Deficiencies per Year
8
6
4
2
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 24, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - SYLVESTER, indicating a regulatory inspection was conducted.
Findings
The document contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Jun 24, 2025
Visit Reason
A revisit survey was conducted on June 24, 2025, including investigation of three complaint intake numbers in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the June 2, 2025 recertification survey were found to be corrected. The complaint investigation found one complaint substantiated without deficiencies and two complaints unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00255478 and GA00255130 were unsubstantiated; GA00255300 was substantiated without deficiencies.
Report Facts
Complaint Intake Numbers investigated: 3
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Jun 24, 2025
Visit Reason
A revisit survey was conducted on June 24, 2025, including investigation of three complaint intake numbers in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the June 2, 2025, recertification survey were found to be corrected. The complaint investigation found one complaint substantiated without deficiencies and two complaints unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00255478 and GA00255130 were unsubstantiated; GA00255300 was substantiated without deficiencies.
Report Facts
Complaint Intake Numbers investigated: 3
Inspection Report
Follow-Up
Deficiencies: 0
Jun 10, 2025
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 during the follow-up survey.
Inspection Report
Life Safety
Census: 106
Capacity: 117
Deficiencies: 7
Apr 28, 2025
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program and to perform a Life Safety Code Survey assessing compliance with Medicare/Medicaid participation requirements and NFPA standards.
Findings
The facility was found not in substantial compliance with emergency preparedness training requirements and multiple Life Safety Code deficiencies including corridor width obstruction, improper interior wall and ceiling finishes, sprinkler system maintenance issues, and electrical system installation problems. Some citations were corrected during the survey.
Severity Breakdown
F: 3
E: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Emergency preparedness program staff training was inadequate; staff were unfamiliar with the program. | F |
| Facility failed to maintain corridor width due to objects obstructing hallways on Wing 2. | E |
| Interior wall and ceiling finishes did not meet flame spread rating requirements near sprinkler riser. | E |
| Improper storage height in kitchen pantry affecting sprinkler system compliance. | F |
| Fire sprinkler system gauges needed replacement/recalibration. | F |
| Open wire splices found on both sides of fire doors in Wing 1. | E |
| Power strip found on floor of Administrator's office (corrected during survey). | E |
Report Facts
Census: 106
Total Capacity: 117
Stories: 1
Construction Type: 3
Construction Date: 1993
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness and Life Safety Code deficiencies during the survey |
Inspection Report
Routine
Census: 105
Deficiencies: 4
Apr 25, 2025
Visit Reason
A standard survey was conducted from April 22, 2025 through April 25, 2025, including investigation of Complaint Intake Number GA00253562, which was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure call light accessibility, bathing and personal hygiene assistance, checking gastric residuals prior to enteral feeding, and maintaining infection control protocols related to Enhanced Barrier Precautions and hand hygiene.
Complaint Details
Complaint Intake Number GA00253562 was investigated in conjunction with the standard survey and was unsubstantiated.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure call devices were accessible for one resident, placing the resident at risk of accident or unmet needs. | SS= D |
| Failed to ensure bathing and personal hygiene assistance were provided for one resident, risking unmet hygiene preferences. | SS= D |
| Failed to ensure gastric residual was checked prior to administering enteral nutrition via gastrostomy tube for one resident, increasing risk of health complications. | SS= D |
| Failed to maintain infection control and prevention program related to Enhanced Barrier Precautions and hand hygiene for two residents, including failure to wear required PPE and perform hand hygiene between glove changes. | SS= D |
Report Facts
Residents present: 105
Residents observed for call light accessibility: 33
Residents reviewed for bathing: 3
Sample residents: 32
Residents reviewed for G-Tubes: 2
Sample residents: 36
Residents reviewed for Enhanced Barrier Precautions: 15
G-Tube feeding rate: 57
Gastric residual threshold: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN4 | Licensed Practical Nurse | Confirmed call light was not within reach of resident R68 and moved it to the bed |
| CNA2 | Certified Nurse Aide | Reported placing call light on resident R68's bed and noted housekeeping sometimes moved it |
| Administrator | Stated facility did not have a policy addressing call light accessibility | |
| Director of Nursing | Director of Nursing | Reported staff in-service trainings on call light placement and acknowledged lack of policy for ADL care or shower/bath |
| LPN5 | Licensed Practical Nurse | Interviewed regarding resident R92's bathing care and acknowledged failure to document refusal of care; also failed to follow Enhanced Barrier Precautions for resident R211 |
| CNA4 | Certified Nursing Assistant | Provided bed bath and nail care to resident R92 and reported resident refusal of bed bath |
| RN1 | Registered Nurse | Described proper procedure for checking gastric residual |
| LPN2 | Licensed Practical Nurse | Administered enteral feeding without checking gastric residual and failed to perform hand hygiene between glove changes for resident R65 |
| RN2 | Registered Nurse | Responded to enteral feeding pump alarm for resident R65 |
| LPN5 | Licensed Practical Nurse | Failed to don gown and gloves when providing care to resident R211 on Enhanced Barrier Precautions |
| Assistant Director of Nursing | Assistant Director of Nursing | Facility Infection Preventionist who acknowledged LPN5's failure to follow PPE guidance |
Inspection Report
Routine
Deficiencies: 4
Apr 25, 2025
Visit Reason
A State Licensure survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health at Pruitthealth Sylvester from April 22, 2025, through April 25, 2025, to assess compliance with state health regulations.
Findings
The facility was found deficient in infection control practices related to Enhanced Barrier Precautions and hand hygiene for two residents, call light accessibility for one resident, bathing and personal hygiene assistance for another resident, and failure to check gastric residual prior to enteral feeding for one resident. These deficiencies posed risks of infection, injury, unmet needs, and health complications.
Deficiencies (4)
| Description |
|---|
| Failure to maintain infection control and prevention program related to Enhanced Barrier Precautions and hand hygiene for two residents; staff failed to wear required PPE and perform hand hygiene between glove changes. |
| Failure to ensure call devices were accessible for one resident. |
| Failure to ensure bathing and personal hygiene assistance were provided for one resident. |
| Failure to ensure gastric residual was checked prior to administering enteral nutrition via gastrostomy tube for one resident. |
Report Facts
Residents reviewed for Enhanced Barrier Precautions: 15
Residents reviewed for call light accessibility: 33
Residents reviewed for bathing: 32
Residents reviewed for gastrostomy tubes: 36
Gastric residual threshold: 100
Jevity feeding rate: 57
Water flush volume: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Failed to wear PPE and follow Enhanced Barrier Precautions for resident R211; acknowledged failure during interview. |
| LPN2 | Licensed Practical Nurse | Failed to perform hand hygiene between glove changes and did not check gastric residual prior to feeding resident R65. |
| RN2 | Registered Nurse | Responded to enteral feeding pump alarm for resident R65. |
| RN1 | Registered Nurse | Described proper procedure for checking gastric residual. |
| LPN4 | Licensed Practical Nurse | Confirmed call light was not within reach of resident R68 and moved it to bed. |
| CNA2 | Certified Nurse Aide | Reported housekeeping staff sometimes moved call light away from resident R68's bed. |
| LPN5 | Licensed Practical Nurse | Interviewed regarding resident R92's refusal of bed baths and segmented care. |
| CNA4 | Certified Nursing Assistant | Provided bed bath, nail care, and encouraged resident R92 to be out of bed. |
| Assistant Director of Nursing | Assistant Director of Nursing and Infection Preventionist | Acknowledged LPN5's failure to follow PPE guidance. |
| Director of Nursing | Director of Nursing | Discussed staff training on call light placement and resident R92's refusal of care documentation. |
| Administrator | Administrator | Discussed call light accessibility training and facility policies. |
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Feb 26, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by codes GA00232329, GA00235574, GA00239937, GA00242144, GA00242305, and GA00242306.
Findings
The complaints investigated during the survey were found to be unsubstantiated, and no deficiencies were cited.
Complaint Details
The survey investigated complaints GA00232329, GA00235574, GA00239937, GA00242144, GA00242305, and GA00242306, all of which were unsubstantiated.
Report Facts
Census: 104
Inspection Report
Life Safety
Census: 87
Capacity: 117
Deficiencies: 0
Dec 5, 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 substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Routine
Census: 90
Deficiencies: 0
Dec 4, 2022
Visit Reason
A standard survey was conducted at Pruitt Health-Sylvester from December 2, 2022 through December 4, 2022 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
Deficiencies: 0
May 12, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - SYLVESTER, 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
Complaint Investigation
Deficiencies: 0
Mar 9, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00219690, GA00219761, GA00220429 and GA00221121 from 2/25/2022 through 3/9/2022.
Findings
There were no State Licensure Citations cited during the survey.
Complaint Details
Investigation of complaints GA00219690, GA00219761, GA00220429 and GA00221121 was conducted with no licensure citations found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 9, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00219690, GA00219761, GA00220429, and GA00221121 from 2/25/2022 through 3/9/2022.
Findings
The facility was found to be in compliance with infection control regulations. Complaints GA00219690 and GA00220429 were unsubstantiated. Complaint GA00219761 was unsubstantiated but an additional concern was identified with a deficiency cited. Complaint GA00221121 was substantiated with deficiencies related to failure to report an allegation of illegal drug use to law enforcement, failure to timely report an allegation of abuse and misappropriation of property to the State Survey Agency, and failure to ensure medications were administered as ordered and accurately documented.
Complaint Details
Complaints GA00219690 and GA00220429 were unsubstantiated. Complaint GA00219761 was unsubstantiated but an additional concern was identified with a deficiency cited. Complaint GA00221121 was substantiated with deficiencies.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report an allegation of illegal drug use to law enforcement for one resident (R#3). | SS=D |
| Failure to ensure that an allegation of abuse and misappropriation of property was reported to the State Survey Agency in a timely manner for one resident (R"A"). | SS=D |
| Failure to ensure that medications were administered as ordered and accurately documented in the clinical record for one resident (R"A"). | SS=D |
Report Facts
Number of residents in sample: 19
Date of resident R#3 admission: Sep 8, 2020
Date of nurse's note documenting marijuana allegation: Nov 22, 2021
Date of hospital positive THC test: Nov 23, 2021
Date of facility follow-up report: Nov 30, 2021
Date of resident R"A" medication removal allegation: Jan 8, 2022
Date of report to State Survey Agency for R"A" allegation: Jan 18, 2022
Date of follow-up report to State Survey Agency: Jan 26, 2022
Date of medication administration incident: Mar 4, 2022
Blood sugar level: 246
Blood sugar level: 219
Blood sugar level: 220
Insulin units administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Named in allegations of medication removal and inappropriate insulin administration |
| LPN BB | Licensed Practical Nurse | Named in medication administration errors on 3/4/22 |
| Administrator | Confirmed failure to notify law enforcement and delayed reporting to State Survey Agency | |
| Director of Nursing | DON | Confirmed failure to notify law enforcement and delayed reporting to State Survey Agency |
| Certified Nursing Assistant AA | CNA | Suspended related to marijuana allegation involving resident R#3 |
Inspection Report
Deficiencies: 0
Feb 11, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - SYLVESTER, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Feb 11, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 12/2/2021 Complaint Survey.
Findings
All deficiencies cited as a result of the 12/2/2021 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 12/2/2021; all cited deficiencies were corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00218104, GA00218774, and GA00219190 from 11/30/21 through 12/2/21.
Findings
The facility was found to be in compliance with infection control regulations. Complaints GA00218104 and GA00219190 were unsubstantiated. Complaint GA00218774 was substantiated due to a medication error rate of 23%, with nine medication omission errors observed during medication administration for three residents.
Complaint Details
Complaint GA00218774 was substantiated due to medication errors. Complaints GA00218104 and GA00219190 were unsubstantiated.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to ensure the medication error rate was less than 5%, with nine medication omission errors for three residents during medication administration observations. | E |
Report Facts
Medication administration opportunities: 38
Medication errors: 9
Medication error rate: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication omission errors during medication administration |
| Director of Health Services | Provided statements regarding medication cart tablet and medication administration procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00218104, GA00218774 and GA00219190 from 11/30/21 through 12/2/21. Complaints GA00218104 and GA00219190 were unsubstantiated. Complaint GA00218774 was substantiated with deficiencies.
Findings
The facility failed to ensure timely reorder and administration of medication for one resident, resulting in missed doses of ketotifen fumarate eye drops. Additionally, the facility had a medication error rate of 23% due to nine medication omission errors for three residents during medication administration observations, partly due to a non-working medication cart tablet and failure to use alternate methods to verify orders.
Complaint Details
Complaint GA00218774 was substantiated with deficiencies related to medication administration and timely medication reorder. Complaints GA00218104 and GA00219190 were unsubstantiated.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that a medication was reordered and administered in a timely manner for one resident (R "A") from a total sample of 13 residents. | Level D |
| Failed to ensure medication error rate was less than 5%, with nine medication omission errors for three residents (R#5, R#6, and R#7) resulting in a 23% error rate. | Level E |
Report Facts
Medication error opportunities: 38
Medication errors: 9
Medication error rate: 23
Resident sample size: 13
Resident sample size: 3
Missed medication days: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication omission errors and failure to reorder medication timely |
| Director of Health Services | Provided statements regarding medication reorder delays and medication administration procedures |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Sep 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey investigating complaint GA00217080 was conducted.
Findings
The complaint GA00217080 was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices.
Complaint Details
Complaint GA00217080 was unsubstantiated.
Inspection Report
Renewal
Census: 89
Deficiencies: 0
Jun 4, 2021
Visit Reason
A licensure survey was conducted at PruittHealth - Sylvester from June 1, 2021 through June 4, 2021 to assess compliance with licensure requirements.
Findings
The standard survey revealed that the facility was in substantial compliance.
Inspection Report
Routine
Census: 89
Deficiencies: 0
Jun 4, 2021
Visit Reason
A standard survey was conducted at PruittHealth - Sylvester from June 1, 2021 through June 4, 2021 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 81
Capacity: 117
Deficiencies: 0
Jun 2, 2021
Visit Reason
A Life Safety Code Survey was conducted to review the facility's compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid at Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also in substantial compliance with 42 CFR 483.73.
Report Facts
Stories: 1
Construction Type: 111200
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 8, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00213227.
Findings
The complaint GA00213227 was unsubstantiated and no deficiencies were identified during the survey.
Complaint Details
Complaint GA00213227 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Mar 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaint #GA00212822.
Findings
The complaint was unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and had implemented recommended COVID-19 practices.
Complaint Details
Complaint #GA00212822 was unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 24, 2020
Visit Reason
An Abbreviated Partial Extended Survey was conducted to investigate multiple complaints identified by numbers #GA00209669, #GA00208022, #GA00207105, #GA00206684, #GA00205578, and #GA00204201.
Findings
All complaints investigated during the survey were found to be unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00209669, #GA00208022, #GA00207105, #GA00206684, #GA00205578, and #GA00204201 were investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant federal regulations and preparedness for 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 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 82
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00200140.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00200140 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 0
Oct 24, 2018
Visit Reason
A revisit survey and a Complaint survey were conducted to investigate Complaint intake number GA00191141 and to verify correction of deficiencies cited in the 8/23/18 Recertification survey.
Findings
All deficiencies cited in the 8/23/18 Recertification survey were found to be corrected and the complaint GA00191141 was found to be unsubstantiated.
Complaint Details
Complaint intake number GA00191141 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 0
Oct 24, 2018
Visit Reason
A Revisit survey and a Complaint survey were conducted to investigate complaint intake number GA00191141 and to verify correction of deficiencies cited in the 8/23/18 Recertification survey.
Findings
All deficiencies cited in the 8/23/18 Recertification survey were found to be corrected and the complaint GA00191141 was found to be unsubstantiated.
Complaint Details
Complaint GA00191141 was investigated and found to be unsubstantiated.
Report Facts
Census: 99
Inspection Report
Follow-Up
Deficiencies: 0
Oct 12, 2018
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 during the follow-up survey.
Inspection Report
Life Safety
Census: 99
Capacity: 117
Deficiencies: 5
Aug 20, 2018
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to properly maintain hazardous area doors, fire alarm system, corridor doors, and electrical systems, which could place residents and staff at risk in the event of fire.
Severity Breakdown
E: 1
F: 1
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Hazardous area doors not closing and latching properly, including dry storage and food storage doors blocked open, maintenance office door lacking door closer, and medical records office door not closing. | E |
| Fire alarm system initiation deficiencies due to smoke detectors located within 36 inches of air register grills in corridor and medical records storage room. | F |
| Corridor door (MDS/Careplans office) has a louver installed, which is not permitted. | D |
| Missing cover plate on electrical junction box in clock out room. | D |
| Use of unapproved cube adapter for portable oxygen machine in Room #54. | D |
Report Facts
Residents at risk due to hazardous area door deficiencies: 48
Residents and staff at risk due to fire alarm system deficiencies: 86
Staff at risk due to corridor door deficiencies: 2
Residents and staff at risk due to electrical system deficiencies: 3
Census: 99
Total licensed capacity: 117
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Dec 11, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2017-09-28.
Findings
All deficiencies cited as a result of the 9/28/17 standard survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 22, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags were noted to have been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 4, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00182571 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00182571 was investigated and found to have no deficiencies.
Inspection Report
Routine
Census: 106
Deficiencies: 5
Sep 28, 2017
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including residents' right to receive mail promptly, housekeeping and maintenance deficiencies, inaccurate resident assessments, food safety and sanitation issues, and malfunctioning resident call systems in bathrooms.
Severity Breakdown
E: 2
D: 1
B: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents receive delivered mail promptly within 24 hours including weekends. | E |
| Failed to maintain sanitary, orderly, and comfortable interior including buildup on wheelchairs, stained and chipped floor tiles, rust discoloration in sinks. | D |
| Failed to accurately code dental status in resident assessments for edentulous residents without dentures. | B |
| Failed to ensure food safety and sanitation including opened undated food items, expired food, unclean microwave, improper cooler temperatures, lack of hot water for handwashing, and improper dishwashing procedures. | F |
| Failed to ensure all components of the nurse call system in resident bathrooms and common shower room were fully functional. | E |
Report Facts
Resident census: 106
Sample size: 35
Temperature of milk cooler: 50
Temperature of milk cooler: 46
Sanitizing water concentration: 200
Expiration date: Jun 1, 2016
Inspection Report
Life Safety
Census: 105
Capacity: 117
Deficiencies: 8
Sep 26, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to provide emergency lighting throughout the facility, failure to maintain hazardous areas as smoke tight, improper installation of smoke detectors, failure to maintain sprinkler systems, corridor doors not maintained properly, fire barriers not properly sealed, electrical system code violations, and smoking area not properly protected.
Severity Breakdown
E: 3
D: 4
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide emergency lighting throughout the facility including enclosed courtyard, dietary exit, wing 1 dayroom, and wing 1 sprinkler exit. | E |
| Failed to maintain hazardous areas as smoke tight; doors in dietary dry storage and medical records storage rooms not equipped with self-closing devices. | E |
| Failed to ensure smoke detectors properly installed; detectors too close to air registers in dietary hallway, medical records, and wing 2 clean utility. | E |
| Failed to properly maintain sprinkler system; sprinkler piping in attic supporting external wiring loads. | D |
| Failed to maintain corridor doors; kitchen to dining area door will not close properly and does not latch. | D |
| Failed to properly maintain fire rated smoke barriers; multiple fire barriers not sealed with listed fire stop system. | F |
| Failed to ensure electrical system complies with NFPA 70; electrical panel box lacks 36 inch clearance and unsecured junction box in IT cable room. | D |
| Failed to ensure smoking area is properly protected; ashtrays of noncombustible material and safe design not provided. | D |
Report Facts
Census: 105
Total Capacity: 117
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who accompanied surveyor and confirmed findings during the inspection |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 4, 2017
Visit Reason
The visit was an abbreviated/partial extended survey investigating complaint GA 00173037.
Findings
No health deficiencies were cited during the survey.
Complaint Details
Complaint GA 00173037 was investigated during this abbreviated survey; no deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 28, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00170034.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint #GA00170034 was investigated and found to be unsubstantiated with no deficiencies.
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