Inspection Reports for Pruitthealth – Griffin

619 NORTHSIDE DRIVE, GA, 30223

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Deficiencies per Year

16 12 8 4 0
2017
2018
2019
2020
2021
2022
2023
2024
Moderate Low Unclassified

Census Over Time

20 40 60 80 Jul '17 Mar '19 Jan '21 May '22 Sep '23 Apr '24 Oct '24
Census Capacity
Inspection Report Complaint Investigation Census: 50 Deficiencies: 2 Oct 22, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints (GA00245693, GA00246151, GA00246863, GA00247101, and GA00248512) at the facility.
Findings
The facility failed to ensure money taken from the Resident Trust Account was accounted for and used for resident needs for 30 of 38 sampled residents. The Financial Counselor misappropriated resident funds totaling $23,717.40. The facility conducted audits, notified law enforcement, terminated the FC, and initiated corrective actions including refunds and monthly audits.
Complaint Details
Complaints GA00246151 and GA00248512 were substantiated with deficiencies. Complaints GA00245693, GA00246863, and GA00247101 were unsubstantiated with no deficiencies cited.
Severity Breakdown
SS=F: 2
Deficiencies (2)
DescriptionSeverity
Failed to ensure money taken from the Resident Trust Account was accounted for and used for resident needs for 30 of 38 sampled residents.SS=F
Failed to prevent misappropriation of residents funds for thirty of thirty-eight sampled residents.SS=F
Report Facts
Residents affected: 30 Amount misappropriated: 23717.4 Census: 50 Residents sampled: 38
Employees Mentioned
NameTitleContext
Financial Counselor (FC)Employee who misappropriated resident funds; employed from 12/18/2023 to 4/29/2024.
Facility DirectorProvided interview details about the financial audit and misappropriation.
Director of Financial AuditsConducted audit that discovered discrepancies in resident trust funds.
Inspection Report Plan of Correction Deficiencies: 0 Apr 18, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - GRIFFIN, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings within the provided page.
Inspection Report Re-Inspection Census: 47 Deficiencies: 1 Apr 18, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies identified in the February 25, 2024 survey.
Findings
The revisit survey found that while all previous deficiencies were corrected, the facility was still not in substantial compliance with Medicare/Medicaid regulations, resulting in new deficiencies.
Deficiencies (1)
Description
Facility was not in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R., Part 43, Subpart B-Requirements for Long Term Care Facilities; specifically related to F759.
Inspection Report Follow-Up Deficiencies: 0 Apr 11, 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: 55 Deficiencies: 7 Feb 25, 2024
Visit Reason
A State Licensure survey was conducted at Pruitthealth-Griffin from February 23, 2024 through February 25, 2024 to assess compliance with state health regulations and facility standards.
Findings
The survey revealed multiple deficiencies including failure to follow recipes for pureed meals, failure to decrease medication dosage as ordered, ineffective infection control practices including lack of COVID-19 signage and cross-contamination risks in laundry, lack of a certified Infection Preventionist, failure to follow care plans for medication dose reduction, environmental sanitation issues such as broken furniture and dust buildup, kitchen sanitation problems including unclean equipment and unlabeled food, and failure to provide or document influenza and pneumococcal vaccinations for several residents.
Deficiencies (7)
Description
Failure to follow recipes for preparing pureed meals compromising nutritive value for seven of 55 residents on a pureed diet.
Failure to decrease dose of buspirone for one resident as ordered by physician.
Failure to maintain effective infection control program including lack of COVID-19 signage, improper linen handling, and absence of a qualified Infection Preventionist.
Failure to follow care plan for medication dose reduction for one resident.
Environmental sanitation deficiencies including broken dresser drawer, missing baseboards, hole in closet door, and dust buildup on air conditioner filters in resident rooms.
Physical plant deficiencies including dirty exhaust hood filters, unlabeled and undated opened food items, unclean kitchen equipment, and peeling ceiling sheetrock.
Failure to provide evidence that four residents were offered or administered influenza and pneumococcal vaccines as required.
Report Facts
Residents on pureed diet affected: 7 Total residents: 55 Residents reviewed for unnecessary medications: 5 Rooms with environmental sanitation issues: 3 Residents with vaccine documentation issues: 4
Employees Mentioned
NameTitleContext
Licensed Practical Nurse (LPN) Unit Manager EELPN Unit ManagerNamed in medication error finding related to failure to decrease buspirone dose.
Director of Health Services (DHS)Director of Health ServicesVerified medication order issues, infection control deficiencies, and vaccination documentation failures.
Assistant Director of Health Services (ADHS)Assistant Director of Health ServicesInvolved in infection control program and medication order follow-up.
Dietary Manager (DM)Dietary ManagerObserved preparing pureed meals improperly and confirmed kitchen sanitation issues.
Laundry SupervisorLaundry SupervisorProvided information on laundry cross-contamination risks.
Maintenance Director (MD)Maintenance DirectorInterviewed regarding environmental sanitation and maintenance issues.
Medical Records ClerkMedical Records ClerkObserved entering clean laundry area improperly.
Admission Director (AD)Admission DirectorResponsible for obtaining vaccine consents; acknowledged missing consents.
AdministratorFacility AdministratorConfirmed awareness of deficiencies and expectations for compliance.
Inspection Report Routine Census: 55 Deficiencies: 15 Feb 25, 2024
Visit Reason
A standard survey was conducted at PruittHealth-Griffin from February 23, 2024 through February 25, 2024, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies in grievance handling, environment maintenance, MDS assessments, PASARR screening, care plan implementation, medication administration, infection control, immunization documentation, and COVID-19 vaccine administration.
Complaint Details
Complaint Intake Numbers GA00239447, GA00239448, GA00239926, GA00240825, GA00242005, and GA00242192 were investigated. All but GA00240825 were unsubstantiated. GA00240825 was substantiated with deficiencies.
Severity Breakdown
E: 5 D: 5 F: 4 C: 1 B: 1
Deficiencies (15)
DescriptionSeverity
Failed to ensure resident grievances were addressed properly.E
Failed to maintain residents' furniture and environment in good and functional condition.E
Failed to complete quarterly MDS assessments timely for three residents.B
Failed to transmit MDS assessments within 14 days of completion for eight residents.C
Failed to ensure Level I PASARR screening was completed prior to admission for one resident with mental illness.D
Failed to follow care plan for unnecessary medications for one resident.D
Failed to transcribe and administer correct doses of Eliquis for one resident.D
Failed to decrease dose of buspirone as ordered for one resident.D
Failed to follow recipes for preparing pureed meals, compromising nutritive value.E
Failed to maintain sanitary kitchen environment including clean hood filters, proper labeling and dating of food, and ceiling maintenance.F
Failed to post COVID-19 signage at facility entrance and maintain proper linen handling to prevent cross-contamination.F
Failed to provide evidence of periodic review and follow-up of antibiotic prescribing practices for ten months.F
Failed to employ a qualified Infection Preventionist.F
Failed to provide evidence that two residents were offered influenza and pneumococcal vaccines and two residents were administered these vaccines after consenting.E
Failed to offer and/or administer COVID-19 vaccine to two residents reviewed for vaccines.D
Report Facts
Residents receiving pureed diet: 7 Residents sampled: 36 Residents with late MDS transmission: 8 Residents with missing vaccine consents: 2 Residents not offered COVID-19 vaccine: 2
Employees Mentioned
NameTitleContext
DHSDirector of Health ServicesNamed in multiple findings including infection control, MDS, vaccine administration, and antibiotic stewardship
ADAdmission DirectorNamed in vaccine consent and admission packet deficiencies
AdministratorFacility AdministratorNamed in infection control and grievance process findings
LPN UM EELicensed Practical Nurse Unit ManagerNamed in medication and vaccine consent follow-up
DMDietary ManagerNamed in pureed food preparation and kitchen sanitation findings
Laundry SupervisorHousekeeper/Laundry SupervisorNamed in laundry sanitation and infection control findings
Inspection Report Life Safety Census: 52 Capacity: 69 Deficiencies: 2 Feb 24, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically failing to secure and mark the Fire Alarm Control Panel breaker and failing to conduct required fire drills for two calendar quarters impacting all shifts.
Severity Breakdown
SS= D: 1 SS= F: 1
Deficiencies (2)
DescriptionSeverity
Failed to place a lock on the Fire Alarm Control Panel breaker and the breaker was not marked in red.SS= D
Failed to conduct fire drills for each calendar quarter for each shift, with missing documentation for the 3rd and 4th quarters of 2023.SS= F
Report Facts
Census: 52 Total Capacity: 69 Missing fire drills quarters: 2
Employees Mentioned
NameTitleContext
Staff MConfirmed findings regarding fire alarm breaker and fire drill documentation
Inspection Report Abbreviated Survey Census: 47 Deficiencies: 0 Sep 25, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (#GA00239315, #GA00236790, GA00236789, GA00224657, and GA00224383).
Findings
Four complaints (#GA00239315, GA00236789, GA00224657, and GA00224383) were unsubstantiated with no deficiencies cited. One complaint (#GA00236790) was substantiated but with no deficiency cited.
Complaint Details
Complaints #GA00239315, GA00236789, GA00224657, and GA00224383 were unsubstantiated. Complaint #GA00236790 was substantiated with no deficiency cited.
Inspection Report Deficiencies: 0 Aug 4, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - GRIFFIN, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report Re-Inspection Census: 40 Deficiencies: 0 Aug 4, 2022
Visit Reason
A revisit survey was conducted from 8/1/22 through 8/4/22 to verify correction of deficiencies cited in the 4/28/22 Standard Survey.
Findings
All deficiencies cited as a result of the 4/28/22 Standard Survey were found to be corrected during this revisit survey.
Inspection Report Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 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 to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified beds: 69 Census: 44
Inspection Report Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 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 Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found to be in compliance with the requirements set forth in 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found compliant.
Report Facts
Certified beds: 69 Census: 44
Inspection Report Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness requirements.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare/Medicaid under 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also compliant with 42 CFR § 483.73.
Inspection Report Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 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 to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report Life Safety Census: 44 Capacity: 69 Deficiencies: 0 May 2, 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 Life Safety Code requirements and the Emergency Preparedness Program met regulatory standards.
Report Facts
Certified beds: 69 Census: 44
Inspection Report Renewal Deficiencies: 5 Apr 28, 2022
Visit Reason
A Licensure Survey was conducted from 04/25/2022 through 04/28/2022 to assess compliance with licensure requirements and facility policies.
Findings
The facility failed to provide adequate assistance with activities of daily living including grooming, nail care, and bowel monitoring for several residents. There was a lack of policy for ADL care and bowel monitoring. One resident did not receive planned restorative nursing services to prevent decline in range of motion. Another resident had inappropriate ongoing use of an indwelling urinary catheter without proper evaluation. Additionally, the facility failed to offer pneumococcal and influenza vaccinations to several residents in accordance with CDC guidelines and had outdated vaccination policies.
Deficiencies (5)
Description
Failure to ensure assistance with grooming, personal clothing, shaving, and nail care for residents 16, 20, 28, and 32.
Failure to ensure adequate bowel monitoring and intervention for resident 27.
Failure to provide planned restorative nursing services to resident 13 to prevent further decrease in range of motion.
Failure to ensure appropriate indication and evaluation for ongoing use of an indwelling urinary catheter for resident 30.
Failure to offer pneumococcal and influenza vaccinations to residents 13, 31, and 39 according to current CDC guidelines.
Report Facts
Sample size: 20 BIMS scores: 3 BIMS scores: 4 BIMS scores: 2 Dates of survey: 4
Employees Mentioned
NameTitleContext
Director of Health ServicesDirector of Health Services (DHS)Acknowledged inadequate ADL care and lack of bowel monitoring policy.
Licensed Practical Nurse Unit ManagerLPN Unit Manager (LPNUM)Acknowledged CNAs provide ADL care but do not monitor task completion; unaware of bowel monitoring policy.
Certified Occupational Therapy AssistantCOTAAcknowledged resident 13 was discharged from OT services and did not know who performed ROM services thereafter.
Physical TherapistPTAcknowledged resident 13's hand contracture and lack of referral for OT services since discharge.
Medical DirectorMedical Director and Primary Care PhysicianOrdered urinary catheter for resident 30 but lacked documentation for ongoing catheter use justification.
Nurse ConsultantNCReported lack of fluid intake/output monitoring and absence of catheter use policies.
Infection PreventionistIPAcknowledged vaccination policies not aligned with CDC guidelines and incomplete vaccination records.
Inspection Report Routine Census: 35 Deficiencies: 0 Jan 27, 2021
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 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report Routine Census: 57 Deficiencies: 0 Jul 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to emergency preparedness and infection control practices.
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 Abbreviated Survey Census: 60 Deficiencies: 0 Dec 30, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was initiated to investigate complaints GA00198360 and GA00198100 to determine compliance with Federal and State Long Term Care Requirements.
Findings
The complaints GA00198360 and GA00198100 were found to be unsubstantiated.
Complaint Details
Complaints GA00198360 and GA00198100 were investigated and found to be unsubstantiated.
Inspection Report Routine Census: 64 Deficiencies: 0 Mar 28, 2019
Visit Reason
A standard survey was conducted at Pruitthealth Griffin from March 25, 2019 through March 28, 2019 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B-Requirements for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations, with some deficiencies noted related to the standard survey.
Inspection Report Life Safety Census: 61 Capacity: 69 Deficiencies: 0 Mar 26, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan met the necessary standards.
Report Facts
Certified beds: 69 Census: 61
Inspection Report Complaint Investigation Deficiencies: 0 Sep 10, 2018
Visit Reason
A complaint survey was conducted on 9/10/18 to investigate complaints #GA00189896 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00189896 was investigated and found to have no deficiencies.
Inspection Report Plan of Correction Deficiencies: 0 May 22, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PruittHealth - Griffin, related to regulatory compliance following an inspection.
Findings
The document does not provide specific findings or deficiencies; it primarily serves as a form for reporting deficiencies and the provider's plan of correction.
Inspection Report Follow-Up Deficiencies: 0 May 21, 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 during this follow-up survey.
Inspection Report Life Safety Census: 58 Capacity: 69 Deficiencies: 1 Mar 28, 2018
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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to maintain smoke barrier walls with a fire resistance rating of at least one-half hour. Observations revealed unsealed and improperly sealed penetrations in smoke barriers, which could place 58 residents at risk in the event of fire.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failed to maintain smoke barrier walls with construction having a fire resistance rating of at least one-half hour, including unsealed penetrations and improper sealing methods.SS=F
Report Facts
Census: 58 Certified beds: 69
Employees Mentioned
NameTitleContext
Staff JConfirmed findings of improperly maintained smoke barriers during facility tour
Inspection Report Re-Inspection Deficiencies: 0 Sep 29, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the FMS Comparative survey conducted from 7/24/17 through 7/27/17.
Findings
All deficiencies cited in the previous survey were found to be corrected, and the facility was in substantial compliance as of 9/19/17.
Inspection Report Complaint Investigation Deficiencies: 0 Sep 20, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00179829 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health Griffin.
Complaint Details
Complaint #GA00179829 was investigated and found to have no deficiencies.
Inspection Report Follow-Up Deficiencies: 0 Aug 29, 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 during the follow-up survey.
Inspection Report Routine Census: 63 Deficiencies: 15 Jul 27, 2017
Visit Reason
A Comparative Federal Monitoring Survey was conducted to assess compliance with 42CFR, Subpart B-Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to post survey results prominently, unsafe medication self-administration, lack of staff knocking before entering rooms, failure to provide written notice before roommate changes, incomplete care plans, failure to monitor resident behaviors related to psychotropic medications, medication errors, infection control lapses, expired medications in medication carts, and inadequate privacy curtains in resident rooms.
Severity Breakdown
Level C: 1 Level D: 8 Level E: 3
Deficiencies (15)
DescriptionSeverity
Failed to post notice of availability of survey results in a prominent location accessible to residents and public.Level C
Failed to ensure one resident was safe to self-administer medications; family brought medications into room without proper assessment or physician orders.Level D
Failed to ensure staff knocked before entering resident rooms during medication pass for three residents.Level D
Failed to provide written notice before roommate change for one resident.Level D
Failed to develop comprehensive care plans addressing medication storage and dental needs for two residents.Level D
Failed to revise care plan after resident to resident altercation for one resident.
Failed to accurately collect toileting data and provide incontinence care to prevent infection for three residents.
Failed to ensure staff washed hands and changed gloves appropriately during resident care.Level D
Failed to provide full visual privacy with curtains in six resident rooms.Level E
Failed to ensure medications were not maintained at bedside for one resident, posing safety risk.Level D
Failed to document physician rationale for continuing anticonvulsant medication without gradual dose reduction for one resident.Level D
Failed to ensure resident received prescribed antidepressant medication for 27 days due to medication order discontinuation error.Level E
Failed to monitor and document specific target behaviors related to psychotropic medication use for one resident.Level E
Failed to ensure resident was provided dental services to evaluate for dentures or other dental needs.Level D
Failed to ensure expired medications were removed from medication cart.Level D
Report Facts
Census: 63 Expired medications: 8 Missed doses: 27 Residents with privacy curtain deficiency: 6
Employees Mentioned
NameTitleContext
LPN #3Licensed Practical NurseNamed in medication self-administration and expired medication findings
LPN #4Licensed Practical NurseNamed in expired medication and hand hygiene findings
LPN #5Licensed Practical NurseNamed in psychotropic medication monitoring and medication error findings
LPN #6Licensed Practical NurseNamed in psychotropic medication monitoring and medication error findings
Director of NursingDirector of NursingNamed in multiple findings including medication errors, psychotropic monitoring, expired medications, and dental services
MDS CoordinatorMDS CoordinatorNamed in care plan and psychotropic medication monitoring findings
CNA #2Certified Nursing AssistantNamed in hand hygiene and infection control findings
CNA #1Certified Nursing AssistantNamed in bladder function documentation findings
Housekeeping DirectorHousekeeping DirectorNamed in privacy curtain deficiency finding
Psych Services Nurse PractitionerNurse PractitionerNamed in psychotropic medication monitoring findings
Inspection Report Routine Census: 64 Deficiencies: 0 Jul 7, 2017
Visit Reason
A standard survey was conducted at Pruitthealth-Griffin from July 5, 2017 to July 7, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report Life Safety Census: 62 Capacity: 69 Deficiencies: 2 Jul 5, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to unsealed penetrations in the sprinkler riser/electrical room and the use of an extension cord as permanent wiring in the kitchen area, both of which could place residents at risk in the event of a fire.
Severity Breakdown
SS= D: 2
Deficiencies (2)
DescriptionSeverity
Failure to properly maintain hazardous area enclosures; unsealed penetrations in the sprinkler riser/electrical room.SS= D
Use of an extension cord as permanent wiring in the kitchen area for the blower motor on the exhaust fan for the stove.SS= D
Report Facts
Residents at risk: 20 Census: 62 Total licensed beds: 69
Employees Mentioned
NameTitleContext
Staff JInterviewed and confirmed findings related to hazardous area enclosures and electrical wiring
Inspection Report Re-Inspection Deficiencies: 0 Apr 10, 2017
Visit Reason
A revisit survey was conducted on 4/10/17 to the Abbreviated Survey conducted on 2/23/17.
Findings
The facility had corrected the cited deficiencies from the prior abbreviated survey.
Inspection Report Abbreviated Survey Deficiencies: 3 Feb 23, 2017
Visit Reason
An Abbreviated Survey was conducted on February 23, 2017, to investigate multiple complaints against the facility, including complaint GA00166115 which was substantiated.
Findings
The facility was found not in compliance with Federal and State Long Term Care Requirements, specifically failing to notify the physician of significant weight gain for one resident (#3) with congestive heart failure, and failing to provide care and services according to professional standards and the resident's care plan.
Complaint Details
The visit was complaint-related, investigating complaints GA00171761, GA00163634, GA00165181, GA00165573, GA00166115, and GA00170940. Complaint GA00166115 was substantiated.
Severity Breakdown
SS= D: 3
Deficiencies (3)
DescriptionSeverity
Failure to notify the physician of significant weight gain for resident #3.SS= D
Failure to provide care and services according to professional standards by not notifying the physician for significant weight gain for resident #3.SS= D
Failure to provide services in accordance with the resident's written plan of care related to notification of physician for significant weight gain for resident #3.SS= D
Report Facts
Weight gain percentage: 5.86 Resident weight: 324 Resident weight: 337 Resident weight: 343.2 Resident weight: 335 Sample size: 17

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