure to document wound measurements weekly for one resident (R40) receiving wound care, risking deterioration and infection. |
| Failure to ensure all medications were taken and not left unattended for one resident (R224), risking incorrect medication dosage. |
| Failure to properly date, label, and store food items; failure to clean ice machine; and failure to perform proper hand hygiene during food handling, potentially affecting 68 residents. |
Report Facts
Residents receiving puree diet: 7
Residents sampled for infection control: 36
Residents sampled for medication safety: 36
Residents affected by physical plant deficiencies: 68
Brief Interview for Mental Status (BIMS) score: 4
Brief Interview for Mental Status (BIMS) score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Nurse (RN) | Named in intravenous antibiotic therapy deficiency for improper PICC line flushing and medication administration. |
| NN | Interim Infection Preventionist (IP) Registered Nurse (RN) | Provided information on PICC line protocols and infection prevention training. |
| FF | Registered Nurse (RN) | Observed performing wound care with deficient infection control practices and interviewed regarding wound care documentation. |
| AA | Licensed Practical Nurse (LPN) | Confirmed medication left unattended at bedside and documented resident spitting out medication. |
| OO | Dietary Aide | Observed preparing puree food without recipe and improper glove use. |
| PP | Dietary Aide | Interviewed about puree food preparation practices. |
| DM | Dietary Manager | Confirmed food safety deficiencies and expectations for recipe adherence and contamination prevention. |
| DHS | Director of Health Services | Provided expectations regarding medication administration and resident safety. |
| ADHS | Assistant Director of Health Services | Provided expectations regarding medication administration and resident safety. |
| DON | Director of Nursing | Provided information on PICC line care, wound care nurses, and training. |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 10
May 22, 2025
Visit Reason
A recertification survey was conducted from May 20, 2025 through May 22, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written notification for room changes, improper IV antibiotic therapy, unsafe denture storage, inadequate wound care documentation, medication administration errors, oxygen therapy without physician orders, failure to document controlled substances properly, improper puree food preparation, food safety violations, and lapses in infection control practices.
Complaint Details
Complaint Intake Numbers GA0023113, GA00253366, GA00253503, GA00254531, and GA254821 were investigated in conjunction with this standard survey.
Severity Breakdown
SS= D: 7
SS= E: 2
SS= F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide written notification to resident and representative explaining room move. | SS= D |
| Failed to provide care meeting professional standards for IV antibiotic therapy. | SS= E |
| Failed to ensure safe and sanitary storage of dentures. | SS= D |
| Failed to document wound measurements for pressure ulcer wound care. | SS= D |
| Failed to ensure medications were taken and not left unattended on bedside table. | SS= D |
| Failed to have physician's order for oxygen administration and failed to provide correct oxygen flow. | SS= D |
| Failed to document controlled substances immediately after administration. | SS= D |
| Failed to follow recipe and use measurement devices when preparing puree food. | SS= E |
| Failed to ensure food items were properly dated, labeled, stored; ice machine was contaminated; improper hand hygiene while handling food. | SS= F |
| Failed to implement appropriate infection control practices including hand hygiene and disinfecting reusable medical equipment. | SS= D |
Report Facts
Resident census: 70
IV antibiotic dose: 5
Oxygen flow rate: 2
Oxygen flow rate: 3
Puree vegetable serving size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Named in IV antibiotic therapy and controlled substances documentation findings |
| LPN AA | Licensed Practical Nurse | Named in denture storage, medication administration, and oxygen therapy findings |
| Director of Nursing | DON | Interviewed regarding IV antibiotic therapy, oxygen therapy, and controlled substances documentation |
| Director of Health Services | DHS | Interviewed regarding denture storage, medication administration, oxygen therapy, and controlled substances documentation |
| Assistant Director of Health Services | ADHS | Interviewed regarding denture storage, medication administration, oxygen therapy, and controlled substances documentation |
| Dietary Aide OO | Dietary Aide | Observed and interviewed regarding puree food preparation and hand hygiene |
| Dietary Manager | DM | Interviewed regarding puree food preparation and food safety |
| LPN CC | Licensed Practical Nurse | Named in infection control finding for failure to disinfect equipment |
| RN FF | Registered Nurse | Observed and interviewed regarding wound care and infection control |
| IP RN NN | Infection Preventionist | Interviewed regarding infection control training and practices |
Inspection Report
Annual Inspection
Deficiencies: 6
May 22, 2025
Visit Reason
A State Licensure survey was conducted at Pruitthealth Fairburn from May 20, 2025, through May 22, 2025, to assess compliance with state health and safety regulations.
Findings
The survey identified multiple deficiencies including failure to meet professional standards in intravenous antibiotic therapy, improper preparation of puree diets, inadequate infection control practices, failure to document wound measurements, medication safety issues, and physical plant sanitation concerns.
Deficiencies (6)
| Description |
|---|
| Failure to provide care meeting professional standards for intravenous antibiotic therapy for one resident (R124), risking infection and sepsis. |
| Failure to follow recipes and use measurement devices when preparing puree food for three residents, risking nutritional imbalance and aspiration. |
| Failure to ensure appropriate infection control practices for one resident (R40), including hand hygiene and equipment disinfection, risking disease transmission. |
| Failure to document wound measurements for one resident (R40) receiving wound care, risking wound deterioration and sepsis. |
| Failure to ensure medications were taken and not left unattended for one resident (R224), risking incorrect medication dosage. |
| Failure to properly date, label, and store food items; failure to clean ice machine; and improper hand hygiene during food handling, risking contamination for 68 residents. |
Report Facts
Residents receiving puree diet: 7
Residents sampled: 36
Residents affected by physical plant deficiencies: 68
Medication dosage: 2
Vitamin D3 dosage: 2
Wound care measurement last documented: Jan 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Administered ceftriaxone incorrectly and failed to follow PICC line protocol. |
| RN NN | Interim Infection Preventionist | Provided information on PICC line protocols and infection control training. |
| DON | Director of Nursing | Provided information on PICC care, wound care nurses, and training. |
| LPN CC | Licensed Practical Nurse | Failed to disinfect blood pressure machine and misunderstood equipment covering protocol. |
| RN FF | Registered Nurse | Observed performing wound care improperly and confirmed wound assessment expectations. |
| LPN AA | Licensed Practical Nurse | Confirmed medication left unattended at bedside and documented resident spitting out medication. |
| Dietary Aide OO | Dietary Aide | Observed not following puree food recipe and improper glove use. |
| Dietary Manager | Dietary Manager | Confirmed food safety deficiencies and expectations for recipe adherence and contamination prevention. |
| DHS | Director of Health Services | Stated expectations for medication administration and resident supervision. |
| ADHS | Assistant Director of Health Services | Stated expectations that no pills be left at residents' bedside. |
| Administrator | Stated all staff expected to follow guidelines and proper procedures. |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 10
May 22, 2025
Visit Reason
A recertification survey was conducted from May 20, 2025 through May 22, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with multiple deficiencies including failure to provide written notification for room changes, improper IV antibiotic therapy, unsafe denture storage, incomplete wound care documentation, medication administration errors, oxygen therapy without physician orders, improper controlled substance documentation, failure to follow puree food recipes, improper food storage and hygiene, and inadequate infection control practices.
Complaint Details
Complaint Intake Numbers GA0023113, GA00253366, GA00253503, GA00254531, and GA254821 were investigated in conjunction with this standard survey.
Severity Breakdown
SS= D: 7
SS= E: 2
SS= F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to provide written notification to resident and representative regarding room change. | SS= D |
| Failure to provide care meeting professional standards for IV antibiotic therapy. | SS= E |
| Failure to ensure safe and sanitary storage of dentures. | SS= D |
| Failure to document wound measurements for pressure ulcer wound care. | SS= D |
| Failure to ensure medications were taken and not left unattended on bedside table. | SS= D |
| Failure to have physician's order for oxygen administration and failure to provide correct oxygen flow. | SS= D |
| Failure to document controlled substances immediately after administration. | SS= D |
| Failure to follow puree food recipe and use measurement devices. | SS= E |
| Failure to properly date, label, and store food items; failure to clean ice machine; failure to perform proper hand hygiene while handling food. | SS= F |
| Failure to implement appropriate infection control practices including hand hygiene and equipment disinfection. | SS= D |
Report Facts
Resident census: 70
IV antibiotic dose: 5
Oxygen flow rate: 2
Oxygen flow rate: 3
Medication doses: 3
Puree vegetable serving size: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Named in IV antibiotic therapy and controlled substance documentation deficiencies |
| LPN AA | Licensed Practical Nurse | Named in medication administration and oxygen therapy deficiencies |
| Director of Health Services | Named in medication administration, oxygen therapy, and controlled substance documentation deficiencies | |
| Assistant Director of Health Services | Named in medication administration and oxygen therapy deficiencies | |
| Dietary Aide OO | Named in puree food preparation and food hygiene deficiencies | |
| Dietary Manager | Named in puree food preparation and food hygiene deficiencies | |
| LPN CC | Licensed Practical Nurse | Named in infection control deficiency related to equipment disinfection |
| RN FF | Registered Nurse | Named in wound care and infection control deficiencies |
| Interim Infection Preventionist RN NN | Infection Preventionist | Named in infection control deficiency |
Inspection Report
Routine
Deficiencies: 6
May 22, 2025
Visit Reason
A State Licensure survey was conducted at Pruitthealth Fairburn from May 20, 2025, through May 22, 2025, to assess compliance with state health and safety regulations.
Findings
The survey identified multiple deficiencies including failure to meet professional standards in intravenous antibiotic therapy, improper preparation of puree diets, inadequate infection control practices, failure to document wound measurements, medication safety issues, and physical plant sanitation concerns.
Deficiencies (6)
| Description |
|---|
| Failure to provide care meeting professional standards for intravenous antibiotic therapy for one resident (R124), risking infection and sepsis. |
| Failure to follow recipes and use measurement devices when preparing puree food for three residents, risking nutritional imbalance and aspiration. |
| Failure to implement appropriate infection control practices for one resident (R40), including hand hygiene and equipment disinfection. |
| Failure to document wound measurements for one resident (R40) receiving wound care, risking wound deterioration and sepsis. |
| Failure to ensure medications were taken and not left unattended for one resident (R224), risking incorrect medication dosage. |
| Failure to ensure proper dating, labeling, storage of food items, cleanliness of ice machine, and proper hand hygiene during food handling, affecting 68 residents. |
Report Facts
Residents receiving puree diet: 7
Residents sampled for infection control: 36
Residents receiving wound care: 7
Residents sampled for medication safety: 36
Residents affected by physical plant deficiencies: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Registered Nurse (RN) | Named in intravenous antibiotic therapy deficiency and infection control observation. |
| NN | Interim Infection Preventionist (IP) RN | Provided information on PICC line protocols and infection control training. |
| FF | Registered Nurse (RN) | Observed performing wound care with deficiencies and interviewed regarding wound care documentation. |
| AA | Licensed Practical Nurse (LPN) | Observed and interviewed regarding medication left unattended at bedside. |
| OO | Dietary Aide | Observed and interviewed regarding puree food preparation and hand hygiene. |
| PP | Dietary Aide | Interviewed regarding puree food preparation practices. |
| DM | Dietary Manager | Interviewed regarding food safety and puree food preparation deficiencies. |
| DHS | Director of Health Services | Interviewed regarding medication administration expectations. |
| ADHS | Assistant Director of Health Services | Interviewed regarding medication administration expectations. |
| DON | Director of Nursing | Interviewed regarding PICC care, wound care nurses, and wound care documentation. |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 10
May 22, 2025
Visit Reason
A recertification survey was conducted from May 20, 2025 through May 22, 2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to provide written notification for room changes, improper IV antibiotic therapy, unsafe denture storage, inadequate wound care documentation, medication administration errors, oxygen therapy without physician orders, failure to document controlled substances properly, improper puree food preparation, food safety violations, and lapses in infection control practices.
Complaint Details
Complaint Intake Numbers GA0023113, GA00253366, GA00253503, GA00254531, and GA254821 were investigated in conjunction with this standard survey.
Severity Breakdown
SS= D: 6
SS= E: 2
SS= F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide written notification to resident and representative regarding room change. | SS= D |
| Failed to provide care meeting professional standards for IV antibiotic therapy, including incorrect flushing and missing antiseptic cap. | SS= E |
| Failed to ensure safe and sanitary storage of dentures; dentures found on unclean surface and not in labeled container. | SS= D |
| Failed to document wound measurements weekly for resident with pressure ulcer, risking wound deterioration. | SS= D |
| Failed to ensure medications were taken and not left unattended, risking incorrect dosage. | SS= D |
| Failed to have physician's order for oxygen administration and failed to provide correct oxygen flow for two residents. | SS= D |
| Failed to document controlled substances immediately after administration for three residents, risking medication errors. | SS= D |
| Failed to follow recipe and use measurement devices when preparing puree food, risking inconsistent texture and nutritional imbalance. | SS= E |
| Failed to ensure food items were properly dated, labeled, and stored; ice machine contaminated; improper hand hygiene during food handling. | SS= F |
| Failed to implement appropriate infection control practices including hand hygiene and disinfection of reusable medical equipment. | SS= D |
Report Facts
Resident census: 70
IV flush volume: 5
Oxygen flow rate: 2
Oxygen flow rate: 3
Medication doses: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Named in IV antibiotic therapy and controlled substances documentation findings |
| LPN AA | Licensed Practical Nurse | Named in denture storage and medication administration findings |
| ADHS | Assistant Director of Health Services | Interviewed regarding oxygen therapy and medication administration expectations |
| DHS | Director of Health Services | Interviewed regarding controlled substances and oxygen therapy findings |
| RN FF | Registered Nurse | Named in wound care and infection control findings |
| LPN CC | Licensed Practical Nurse | Named in infection control and oxygen therapy findings |
| Dietary Aide OO | Dietary Aide | Named in puree food preparation and food safety findings |
| Dietary Manager | Dietary Manager | Named in puree food preparation and food safety findings |
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Aug 15, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00242898 and GA00236701.
Findings
Complaint GA00242898 was unsubstantiated, and complaint GA00236701 was substantiated. No regulatory violations were cited during the survey.
Complaint Details
Complaint GA00242898 was unsubstantiated. Complaint GA00236701 was substantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for the facility PRUITTHEALTH - FAIRBURN, summarizing deficiencies identified during a survey completed on 11/21/2023.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 71
Deficiencies: 0
Nov 21, 2023
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a prior inspection.
Findings
The revisit survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B. Deficiencies were identified related to the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 20, 2023
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 deficiencies have been corrected during the follow-up survey.
Inspection Report
Routine
Deficiencies: 1
Oct 5, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth Fairburn Healthcare Center from October 2, 2023 through October 5, 2023 to assess compliance with state health regulations.
Findings
The facility failed to ensure hand hygiene was performed during medication administration for two of five residents observed, posing a potential infection risk. Interviews with staff confirmed the deficiency and expectations for hand hygiene during medication passes.
Deficiencies (1)
| Description |
|---|
| Failure to perform hand hygiene during medication administration for two of five residents observed. |
Report Facts
Residents observed during medication administration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Did not sanitize hands prior to medication administration as observed. |
| UM1 | Unit Manager | Observed and confirmed RN2's failure to perform hand hygiene. |
| CNC1 | Clinical Nurse Consultant | Stated expectation that nurses perform hand hygiene during medication pass. |
| Director of Nursing | Director of Nursing | Stated expectation that staff follow hand hygiene during medication administration. |
Inspection Report
Routine
Census: 72
Deficiencies: 5
Oct 5, 2023
Visit Reason
A standard survey was conducted from October 2 through October 5, 2023, including investigation of two complaint intake numbers which were found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to resolve resident grievances about food quality, late medication administration, failure to serve hot and palatable food, failure to inform residents about arbitration agreement provisions, and failure to perform hand hygiene during medication administration.
Complaint Details
Complaint Intake Numbers GA00235007 and GA00228687 were investigated and found to be unsubstantiated.
Severity Breakdown
E: 3
F: 1
D: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to act to resolve resident council grievances regarding food being cold and unpalatable for 13 of 18 sampled residents. | E |
| Failure to ensure two of five residents received medications within the hour before or after the ordered time. | E |
| Failure to serve food that was palatable and hot to 4 of 18 sampled residents. | E |
| Failure to inform three sampled residents and/or their representatives that arbitration agreements survive the death of the patient and remain in effect after other agreements are terminated. | F |
| Failure to ensure hand hygiene was performed during medication administration for two of five residents observed. | D |
Report Facts
Resident census: 72
Number of sampled residents with food grievance: 13
Number of residents observed for medication timing: 5
Number of residents interviewed for food palatability: 18
Number of residents reviewed for arbitration agreement: 3
Number of residents observed for hand hygiene: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Observed administering medications late and failing to perform hand hygiene during medication administration |
| UM1 | Unit Manager | Observed medication administration and confirmed late medication and hand hygiene issues |
| LPN1 | Licensed Practical Nurse | Observed administering medications late |
| CNC1 | Clinical Nurse Consultant | Provided information on medication administration expectations |
| DON | Director of Nursing | Stated expectations for medication administration timing and hand hygiene |
| Dietary Manager | Provided information on meal delivery issues and food temperatures | |
| Administrator | Acknowledged resident complaints about food quality and temperature | |
| Regional Admission Director | Discussed arbitration agreement signing process and lack of explanation of certain provisions | |
| Former Admission Coordinator | Explained arbitration agreement to residents but was unfamiliar with survival clause |
Inspection Report
Life Safety
Census: 72
Capacity: 82
Deficiencies: 3
Oct 4, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in self-closing fire/smoke doors, exit signage illumination, and sprinkler system maintenance. Specific issues included a broken self-closing door in the laundry, a non-illuminated exit sign in the 200 hallway, and a sprinkler head in a loaded condition in the kitchen manager's office.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire/smoke door and self-closure at the laundry found broken and parts missing. | SS= D |
| Exit sign in the 200 hallway not illuminated in AC power mode. | SS= D |
| Sprinkler head in the kitchen manager's office found to be in a loaded condition. | SS= D |
Report Facts
Census: 72
Total Capacity: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Abbreviated Survey
Census: 68
Deficiencies: 0
Feb 16, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Survey investigating complaints #GA00227951, #GA00225843, #GA00225736, and #GA00224740 was conducted.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Complaint Details
Complaints #GA00227951, #GA00225843, #GA00225736, and #GA00224740 were unsubstantiated with no regulatory violations cited.
Report Facts
Complaints investigated: 4
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Aug 5, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/12/22 Complaint Survey.
Findings
All deficiencies cited as a result of the 5/12/22 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 5/12/22; all cited deficiencies were corrected.
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 0
May 12, 2022
Visit Reason
A revisit survey was conducted from 5/9/22 through 5/12/22 to verify correction of previous deficiencies and to investigate complaints GA00223551 and GA00223792.
Findings
All deficiencies cited in the 3/10/22 Standard Survey were found to be corrected. The complaint investigation found the complaints substantiated with deficiencies.
Complaint Details
Complaint Intake Numbers GA00223551 and GA00223792 were investigated and found substantiated with deficiencies.
Report Facts
Facility census: 50
Inspection Report
Abbreviated Survey
Census: 54
Deficiencies: 2
May 12, 2022
Visit Reason
An abbreviated/partial extended survey was conducted from May 9 to May 12, 2022, investigating complaints GA00223551 and GA00223792. Complaint GA00219665 was unsubstantiated, while the other two complaints were substantiated with deficiencies.
Findings
The facility failed to provide adequate Activities of Daily Living (ADL) care and sufficient nursing staff for dependent residents, resulting in residents being left soiled for extended periods and delays in care. Staffing shortages were noted, especially after the facility stopped using agency staff in April 2022, impacting resident care and timely assistance.
Complaint Details
The survey was complaint-related, investigating complaints GA00223551 and GA00223792 which were substantiated with deficiencies. Complaint GA00219665 was unsubstantiated.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure dependent residents were provided ADL care related to incontinence and dressing for two of seven sampled residents. | D |
| Failure to provide sufficient nursing staff with appropriate competencies and skills to assure resident safety and meet care needs. | D |
Report Facts
Resident census: 54
Number of sampled residents with deficiencies: 2
Number of missed outpatient therapy appointments: 12
Number of residents per CNA: 25
Staffing on day shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding staffing shortages and workload |
| CC | Certified Nursing Assistant (CNA) | Interviewed about rounding expectations and staffing challenges |
| BBB | Anonymous Staff | Reported witnessing residents left soiled for entire shifts and staffing shortages |
| Administrator | Interviewed about grievances and staffing issues | |
| Director of Nursing (DON) | Interviewed about staffing expectations and rounds |
Inspection Report
Deficiencies: 0
May 12, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility PRUITTHEALTH - FAIRBURN, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies beyond the statement of deficiencies heading.
Inspection Report
Routine
Census: 60
Deficiencies: 8
Mar 10, 2022
Visit Reason
A standard routine survey was conducted from March 7, 2022 through March 10, 2022, including investigation of complaint intake numbers GA00216521, GA00216299, and GA00216477.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to develop comprehensive care plans for residents, incomplete discharge summaries, medication administration errors, failure to provide appropriate range of motion treatments, improper respiratory care including oxygen administration, medication record discrepancies, unsecured medications, and unsanitary kitchen conditions.
Complaint Details
Complaint Intake Numbers GA00216521, GA00216299, and GA00216477 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 7
SS= E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop and implement comprehensive care plans reflecting residents' needs for oxygen therapy and contracture treatment. | SS= D |
| Failure to complete a recapitulation of stay in discharge summary for a discharged resident. | SS= D |
| Failure to ensure medication administration followed professional standards; nurse prepared and administered medications for two residents simultaneously and did not ensure chewable medications were administered properly. | SS= D |
| Failure to provide appropriate treatment and services to maintain or improve range of motion for a resident with limited mobility. | SS= D |
| Failure to ensure respiratory care was provided according to physician orders; oxygen flow rates were incorrect and respiratory equipment was improperly stored and not dated for change. | SS= D |
| Failure to maintain accurate controlled medication records; narcotic count did not reconcile with medication record. | SS= D |
| Failure to securely store medications; medication cart was left unlocked and unattended, loose and unidentified pills were found in medication cart drawers, and medications were left unattended on nurses' station and medication carts. | SS= D |
| Failure to maintain sanitary conditions in the kitchen; greasy and dirty floors, missing grout, dust and food debris on floor mats, uncovered and dirty meat slicer, splashes on walls and ceiling, dirty doorbell device, dirty fan, food debris on freezer floor, and lack of cleaning schedules. | SS= E |
Report Facts
Resident census: 60
Tramadol tablets counted: 23
Tramadol tablets recorded: 24
Oxygen flow rate: 2
Oxygen flow rate observed: 0.5
Oxygen flow rate observed: 1.5
Number of unidentified loose pills: 7.5
Number of residents affected by unsanitary kitchen conditions: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Confirmed resident #217 was not administered oxygen per physician's order and oxygen tubing was not dated. |
| Director of Nursing | Director of Nursing | Verified multiple deficiencies including oxygen administration, medication cart security, and medication record keeping. |
| LPN1 | Licensed Practical Nurse | Observed preparing and administering medications for two residents simultaneously and administering chewable medication incorrectly. |
| Therapy Outcomes Coordinator | Therapy Outcomes Coordinator | Confirmed failure to provide range of motion exercises and splints for resident #5. |
| Assistant Director of Nursing | Assistant Director of Nursing | Counted narcotics and confirmed discrepancy in controlled medication record for resident #26. |
| LPN4 | Licensed Practical Nurse | Admitted leaving medication cart unlocked and unattended. |
| LPN5 | Licensed Practical Nurse | Admitted leaving medication cart unlocked and unattended due to staffing and workload. |
| Dietary Manager | Dietary Manager | Confirmed lack of cleaning schedule and inadequate cleaning in kitchen. |
| Maintenance Director | Maintenance Director | Confirmed last power wash of kitchen floor was in January 2022. |
| Administrator | Administrator | Expressed expectation for more frequent kitchen cleaning. |
Inspection Report
Original Licensing
Deficiencies: 6
Mar 10, 2022
Visit Reason
A Licensure Survey was conducted from March 7, 2022 through March 10, 2022 to assess compliance with state regulations for the facility.
Findings
The survey identified multiple deficiencies including failure to complete a recapitulation of stay for a discharged resident, medication management issues such as unsecured medication carts and unaccounted controlled substances, incomplete care plans for residents regarding oxygen therapy and range of motion treatments, and unsanitary kitchen conditions affecting food safety.
Deficiencies (6)
| Description |
|---|
| Failure to complete a recapitulation of stay for one discharged resident (R#47). |
| Failure to maintain and account for controlled medication records and secure medication storage for multiple residents. |
| Medication carts left unlocked and unattended, and presence of unidentified loose pills in medication carts. |
| Failure to develop comprehensive care plans reflecting oxygen therapy needs for resident R#217. |
| Failure to provide treatment and care including range of motion exercises and splints for resident R#5 with contractures. |
| Failure to maintain sanitary conditions in the kitchen, including greasy floors, missing grout, dust and food debris on equipment and surfaces, and lack of cleaning schedules. |
Report Facts
Residents with medication storage issues: 4
Residents reviewed for discharge: 3
Residents sampled for care plans: 22
Residents affected by kitchen sanitation issues: 53
Medication carts observed: 3
Medication doses counted: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Administered medication without recording on controlled medication record. |
| Licensed Practical Nurse 4 | LPN | Left medication cart unlocked and unattended on 300-hall. |
| Licensed Practical Nurse 5 | LPN | Left medication cart unlocked and unattended due to workload. |
| Director of Nursing | Director of Nursing (DON) | Confirmed medication cart should always be locked and verified deficiencies. |
| Licensed Practical Nurse 6 | LPN | Confirmed narcotic medication removal should be accounted for on controlled medication record. |
| Licensed Practical Nurse 1 | LPN | Confirmed medication should not be left unattended on medication cart. |
| Licensed Practical Nurse 2 | LPN | Confirmed medications should not be left unattended on nurses' station. |
| Registered Nurse 1 | RN | Verified medication cart was left unlocked and unattended. |
| Therapy Outcomes Coordinator | Therapy Outcomes Coordinator (TOC) | Confirmed care plan deficiencies and therapy referral failures for resident R#5. |
| Dietary Manager | Dietary Manager (DM) | Confirmed lack of cleaning schedule and unsanitary kitchen conditions. |
| Maintenance Director | Maintenance Director (MD) | Provided information on power wash cleaning schedule for kitchen floors. |
| Administrator | Administrator | Expressed expectations for improved kitchen cleanliness. |
Inspection Report
Life Safety
Census: 60
Capacity: 82
Deficiencies: 0
Mar 8, 2022
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 compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Routine
Census: 51
Deficiencies: 0
Jan 28, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 46
Deficiencies: 0
Jan 14, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00207522, #GA00204942, #GA00208113, and #GA00208185 between January 11 and January 14, 2021.
Findings
Complaints #GA00207522, #GA00204942, and #GA00208113 were unsubstantiated with no deficiencies found. Complaint #GA00208185 was substantiated but with no deficiencies identified.
Complaint Details
Four complaints were investigated: #GA00207522, #GA00204942, #GA00208113, and #GA00208185. Three complaints were unsubstantiated with no deficiencies, and one complaint was substantiated with no deficiencies.
Report Facts
Complaints investigated: 4
Census: 46
Inspection Report
Routine
Census: 50
Deficiencies: 0
Dec 29, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 28, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00209923 and #GA00209963.
Findings
The complaints #GA00209923 and #GA00209963 were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00209923 and #GA00209963 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 43
Deficiencies: 0
Oct 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and 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 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 65
Deficiencies: 0
Aug 4, 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 to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 70
Deficiencies: 0
Jul 14, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at PruittHealth Fairburn on July 14, 2020.
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, including implementation of CMS and CDC recommended practices for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 2, 2020
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 deficiencies had been corrected during the follow-up visit.
Inspection Report
Renewal
Deficiencies: 0
Jan 30, 2020
Visit Reason
The inspection was conducted as a Licensure Survey to assess compliance for renewal of the facility's license.
Findings
No deficiencies were identified during the Licensure Survey.
Inspection Report
Routine
Census: 69
Deficiencies: 0
Jan 30, 2020
Visit Reason
A standard survey was conducted at PruittHealth-Fairburn from January 27, 2020 through January 30, 2020. In addition, Complaint Intake Number GA00202071 was investigated in conjunction with this standard survey.
Findings
The standard survey revealed that the facility was in compliance with the Health portion of the Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Complaint Intake Number GA00202071 was investigated in conjunction with this standard survey.
Inspection Report
Life Safety
Census: 71
Capacity: 82
Deficiencies: 1
Jan 28, 2020
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) standards.
Findings
The facility was found not in substantial compliance with fire safety requirements due to failure to maintain the sprinkler system in the laundry area, which posed a risk to 10 staff and residents. Specifically, sprinkler heads had moderate levels of loading, indicating inadequate maintenance.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assure proper minimum maintenance on the fire sprinkler system in the laundry area, with two sprinkler heads having moderate levels of loading and a third in the beginning stages of loading. | SS=E |
Report Facts
Census: 71
Total Capacity: 82
Staff and residents at risk: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of sprinkler system loading during facility tour |
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Sep 19, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00197654, GA00198272, and GA00198759 to determine compliance with Federal and State Long Term Care Requirements.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Complaint Details
The survey was complaint-related, investigating three complaints which were ultimately unsubstantiated.
Report Facts
Resident Census: 78
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Jun 20, 2019
Visit Reason
An abbreviated survey was conducted to investigate three complaint allegations identified as GA00196747, GA00196016, and GA00197239.
Findings
The investigation concluded with no deficiencies substantiated related to the complaints.
Complaint Details
The abbreviated survey investigated three complaints (GA00196747, GA00196016, GA00197239) and none were substantiated with deficiencies.
Report Facts
Complaint investigations: 3
Census: 78
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00192996 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00192996 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Census: 78
Deficiencies: 0
Oct 15, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/16/18 recertification survey.
Findings
All deficiencies cited as a result of the 8/16/18 recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 5, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags and deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags and deficiencies had been corrected as of the follow-up survey date.
Inspection Report
Routine
Census: 73
Deficiencies: 8
Aug 16, 2018
Visit Reason
A standard survey was conducted at PruittHealth-Fairburn from August 13, 2018 through August 16, 2018, including investigation of Complaint Intake Number GA00190201.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations. Deficiencies included failure to accommodate resident needs such as call light accessibility, incomplete baseline and comprehensive care plans, failure to follow activity plans, failure to update care plans after incidents, unsafe transfer practices resulting in a tibia fracture, improper use of medical equipment causing injury, psychotropic medication orders not limited to 14 days or lacking rationale for extension, and food safety violations including expired and unlabeled food in the walk-in cooler.
Complaint Details
Complaint Intake Number GA00190201 was investigated in conjunction with the standard survey.
Severity Breakdown
Level D: 4
Level F: 1
Level G: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to keep call light within reach for resident #45. | Level D |
| Baseline care plan for newly admitted resident #E incomplete and lacking goals and interventions based on physician orders. | Level D |
| Failure to follow activity plans for residents #45, #66, and #69. | Level D |
| Failure to revise care plan to reflect actual harm to resident #C who sustained a tibia fracture and failure to invite resident #45 to care plan meetings. | Level G |
| Failure to ensure safe environment and supervision resulting in resident #C's tibia fracture during transfer by one staff member instead of two as per care plan. | Level G |
| Failure to ensure safe use of Continuous Passive Motion (CPM) machine by resident #E resulting in injury to left hand. | Level G |
| Psychotropic medications for resident #4 were not ordered as needed (PRN) limited to 14 days and lacked documented rationale for extension. | Level D |
| Failure to discard thawed expired meat and failure to properly label and date food items in walk-in cooler. | Level F |
Report Facts
Resident census: 73
Deficiency counts: 8
PRN psychotropic medication administration days: 25
Date of incident: 2018
Date of incident: 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in transfer injury to resident #C and CPM injury to resident #E |
| LPN DD | Case Mix Director | Responsible for care plan updates and assessments |
| LPN HH | Case Mix Director | Responsible for care plan meetings and assessments |
| CNA GG | Certified Nursing Assistant | Interviewed regarding resident #45's activity participation and call light use |
| PTA II | Physical Therapy Aide | Interviewed regarding CPM machine use and staff education |
| CCC | Clinical Competency Coordinator | Responsible for staff in-services, including CPM machine education |
| DHS | Director of Health Services | Interviewed regarding transfer injury and CPM injury |
| NP CC | Nurse Practitioner | Provided medical care and follow-up for resident #C's fracture |
| LPN EE | Licensed Practical Nurse | Interviewed regarding psychotropic medication orders |
| ADHS | Assistant Director of Health Services | Interviewed regarding medication order management |
Inspection Report
Annual Inspection
Deficiencies: 5
Aug 16, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare facility regulations, including nursing care, care planning, resident activities, injury prevention, equipment use, and food safety.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within residents' reach, incomplete and altered care plans, inadequate participation of residents in activities, improper transfer techniques leading to resident injury, lack of staff education on equipment use resulting in resident injury, and food safety violations due to lack of dietary manager and improper food storage.
Deficiencies (5)
| Description |
|---|
| Call lights were consistently found out of reach of resident #45, and staff lacked a policy to ensure call lights were accessible. |
| Care plans for residents #45, #66, and #69 were incomplete, altered without documentation, or not followed, resulting in inadequate social and activity engagement. |
| Resident 'C' sustained a tibial fracture during a manual transfer by a CNA who did not follow the two-person mechanical lift care plan; staff lacked proper training and failed to notify nurses appropriately. |
| Resident 'E' sustained a hand injury from improper use of a Continuous Passive Motion (CPM) machine; staff were not properly trained on equipment use and resident was allowed to self-apply the device. |
| The facility lacked a Dietary Manager for two weeks; food safety violations included spoiled meat in the walk-in cooler and unlabeled, undated boiled eggs. |
Report Facts
Date of survey completion: Aug 16, 2018
BIMS score: 10
BIMS score: 13
Fracture date: Jul 1, 2018
Fracture follow-up appointment: Sep 20, 2018
In-service training date: Jul 2, 2018
Food expiration date on spoiled turkey: Aug 1, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA GG | Certified Nursing Assistant | Reported resident #45 did not use call light and did not take residents #66 and #69 to activities |
| CNA AA | Certified Nursing Assistant | Manually transferred resident 'C' causing injury; reported resident 'E' hand injury from CPM machine |
| Director of Health Services | Reported knowledge of resident 'C' injury and expectations for staff to follow care plans | |
| Medical Director | Notified of resident injury but had not seen resident since accident | |
| Nurse Practitioner CC | Nurse Practitioner | Saw resident 'C' after injury and ordered x-rays and hospital transfer |
| Physical Therapy Aide II | Physical Therapy Aide | Reported lack of staff training on CPM machine and educated resident on its use |
| CCC | Clinical Competency Coordinator | Responsible for staff in-services; confirmed no in-service on CPM machine application |
| Administrator | Reported facility lacked Dietary Manager for two weeks |
Inspection Report
Life Safety
Census: 74
Capacity: 82
Deficiencies: 6
Aug 14, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with the Life Safety Code due to multiple deficiencies including non-functioning emergency lighting, missing sprinkler system components, resident room doors unable to latch, smoke barrier penetrations, smoke doors not closing properly, and presence of an unauthorized portable space heater.
Severity Breakdown
D: 4
E: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Emergency lighting unit outside resident hallway failed to illuminate on test mode. | D |
| Missing sprinkler system escutcheon plate in the kitchen may allow extensive fire growth. | E |
| Resident room doors (Rooms 108 and 313) unable to latch closed, failing to resist passage of smoke. | E |
| Several ceiling penetrations found in rated ceiling in sprinkler riser room, compromising smoke barrier. | D |
| Smoke door for hallway 200 would not close completely shut during fire alarm activation tests. | D |
| Portable space heater found in dietary manager's office without documentation of heating element temperature compliance. | D |
Report Facts
Staff and residents at risk: 48
Staff and residents at risk: 35
Staff and residents at risk: 30
Staff at risk: 8
Staff and residents at risk: 55
Staff at risk: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00188406 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00188406 was investigated and found to have no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 11, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00182793.
Findings
The complaint was investigated and found to be unsubstantiated.
Complaint Details
Complaint GA00182793 was investigated and determined to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 20, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00180978 at Pruitt Health-Fairburn.
Findings
The complaint was not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00180978 was investigated and found to be not substantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 13, 2017
Visit Reason
A revisit survey was conducted on 10/13/17 for the survey of 8/4/17 to verify correction of previously cited deficiencies.
Findings
All previously cited deficiencies were found to be corrected. The facility was in compliance on 9/5/17.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 26, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 73
Capacity: 82
Deficiencies: 3
Aug 1, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain sprinkler system documentation and readiness, and corridor doors that did not properly resist smoke passage, placing staff and residents at risk.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Sprinkler system maintenance and testing records were incomplete; date last checked, tester, and water supply source were not provided. | SS=E |
| Loaded sprinkler heads were present in laundry and kitchen areas, and the fire sprinkler riser lacked a data design information plate. | SS=E |
| Two resident doors (Rooms #212 and #116) would not close and latch properly to resist smoke passage. | SS=E |
Report Facts
Staff at risk: 10
Residents at risk: 24
Census: 73
Total licensed beds: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2017
Visit Reason
The inspection was conducted as a complaint investigation for complaints GA0017291 and GA00172707.
Findings
The complaint investigation found no deficient practices at the facility.
Complaint Details
Complaints GA0017291 and GA00172707 were investigated and found to have no deficient practices.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2017
Visit Reason
The inspection was conducted to investigate complaint # GA00171452 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted from 2/9/17 through 2/10/17.
Complaint Details
Complaint # GA00171452 was investigated and found to have no deficiencies.
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