Inspection Reports for Rehabilitation Center of South Georgia
2002 TIFT AVENUE NORTH, TIFTON, GA, 31794
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 9, 2025 found no deficiencies and substantiated two complaints as unsubstantiated. Earlier inspections showed a mix of findings, including substantiated complaints with deficiencies related to resident care, abuse reporting, medication management, and fire safety code violations. Notable issues involved failure to prevent involuntary seclusion, improper destruction of controlled substances, incomplete care plans, and multiple life safety code deficiencies such as fire alarm and sprinkler system maintenance. Several complaint investigations were substantiated, particularly concerning abuse allegations and medication handling, while most complaints were unsubstantiated. The facility has demonstrated correction of prior deficiencies on multiple revisit surveys, indicating some improvement over time despite recurring challenges in care and safety compliance.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
118 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 118
Deficiencies: 0
Date: Apr 9, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00254253 and GA00254533.
Complaint Details
Complaints GA00254253 and GA00254533 were investigated and found to be unsubstantiated.
Findings
Both complaints GA00254253 and GA00254533 were unsubstantiated with no regulatory violations cited.
Inspection Report
Abbreviated Survey
Census: 125
Deficiencies: 0
Date: Dec 12, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their codes GA00249416, GA00249589, GA00250442, GA00251723, GA00251848, and GA00251924.
Complaint Details
Complaints GA00249416, GA00251848, and GA00251924 were unsubstantiated. Complaints GA00249589, GA00250442, and GA00251723 were substantiated.
Findings
Complaints GA00249416, GA00251848, and GA00251924 were found to be unsubstantiated, while complaints GA00249589, GA00250442, and GA00251723 were substantiated. No deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for the Rehabilitation Center of South Georgia following a survey completed on 08/28/2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Date: Aug 28, 2024
Visit Reason
A revisit survey was conducted from August 27, 2024 through August 28, 2024 to verify correction of deficiencies cited in the July 4, 2024 Recertification survey.
Findings
All deficiencies cited as a result of the July 4, 2024 Recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 122
Capacity: 178
Deficiencies: 4
Date: Jul 2, 2024
Visit Reason
A Life Safety Code Survey was 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 fire safety requirements, including failure to properly test and maintain the fire alarm and smoke detection systems, improper storage height within sprinkler head coverage, unsealed penetrations in firewalls, and blocked electrical panels. All deficiencies were confirmed during the survey and corrected by staff during the visit.
Deficiencies (4)
Failure to ensure proper inspection, testing, and maintenance of the fire alarm and smoke detection systems; sensitivity testing of smoke detectors not conducted and no documentation available.
Failure to maintain proper height of stored items in the Laundry Room; items stored in excess of 18 inches within a sprinkler head.
Failure to maintain continuity of fire walls; penetrations in firewalls near room 313 and 600 hall not properly sealed.
Failure to maintain clearance around electrical panels; electrical boxes blocked by folding chairs in Electrical Room.
Report Facts
Census: 122
Total Capacity: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings and corrected deficiencies during survey |
Inspection Report
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the Rehabilitation Center of South Georgia, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
A health revisit was conducted via desk review to verify correction of deficiencies cited in the Complaint Investigation survey conducted on 2024-04-25.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey conducted on 2024-04-25. All cited deficiencies from that complaint investigation have been corrected.
Findings
All deficiencies cited as a result of the Complaint Investigation survey conducted on 2024-04-25 have been corrected.
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
No State Health deficiencies were cited during the survey conducted from April 23, 2024 through April 25, 2024.
Inspection Report
Abbreviated Survey
Census: 118
Capacity: 178
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from April 23 to April 25, 2024, investigating multiple complaint intake numbers.
Complaint Details
Complaint intake GA00241524 was substantiated with no deficiencies cited. Complaint intake GA00241783, GA00245246, and GA00245890 were unsubstantiated. Complaint intake GA00243142 was substantiated with a deficiency cited.
Findings
The survey substantiated one complaint with a deficiency cited related to the Social Service Director's qualifications for a facility licensed for over 120 beds. Other complaints were either unsubstantiated or substantiated with no deficiencies.
Deficiencies (1)
The facility failed to ensure that the Social Service Director had the proper qualifications for a facility with over 120 beds, as the current SSD did not have a Bachelor's degree but was working towards it.
Report Facts
Complaint intake numbers investigated: 5
Facility census: 118
Total licensed capacity: 178
Percentage of Social Worker degree completion: 26
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
A revisit survey was conducted on November 8 through November 9, 2023 to verify correction of deficiencies cited during the September 28, 2023 Complaint Investigation Survey.
Complaint Details
The revisit survey was conducted following a complaint investigation survey on September 28, 2023. All deficiencies from that complaint investigation were corrected.
Findings
All deficiencies cited as a result of the September 28, 2023 Complaint Investigation Survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Rehabilitation Center of South Georgia following a survey completed on November 9, 2023.
Findings
The report contains a summary statement of deficiencies identified during the survey; however, no specific deficiencies or details are provided in the available page.
Inspection Report
Abbreviated Survey
Capacity: 15
Deficiencies: 2
Date: Sep 28, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints initiated on September 6, 2023, and concluded on September 28, 2023. The investigation focused on allegations of abuse and improper medication disposal.
Complaint Details
The survey investigated multiple complaints (GA00232589, GA00232851, GA00232945, GA00235738, GA00236245, GA00236662, GA00236802, GA00237742, GA00239322, GA00239444). Complaints GA00232589 and GA00239322 were substantiated with deficiencies related to abuse and improper medication disposal. The other complaints were unsubstantiated with no deficiencies.
Findings
The facility was found to have substantiated deficiencies related to involuntary seclusion of residents on the Memory Care Unit by a CNA who placed bath linens on top of resident room doors to keep them from opening their doors, and failure to properly destroy fentanyl patches in the presence of two licensed nurses with appropriate documentation.
Deficiencies (2)
Failure to ensure residents on the Memory Care Unit were free from involuntary seclusion when a CNA placed bath linens on top of resident room doors to keep residents from opening their doors.
Failure to ensure fentanyl patches were destroyed in the presence of two licensed nurses and documented on the Certificate of Inventory and Destruction form for one resident.
Report Facts
Resident rooms in Memory Care Unit: 15
Residents in sample: 14
Fentanyl patch dosage: 75
Fentanyl patch application dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in findings for placing bath linens on doors to seclude residents and aggressive behavior |
| LPN AA | Licensed Practical Nurse | Observed CNA CC's aggressive behavior and reported concerns |
| LPN BB | Licensed Practical Nurse | Reported CNA CC placing towels on doors and aggressive behavior |
| Administrator GG | Previous Administrator | Notified of abuse concerns and reported to state; terminated CNA CC |
| Administrator HH | Previous Assistant Administrator | Observed towels on doors, confronted CNA CC, but did not report to higher management |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse and medication disposal findings |
| HR Manager | Human Resources Manager | Investigated abuse allegations and interviewed staff |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 28, 2023
Visit Reason
A State Licensure survey was conducted from September 6, 2023 through September 28, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to ensure fentanyl patches were destroyed in the presence of two licensed nurses and documented on the Certificate of Inventory and Destruction for Reverse Distribution form for one resident (R#9).
Deficiencies (1)
Failure to ensure fentanyl patches were destroyed in the presence of two licensed nurses and documented for one resident (R#9).
Report Facts
Sample size: 14
Fentanyl patch dosage: 75
Dates of fentanyl patch application: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding fentanyl patch disposal and in-service training |
Inspection Report
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for the Rehabilitation Center of South Georgia following a survey completed on April 12, 2023.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 16, 2023 Standard Survey.
Findings
All deficiencies cited as a result of the February 16, 2023 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
The revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 16, 2023
Visit Reason
The inspection was conducted as a State Licensure survey from February 14, 2023 through February 16, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to implement the plan of care for one resident related to activities of daily living, specifically not receiving scheduled showers and baths. Additionally, the facility failed to maintain cleanliness and sanitation of feeding pumps for three residents and failed to maintain the facility environment, including scuffed walls, stained ceiling tiles, and dusty air vents.
Deficiencies (3)
Failure to implement plan of care for resident R#267 related to activities of daily living, specifically not receiving scheduled showers and baths.
Failure to ensure feeding pumps for three residents (R#2, R#5, R#26) were clean and sanitary.
Failure to maintain facility cleanliness including scuffed walls in rooms 206, 210, 212, stained ceiling tiles and scuffed floor tile in bathroom 104, and heavy dust buildup on ceiling vents outside rooms 104 and 105.
Report Facts
Residents affected: 1
Residents affected: 3
Bath dates documented: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed confirming resident R#267 did not receive bath from 12/5/2022 through 12/14/2022 | |
| Director of Nursing | Interviewed regarding bath scheduling and documentation procedures | |
| Administrator | Participated in walk-through confirming environmental deficiencies | |
| Environmental Services Director | Participated in confirmation rounds of feeding pump sanitation issues |
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 6
Date: Feb 16, 2023
Visit Reason
A standard survey was conducted from February 14 through February 16, 2023, including investigation of Complaint Intake Number GA00230277, to assess compliance with Medicare/Medicaid regulations for the Rehabilitation Center of South Georgia.
Complaint Details
Complaint Intake Number GA00230277 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including unclean feeding pumps for residents with gastrostomy tubes, poor maintenance of facility environment such as scuffed walls and dusty air vents, failure to apply for Level II PASRR for a resident with mental illness, failure to implement care plans related to activities of daily living for a resident, failure to provide scheduled showers/baths, and improper storage of respiratory equipment increasing infection risk.
Deficiencies (6)
Feeding pumps for three residents with gastrostomy tubes were not clean and sanitary, with dried formula and grime buildup.
Facility environment was not maintained in a clean and sanitary condition, including scuffed walls, stained ceiling tiles, scuffed floor tiles, and dusty air vents.
Failure to apply for a Level II PASRR for one resident with a positive Level I PASRR for mental illness.
Failure to implement plan of care for one resident related to activities of daily living, specifically not receiving a shower/bath as scheduled.
Failure to ensure scheduled showers and baths were provided for one resident.
Respiratory equipment (CPAP mask and oxygen nasal cannula) for one resident was not properly stored when not in use, increasing risk of respiratory infections.
Report Facts
Resident census: 120
BIMS score: 6
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding feeding pump cleaning, care plan implementation, and respiratory equipment storage | |
| Administrator | Interviewed regarding facility cleanliness and feeding pump expectations | |
| Housekeeping Supervisor | Interviewed regarding cleaning responsibilities for feeding pumps | |
| Assistant Director of Nursing (ADON) | Interviewed regarding resident bathing documentation and care plan adherence | |
| Social Services Director | Interviewed regarding Level II PASRR completion responsibilities | |
| Behavioral Nurse Practitioner | Interviewed regarding behavioral services for resident #87 | |
| Environmental Services Supervisor | Interviewed regarding facility environment concerns |
Inspection Report
Life Safety
Census: 113
Capacity: 178
Deficiencies: 12
Date: Feb 15, 2023
Visit Reason
A Life Safety Code Survey was 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 obstructions in means of egress, failure to maintain emergency lighting and exit signage, deficiencies in kitchen hood fire suppression system, ceiling continuity issues, fire alarm system installation problems, sprinkler system maintenance failures, improper electrical installations, inadequate fire drills, combustible decorations on doors, and generator maintenance deficiencies.
Deficiencies (12)
Exits blocked by trashcans and wheelchairs in the 300 Back Hall.
Failure to complete annual 90-minute test for emergency lights.
Failure to properly inspect, test, and maintain exit lighting.
Failure to properly inspect, test, and maintain kitchen hood fire suppression system; corrosion on control head and pull station.
Cooking equipment not positioned correctly under suppression system nozzles; citation resolved during survey.
Failure to ensure continuity of ceiling; missing ceiling tiles in Kitchen and Back 300 Utility Closet.
Failure to ensure proper installation of fire alarm system; circuit serving fire alarm not locked open, not identified or marked.
Sprinkler system red-tagged and out of service; failure to maintain sprinkler system free from external loads; wire on sprinkler piping in attic.
Improper electrical installations including power strips on floor, open junction boxes, and open wiring splices in attic above 300 Front Hall.
Failure to conduct fire drills at random times on 2nd Shift.
Failure to keep doors free of combustible decorations; Activities Director Office door fully covered in construction paper.
Failure to conduct load bank testing on generator; generator provides emergency power to outlets, fire alarm system, and dining hall.
Report Facts
Census: 113
Total Capacity: 178
Deficiencies cited: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during facility tour |
Inspection Report
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the Rehabilitation Center of South Georgia, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report.
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/04/2022 Re-certification Survey.
Findings
All deficiencies cited as a result of the 10/04/2022 Re-certification Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate a complaint (GA00229301) at the facility.
Complaint Details
The complaint investigation was substantiated.
Findings
The complaint was substantiated, but no deficiencies were cited during the survey.
Report Facts
Complaint ID: Complaint GA00229301 investigated
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility, initiated on September 20, 2022 and concluded on October 4, 2022.
Complaint Details
The survey investigated complaints GA00221625, GA00221707, GA00223645, GA00225713, GA00225845, and GA00226772. Complaints GA00221625, GA00221707, and GA00223645 were unsubstantiated. Complaints GA00225713, GA00225845, and GA00226772 were substantiated with deficiencies.
Findings
Complaints GA00221625, GA00221707, and GA00223645 were unsubstantiated, while complaints GA00225713, GA00225845, and GA00226772 were substantiated with deficiencies. No State Licensure deficiencies were cited despite identified concerns.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (GA00221625, GA00221707, GA00223645, GA00225713, GA00225845, and GA00226772) regarding alleged abuse, neglect, and failure to report incidents at the facility.
Complaint Details
The survey was initiated based on multiple complaints alleging abuse, neglect, and failure to report incidents. Complaints GA00221625, GA00221707, and GA00223645 were unsubstantiated. Complaints GA00225713, GA00225845, and GA00226772 were substantiated with deficiencies and actual harm identified.
Findings
The investigation substantiated deficiencies related to failure to report an allegation of illegal drug use and abuse in a timely manner, and failure to implement timely interventions to prevent injury from bed side rails for two residents. Actual harm was identified for Resident B who sustained bruising and swelling to the head from hitting the upper assist rails on the bed.
Deficiencies (3)
Failure to report an allegation of illegal drug use to the State Survey Agency for one resident.
Failure to report an allegation of abuse to the State Survey Agency in a timely manner for one resident.
Failure to implement timely interventions to prevent further injury from use of side rails for one resident, resulting in actual harm.
Report Facts
Complaints investigated: 6
Residents sampled: 8
Dates of injuries: 2
Date of drug incident: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Completed skin assessment and nurse's notes related to Resident B's injuries |
| LPN GG | Licensed Practical Nurse | Documented nurse's note regarding Resident B's forehead injury on 7/4/22 |
| Administrator | Interviewed regarding failure to report drug incident involving Resident A | |
| Director of Nursing | DON | Interviewed regarding failure to timely report abuse and interventions for Resident B |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 26, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00219461.
Complaint Details
Complaint #GA00219461 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 9/29/2021 Complaint Investigation Survey and to investigate Complaint Intake number GA00218793.
Complaint Details
Complaint Intake number GA00218793 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior complaint investigation were found to be corrected, and the complaint intake was investigated and found to be unsubstantiated.
Report Facts
Census: 117
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00218793.
Complaint Details
Complaint #GA00218793 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for the Rehabilitation Center of South Georgia following a survey completed on 11/17/2021.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Sep 29, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from September 23, 2021 to September 29, 2021, investigating multiple complaints and concerns related to resident care, abuse allegations, medication management, and wound care at the Rehabilitation Center of South Georgia.
Complaint Details
Complaints GA00215334 and GA00215460 were substantiated, while complaints GA00215472 and GA00216957 were unsubstantiated. The substantiated complaints involved failures in abuse reporting and wound care.
Findings
The facility was found to have multiple deficiencies including failure to timely report resident-to-resident altercations and abuse allegations, failure to provide privacy and dignity during care, medication carts not properly secured, and inadequate wound care with failure to follow care plans especially on weekends. Some complaints were substantiated while others were unsubstantiated.
Deficiencies (4)
Failure to timely report resident-to-resident altercations, injuries of unknown origin, and alleged staff to resident abuse for four of five reports reviewed.
Failure to provide privacy by closing window blinds during perineal care and failure to treat a resident in a dignified manner during care.
Failure to ensure two of four medication carts were locked or that locking mechanisms functioned properly.
Failure to develop a care plan for a surgical site for one resident and failure to follow wound care plans on weekends for multiple residents, including failure to provide wound care for pressure ulcers.
Report Facts
Medication carts: 2
Residents with wound care deficiencies: 4
Residents with privacy/dignity issues: 2
Residents with abuse reporting failures: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse, wound care nurse | Named in wound care deficiencies and interview regarding weekend wound care. |
| LPN BB | Licensed Practical Nurse, wound care nurse | Assisted LPN AA with wound care observation. |
| CNA CC | Certified Nurse Aide | Observed providing perineal care without closing window blinds and involved in dignity issue. |
| CNA II | Certified Nurse Aide | Made inappropriate comparison remark and left resident exposed during perineal care. |
| LPN GG | Licensed Practical Nurse | Interviewed regarding medication cart lock malfunction. |
| LPN EE | Licensed Practical Nurse | Interviewed regarding failure to lock medication cart. |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding abuse reporting, privacy, medication cart security, and wound care. |
| Administrator | Facility Administrator | Interviewed regarding medication cart maintenance and wound care responsibilities. |
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Sep 29, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints, some substantiated and some unsubstantiated, related to resident rights, abuse reporting, care planning, wound care, and medication storage.
Complaint Details
The survey investigated complaints GA00215334, GA00215460, GA00215472, and GA00216957. Complaints GA00215472 and GA00216957 were unsubstantiated. Complaints GA00215334 and GA00215460 were substantiated with cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide privacy and dignity during perineal care, failure to timely report abuse allegations, failure to develop and follow comprehensive care plans especially for wound care, failure to provide thorough perineal care, failure to provide wound care on weekends, and failure to properly secure medication carts.
Deficiencies (6)
Failure to provide privacy by closing window blinds during perineal care and failure to treat resident with dignity.
Failure to timely report alleged violations of abuse, neglect, and mistreatment.
Failure to develop and implement comprehensive care plans and failure to follow care plans for wound care on weekends.
Failure to provide thorough perineal care for dependent residents.
Failure to provide wound care on weekends for residents with pressure ulcers and surgical wounds.
Failure to ensure medication carts were locked and locking mechanisms functioned properly.
Report Facts
Dates of wound care omissions: 20
Dates of medication cart observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nurse Aide | Named in findings related to failure to provide privacy and thorough perineal care. |
| CNA II | Certified Nurse Aide | Named in findings related to failure to provide thorough perineal care and dignity. |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy, abuse reporting, wound care, and medication cart lock deficiencies. |
| LPN AA | Licensed Practical Nurse | Named in wound care observations and interviews regarding weekend wound care. |
| LPN GG | Licensed Practical Nurse | Named in medication cart lock deficiency observation and interview. |
| LPN EE | Licensed Practical Nurse | Named in medication cart lock deficiency interview. |
| Administrator | Facility Administrator | Interviewed regarding wound care and medication cart lock responsibilities. |
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 0
Date: May 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00214549.
Complaint Details
Complaint #GA00214549 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 10, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the February 2, 2021 Focused Infection Control Survey.
Findings
All deficiencies cited in the prior focused infection control survey were found to be corrected, and the facility was in substantial compliance as of February 25, 2021.
Inspection Report
Abbreviated Survey
Census: 117
Deficiencies: 2
Date: Feb 2, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted due to a COVID-19 outbreak in the facility to assess compliance with infection control regulations and CMS/CDC recommended practices.
Findings
The facility was found not in compliance with infection control regulations, failing to ensure staff wore proper PPE and performed hand hygiene. Eight of 16 sampled residents who refused COVID-19 testing were not placed on droplet precautions or isolated, increasing risk of infection spread.
Deficiencies (2)
Failure to ensure all staff wore proper personal protective equipment (PPE) and performed hand hygiene.
Failure to place residents who refused COVID-19 testing on droplet precautions, transmission-based precautions, or in private rooms during a COVID-19 outbreak.
Report Facts
Total census: 117
Residents refusing COVID-19 testing: 8
Facility positivity rate: 14.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist AA | Infection Preventionist | Interviewed regarding PPE use and resident testing refusals. |
| Activity Director DD | Activity Director | Observed not wearing proper PPE and interviewed about PPE use. |
| Administrator | Observed not wearing proper PPE and interviewed about PPE directives. | |
| Director of Nursing (DON) | Director of Nursing | Interviewed about PPE requirements on quarantine unit. |
| Certified Nursing Assistant KK | Certified Nursing Assistant | Observed not wearing gown or gloves and not performing hand hygiene. |
| Trained Nursing Assistant JJ | Trained Nursing Assistant | Observed not wearing full PPE when entering resident room. |
| Housekeeping staff II | Housekeeping Staff | Observed cleaning tables with mask below nose. |
| LPN BB | Licensed Practical Nurse | Observed not wearing goggles or face shield. |
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
An Abbreviated/Partial Extended Survey investigating complaint GA00210392 was initiated on 2020-12-28 and concluded on 2020-12-29. Additionally, a COVID-19 Focused Infection Control Survey was conducted in conjunction.
Complaint Details
Complaint GA00210392 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 114
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 30, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number #GA00209849.
Complaint Details
Complaint #GA00209849 was investigated and found to be unsubstantiated.
Findings
The complaint #GA00209849 was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 9, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209397.
Complaint Details
Complaint #GA00209397 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating complaints GA00207937 and GA00206520.
Complaint Details
Complaints GA00207937 and GA00206520 were investigated and found to be unsubstantiated with no regulatory violations cited.
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 implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Total census: 119
Inspection Report
Routine
Census: 115
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were 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 recommended practices to prepare for COVID-19.
Report Facts
Total census: 115
Inspection Report
Routine
Census: 129
Deficiencies: 0
Date: May 5, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Deficiencies: 0
Date: Mar 12, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for the Rehabilitation Center of South Georgia following a survey completed on March 12, 2020.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 132
Deficiencies: 0
Date: Mar 12, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/24/2020 Recertification Survey with a complaint survey attached.
Findings
All deficiencies cited in the prior survey were found to be corrected during this revisit survey.
Report Facts
Census: 132
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 11, 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 survey tags have been corrected during this follow-up survey.
Inspection Report
Renewal
Census: 99
Capacity: 133
Deficiencies: 2
Date: Jan 24, 2020
Visit Reason
The inspection was a licensure survey conducted from January 21, 2020 through January 24, 2020 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to transport clothing from the laundry room in a sanitary manner potentially affecting 99 of 133 residents, and failed to store personal items in a sanitary manner in three of 74 resident bathrooms. Observations included uncovered plastic containers used to transport clean clothing and unlabeled, unbagged urinals and buckets in shared bathrooms.
Deficiencies (2)
Failure to transport clothing from the laundry room in a sanitary manner affecting 99 of 133 residents.
Failure to store personal items in a sanitary manner in three of 74 resident bathrooms.
Report Facts
Residents affected: 99
Total residents: 133
Resident bathrooms: 74
Bathrooms with unsanitary storage: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Head of Housekeeping | Interviewed regarding laundry transport and storage practices. | |
| Director of Nursing (DON) | Confirmed that all clean clothing items should be covered while being transported. | |
| Assistant Director of Nursing (ADON) | Reported that urinals should be labeled and stored in a bag off the floor. |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 7
Date: Jan 24, 2020
Visit Reason
A standard survey was conducted from January 21, 2020 through January 24, 2020, including investigation of two complaints (GA00199499 and GA00194813). Complaint GA00199499 was substantiated with deficiencies.
Complaint Details
Complaint Intake Numbers GA00199499 and GA00194813 were investigated. Complaint GA00199499 was substantiated with deficiencies related to unsanitary conditions, failure to follow physician orders, and inadequate infection control.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsanitary conditions in hallways and resident rooms, failure to maintain wheelchairs in good repair, failure to follow physician orders for blood sugar checks and oxygen administration, inadequate protection of resident medical information, and infection control issues related to laundry transport and storage of personal items.
Deficiencies (7)
Facility failed to ensure sanitary conditions related to cleanliness of hallways and resident rooms, including buildup of dirt, debris, spills, stained walls, bulging ceiling tiles, and dusty air vents.
Facility failed to ensure one wheelchair was in good repair for one resident (R#478).
Facility failed to follow physician orders related to finger stick blood sugar checks for one resident (R#277), with blood sugar checks not performed at ordered times.
Facility failed to follow physician's order for oxygen administration for one resident (R#69), oxygen delivered at incorrect flow rate.
Facility failed to provide adequate protection of resident medical and financial information; resident information was visible on white boards in nurses' stations accessible to unauthorized persons.
Facility failed to transport clothing from laundry in a sanitary manner; uncovered plastic containers with resident clothing items were transported down halls.
Facility failed to store personal items in a sanitary manner in three resident bathrooms; urinals and a gray bucket were not labeled or bagged and were stored on floors or windowsills.
Report Facts
Resident census: 133
Residents reviewed for FSBS: 49
Residents reviewed for oxygen: 44
Resident bathrooms inspected: 74
Resident wheelchairs inspected: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed FSBS was taken late at 1:08 p.m. instead of ordered 11:30 a.m. |
| LPN FF | Licensed Practical Nurse | Confirmed resident oxygen should be at 3 LPM but was observed at 2 LPM |
| ADON | Assistant Director of Nursing | Investigated blood sugar complaint, confirmed white boards contained resident health and insurance information, confirmed urinals should be labeled and bagged |
| DON | Director of Nursing | Confirmed FSBS was not taken as ordered, confirmed expectation that oxygen be checked at correct rate, confirmed patient information should be protected |
| Maintenance Director | Acknowledged facility maintenance issues including bulging ceiling tiles and dusty vents | |
| HSK Supervisor | Housekeeping Supervisor | Confirmed cleaning audit tools, acknowledged staining and splattering on walls, confirmed wheelchair with broken back should not have been given to resident |
| Family Nurse Practitioner | FNP | Stated FSBS should be checked as ordered |
| Head of Housekeeping | Revealed clean clothing transported uncovered in plastic containers without lids |
Inspection Report
Life Safety
Census: 133
Capacity: 176
Deficiencies: 3
Date: Jan 21, 2020
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness requirements at the Rehabilitation Center of South Georgia.
Findings
The facility was found not in substantial compliance with life safety code requirements, including failures in emergency lighting, sprinkler system maintenance, and fire wall integrity, placing residents at risk in the event of an emergency.
Deficiencies (3)
Emergency lighting throughout the facility, including entrance hallway, activity hallway, and showers, failed to illuminate when tested.
Sprinkler heads were found rusted in the conference room and Hallway 200 bathroom, indicating failure to maintain sprinkler system.
Fire wall was penetrated in Hallway 600, compromising smoke barrier construction.
Report Facts
Census: 133
Total Capacity: 176
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting, sprinkler heads, and fire wall penetration during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 7, 2019
Visit Reason
An abbreviated /Partial Extended Survey investigating complaint GA#00193863 was initiated and concluded on 1/7/19.
Complaint Details
Complaint GA#00193863 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated, with no deficiencies found during the investigation.
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 0
Date: Oct 15, 2018
Visit Reason
A revisit survey was conducted in conjunction with an abbreviated/partial survey to investigate complaints GA00191470 and GA00191953.
Complaint Details
The survey was conducted to investigate complaints GA00191470 and GA00191953.
Findings
The revisit and abbreviated partial survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B, with no recommendation for citations.
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 0
Date: Oct 15, 2018
Visit Reason
A revisit survey was conducted in conjunction with an abbreviated/partial survey to investigate complaints GA00191470 and GA00191953.
Complaint Details
Investigation of complaints GA00191470 and GA00191953; no citations recommended.
Findings
The revisit and abbreviated partial survey revealed that the facility was not in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B, with no recommendation for citations.
Report Facts
Resident census: 142
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Routine
Census: 143
Deficiencies: 4
Date: Aug 9, 2018
Visit Reason
A standard survey was conducted at Rehabilitation Center of South Georgia from August 6 to August 9, 2018, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to fully develop comprehensive care plans for mood and behaviors, failure to revise care plans after resident falls, failure to conduct root cause analysis for falls, and failure to provide appropriate mental health treatment and services for a resident with major depressive disorder who expressed suicidal ideations.
Deficiencies (4)
Failed to fully develop comprehensive care plans related to mood and behaviors for one resident (R#134).
Failed to review and/or revise a fall care plan for one resident (R#66) after multiple falls.
Failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and effective fall prevention interventions for one resident (R#66).
Failed to provide appropriate treatment and services for mental/psychosocial concerns for one resident (R#134) with major depressive disorder and suicidal ideations.
Report Facts
Resident census: 143
Sample size: 49
Falls: 7
Cymbalta dosage: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Helped with orders for Cymbalta and monitoring depression behaviors for resident R#134 |
| RN JJ | Registered Nurse, Patient Care Coordinator | Responsible for psychiatric evaluation scheduling for resident R#134 |
| SW HH | Social Worker | Interviewed regarding psychiatric evaluation orders and resident R#134's suicidal statements |
| DON | Director of Nursing | Interviewed regarding fall investigations and mental health care for resident R#134 |
| MD | Medical Director | Interviewed regarding expectations for notification of suicidal statements and psychiatric care |
| Administrator | Interviewed regarding resident care and statements about wanting to die | |
| LPN II | Licensed Practical Nurse | Interviewed regarding resident R#134's mood and dialysis refusals |
| PT | Physical Therapist | Interviewed regarding therapy screening for resident R#66 after falls |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Aug 9, 2018
Visit Reason
The inspection was conducted due to concerns regarding the facility's failure to provide adequate treatment and services to a resident (R#134) who exhibited symptoms of major depressive disorder and expressed suicidal ideations.
Complaint Details
The investigation was complaint-driven based on concerns about the facility's handling of a resident (R#134) who expressed suicidal ideations and refused psychiatric care. The resident repeatedly voiced statements about wanting to die, refused medications, and exhibited behaviors indicating depression and agitation. The facility failed to adequately respond to these behaviors, notify appropriate medical staff, or provide necessary psychiatric evaluation and treatment.
Findings
The facility failed to properly monitor and document the resident's depressive symptoms and suicidal statements, did not notify the attending physician or medical director of the resident's repeated statements about wanting to die, and failed to provide psychiatric or psychological services despite documented needs. The care plan was incomplete and did not fully address the resident's mood and behavioral issues.
Deficiencies (5)
Failure to provide treatment and services to resident with major depressive disorder who repeatedly voiced suicidal ideations.
Failure to monitor and document depressive symptoms in the Medication Administration Record as ordered.
Failure to notify attending physician or medical director of resident's suicidal statements and behaviors.
Failure to provide psychiatric or psychological services despite documented need and resident's refusal.
Failure to fully develop comprehensive care plans related to mood and behaviors for the resident.
Report Facts
Sample size: 49
BIMS score: 14
BIMS score: 10
Medication administration period: 30
Care plan target date: Oct 23, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Helped with orders for Cymbalta and monitoring of depression behaviors; stated nurses did not document monitoring due to electronic record issues. |
| RN JJ | Registered Nurse, Unit 2A Patient Care Coordinator | Added resident to psych evaluation list and provided information about telemedicine psychiatric services. |
| SW HH | Social Worker | Evaluated resident, noted refusal of psychiatric intervention, and acknowledged lack of documentation of refusal. |
| LPN II | Licensed Practical Nurse | Reported resident's refusal of supplements and dialysis and described resident's mood changes. |
| Medical Director | Medical Director | Stated that resident's suicidal statements should have been reported and acted upon; confirmed expectations for staff notification. |
| Administrator | Facility Administrator | Acknowledged resident's statements and care challenges; stated intent to honor resident's rights. |
| LPN FF | Licensed Practical Nurse, MDS Coordinator | Acknowledged not updating behavior care plans despite awareness of resident's suicidal remarks. |
| Nurse Practitioner (NP) | Medical Director's Nurse Practitioner | Ordered Cymbalta initially; was not informed of resident's suicidal statements; noted Cymbalta was not reordered after hospital readmission. |
Inspection Report
Life Safety
Census: 145
Capacity: 178
Deficiencies: 10
Date: Aug 6, 2018
Visit Reason
A Life Safety Code Survey was 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 emergency lighting, hazardous area enclosures, kitchen hood exhaust maintenance, fire alarm system testing, sprinkler system maintenance, corridor door latching, smoke/fire barrier integrity, electrical system maintenance, and oxygen cylinder storage.
Deficiencies (10)
Emergency lighting at the 500 hall exterior exit door was not working.
Hazardous areas such as storage and laundry doors lacked self-closing devices or proper latching.
Kitchen hood exhaust system was not properly cleaned and had heavy grease residue.
Fire alarm system annual inspection showed 3 smoke detectors were not tested.
Sprinkler piping was improperly supporting wiring and other loads in multiple locations.
Dietary kitchen doors on wing #1 and wing #2 were not latching due to missing keeper in lockset.
Smoke barriers had multiple penetrations not properly sealed with listed fire stop systems.
Electrical system deficiencies included uncovered junction boxes, unapproved adapters, and use of extension cords as fixed wiring.
Oxygen cylinder storage room did not separate full and empty cylinders.
Oxygen cylinders were not properly secured to prevent falling and damage.
Report Facts
Census: 145
Total Capacity: 178
Number of smoke detectors not tested: 3
Number of penetrations in smoke barriers not sealed: 10
Number of junction boxes uncovered: 2
Number of unapproved extension cords used as fixed wiring: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 08/06/2018 |
Inspection Report
Re-Inspection
Census: 145
Deficiencies: 0
Date: Apr 24, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in a February 23, 2018 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey from February 23, 2018; all prior deficiencies were corrected.
Findings
All deficiencies cited as a result of the February 23, 2018 Complaint Survey were found to be corrected during this revisit survey.
Report Facts
Census: 145
Inspection Report
Re-Inspection
Census: 142
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/24/17 Standard Survey.
Findings
All deficiencies cited as a result of the 8/24/17 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 6, 2017
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 of the follow-up survey date.
Inspection Report
Life Safety
Census: 134
Capacity: 178
Deficiencies: 15
Date: Aug 22, 2017
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 multiple Life Safety Code requirements including means of egress obstructions, improper locking arrangements, lack of approved guards on ramps, inadequate emergency lighting and exit signage, failure to separate hazardous areas, inadequate cleaning of kitchen exhaust hood, deficient fire alarm system testing, incomplete sprinkler protection and maintenance, improperly mounted fire extinguishers, corridor doors not closing and latching properly, unsealed smoke barrier penetrations, and electrical system code violations.
Deficiencies (15)
Facility failed to maintain exits free from obstructions, placing 22 residents at risk.
Facility failed to provide approved locking arrangements on doors, including multiple locks and latches, placing all residents at risk.
Facility failed to provide approved guards on 4 of 4 landings and ramps greater than 30 inches above grade.
Facility failed to provide emergency lighting throughout the facility.
Facility failed to ensure annual testing and maintenance of exit signage.
Facility failed to separate hazardous areas with smoke resistant partitions.
Facility failed to ensure adequate cleaning of kitchen exhaust hood.
Facility failed to properly test and maintain fire alarm system; 0 of 57 smoke detectors had sensitivity testing.
Facility failed to ensure sprinkler protection throughout the facility; two shower storage rooms not protected.
Facility failed to ensure access to fire department connection and proper clearance to sprinkler heads.
Facility failed to ensure 3 of 25 portable fire extinguishers were correctly mounted.
Facility failed to provide corridor doors that close and latch resisting passage of smoke.
Facility failed to maintain all 1/2 hour fire rated smoke barriers properly; multiple penetrations not sealed.
Facility failed to maintain electrical systems in compliance with NFPA 70; multiple electrical code violations observed.
Facility failed to ensure proper use of electrical extension cords; extension cord used as permanent wiring and surge protector improperly used.
Report Facts
Residents at risk due to exit obstructions: 22
Residents and staff at risk due to hazardous area separation failure: 52
Residents and staff at risk due to sprinkler protection failure: 128
Number of smoke detectors without sensitivity testing: 57
Number of portable fire extinguishers incorrectly mounted: 3
Number of panel boxes with unlabeled breakers: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour on 08/22/2017. | |
| Staff A | Confirmed fire department connection and sprinkler clearance issues during facility tour. |
Inspection Report
Routine
Census: 135
Deficiencies: 2
Date: Aug 21, 2017
Visit Reason
A standard survey was conducted from 8/21/17 through 8/24/17 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance due to improper disposal of garbage and refuse, and failure to maintain an effective pest control program evidenced by observations of trash accumulation, standing water, and live roaches in the kitchen and storage areas.
Deficiencies (2)
Failure to ensure garbage and refuse was properly disposed of and/or contained, including trash bags outside the kitchen door attracting flies and cardboard boxes improperly stored near dumpsters.
Failure to maintain an effective pest control program as evidenced by live and dead roaches observed in the kitchen and dry storage areas, and inadequate pest control vendor documentation and recommendations.
Report Facts
Resident census: 135
Dates of pest control records reviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding trash disposal and pest control issues | |
| Director of Nursing | Interviewed about cardboard storage and pest control issues | |
| Maintenance Director | Interviewed about dumpster and cardboard storage | |
| Maintenance Supervisor | Observed killing a live roach in the kitchen | |
| Administrator | Interviewed regarding pest control program and facility conditions |
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