The most recent inspection on December 23, 2024, substantiated a complaint but did not result in any regulatory deficiencies. Prior inspections showed a pattern of deficiencies related mainly to infection prevention and control, medication storage and administration, resident room cleanliness and maintenance, and safety issues such as unsecured oxygen cylinders and fire safety concerns. Complaint investigations were mostly unsubstantiated, though some earlier complaints were substantiated with deficiencies, particularly regarding wound care and documentation. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed many prior deficiencies, as follow-up surveys frequently noted corrections, indicating some improvement over time despite recurring issues in certain areas.
Deficiencies (last 8 years)
Deficiencies (over 8 years)4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
86420
2017
2018
2019
2020
2021
2022
2023
2024
Census
Latest occupancy rate75 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility had corrected all previously cited deficiencies except for issues related to hazardous area enclosures and gas equipment storage. Specifically, the dirty linen room door did not positively latch upon closing, and medical oxygen cylinders were stored outside in an unsecured location.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Dirty linen room door adjacent to the nursing station did not positively latch upon self-closing.
SS= D
Oxygen cylinders were placed outside of the facility in an unsecured location.
SS= D
Employees Mentioned
Name
Title
Context
Staff M confirmed findings related to the dirty linen room door and oxygen cylinder storage during the tour.
A State Licensure survey was conducted at The Resorts at Pooler Inc. from June 14, 2024 through June 16, 2024 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to provide written bed hold information at transfer, ineffective infection prevention and control program, unsafe medication storage and self-administration practices, unsanitary and poorly maintained resident rooms, and incomplete background checks for some employees.
Deficiencies (5)
Description
Facility failed to provide bed hold information in writing at the time of transfer or within 24 hours for four of six residents reviewed for hospital transfer.
Facility failed to maintain an effective infection prevention and control program with ongoing surveillance and control of infection, lacking documentation for January and February 2024.
Facility failed to ensure unauthorized medications were safely stored and failed to obtain physician order for self-administration of medications for one resident.
Facility failed to ensure resident rooms were clean, homelike, and in good repair on two of three halls, with issues including stained ceiling tiles, dirty curtains, broken sheetrock, missing doorknobs, clutter, and unsanitary conditions.
Facility failed to conduct Georgia Criminal History Check System background checks for three of ten employees reviewed.
Report Facts
Facility census: 77Residents reviewed for bed hold information: 6Residents with missing bed hold info: 4Employees reviewed for background checks: 10Employees without completed background checks: 3
Employees Mentioned
Name
Title
Context
Licensed Practical Nurse AA
Licensed Practical Nurse
Interviewed regarding bed hold policy and medication administration
Unit Manager BB
Unit Manager
Interviewed regarding transfer paperwork and medication self-administration
Director of Nursing
Director of Nursing
Interviewed regarding bed hold policy, infection control, and medication self-administration
Infection Control Preventionist CC
Infection Control Preventionist
Interviewed regarding infection control program and use of McGeer criteria
A standard survey was conducted from June 14 through June 16, 2024, including investigation of Complaint Intake Number GA00246840, which was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure safe medication self-administration and storage, unsanitary and poorly maintained resident rooms, failure to provide written bed hold policy information upon transfer, failure to coordinate PASARR assessments and specialized services, unsafe oxygen equipment storage, and ineffective infection prevention and control program.
Complaint Details
Complaint Intake Number GA00246840 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Severity Breakdown
Level D: 3Level E: 2Level F: 1
Deficiencies (6)
Description
Severity
Failure to ensure unauthorized medications at bedside were safely stored and failure to obtain physician order for self-administration of medications for one resident.
Level D
Failure to ensure resident rooms were clean, homelike, and in good repair on two of three halls.
Level E
Failure to provide bed hold information in writing at time of transfer or within 24 hours for four residents.
Level E
Failure to submit PASARR Level II for one resident after new mental illness diagnosis and failure to implement PASARR recommendations for another resident.
Level D
Failure to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy.
Level D
Failure to maintain an effective infection prevention and control program with ongoing surveillance and use of McGeer criteria for infection tracking.
Level F
Report Facts
Facility census: 76Residents reviewed for bed hold policy: 6Residents with bed hold policy failure: 4Residents with PASARR issues: 2Residents receiving oxygen therapy with unsafe equipment storage: 2Facility census: 77
Employees Mentioned
Name
Title
Context
LPN AA
Licensed Practical Nurse
Interviewed regarding medication administration and self-administration assessment for resident R223.
BB
LPN/Unit Manager
Interviewed regarding residents self-administering medications and medication storage.
DON
Director of Nursing
Interviewed regarding medication self-administration policies, bed hold policies, infection control expectations, and oversight.
Administrator
Interviewed regarding facility repairs and environment.
Housekeeping Supervisor
Interviewed regarding cleaning procedures and staffing.
Maintenance Director
Interviewed regarding maintenance log and repair priorities.
UM DD
Unit Manager
Interviewed regarding PASARR referrals and psychiatric services for resident R16.
SSD
Social Service Director
Interviewed regarding PASARR submissions and psychiatric services.
ICP CC
Infection Control Preventionist
Interviewed regarding infection control program and use of McGeer criteria.
Inspection Report Life SafetyCensus: 76Capacity: 122Deficiencies: 4Jun 15, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to ensure the dirty linen room door positively latched, fire sprinkler heads were free from dust and decorations, extension cords were not used as permanent wiring, and medical oxygen cylinders were not properly secured outside the facility.
Severity Breakdown
SS= D: 3SS= E: 1
Deficiencies (4)
Description
Severity
Dirty linen room door adjacent to the nursing station did not positively latch upon closing.
SS= D
Fire sprinkler heads throughout the facility had accumulated dust and debris and other foreign objects attached.
SS= E
Extension cord was used as a permanent power supply for a freezer in the kitchen mechanical room.
SS= D
Medical oxygen cylinders were placed outside the facility in an unsecured location.
SS= D
Report Facts
Census: 76Total Capacity: 122
Employees Mentioned
Name
Title
Context
Staff M
Confirmed findings during the tour of the facility on 6/15/2024
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate multiple complaint intake numbers from March 4, 2024 through April 30, 2024.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and CMS and CDC recommended practices for COVID-19 preparation. Several complaint intake numbers were substantiated without deficiencies, while others were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00240717, GA00238848, GA00234279, and GA00233071 were substantiated without deficiencies. Complaint Intake Numbers GA00244023, GA00243370, GA00243204, GA00242816, GA00241666, GA00237442, GA00232586, and GA00230491 were unsubstantiated.
Report Facts
Complaint Intake Numbers Investigated: 12
Inspection Report Deficiencies: 0Jan 19, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a healthcare facility inspection conducted at Resorts at Pooler Inc.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
A Licensure Survey was conducted from 11/8/22 through 11/22/22 to assess compliance with medical, dental, and nursing care regulations at Resorts at Pooler Inc.
Findings
The facility failed to ensure that two of three residents reviewed received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers. Documentation and treatment administration records showed missing wound care treatments and inconsistent or inaccurate skin observation documentation for residents #1 and #4.
Deficiencies (2)
Description
Failure to provide necessary wound care treatments and maintain accurate documentation for resident #1, including missing treatments for a femur fracture incision and inconsistent skin observation records.
Failure to provide complete wound care treatments for resident #4, including missing wound care on specified dates and incomplete documentation.
Report Facts
Treatment opportunities missed: 20Residents reviewed: 3Residents with deficiencies: 2
Employees Mentioned
Name
Title
Context
Director of Nursing
Interviewed regarding inability to follow wound care patterns and missing treatments for residents #1 and #4
Administrator
Interviewed regarding gaps in wound care documentation and efforts to hire a wound nurse
An abbreviated survey was conducted to investigate multiple complaint intake numbers related to the facility.
Findings
The facility was found deficient in multiple areas including failure to update care plans related to wound care, failure to provide necessary wound treatments, failure to document Activities of Daily Living (ADL) care and medication administration for several residents, and missing documentation on Medication Administration Records (MARs).
Complaint Details
Complaint intake numbers #GA00225056, GA00226506, GA00226549, GA00226750, GA00226970 and GA00228076 were investigated. Complaints #GA00225056, GA00226750, GA00226970 and GA00228076 were substantiated with deficiencies.
Severity Breakdown
SS=D: 1SS=E: 2
Deficiencies (3)
Description
Severity
Failure to develop or update the care plan of one resident related to wound type, location, and treatment.
SS=D
Failure to ensure two residents received necessary wound treatment and services consistent with professional standards.
SS=E
Failure to document Activities of Daily Living (ADL) care for three residents and medication administration for four residents.
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00224265 and GA00224572.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Complaint Details
The complaints GA00224265 and GA00224572 were investigated and found to be unsubstantiated.
Inspection Report Deficiencies: 0Jun 15, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility Resorts at Pooler Inc, 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 on the page provided.
Inspection Report Deficiencies: 0Jun 15, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted at Resorts at Pooler Inc.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
A Licensure Survey was conducted from 04/19/2022 through 04/22/2022 to assess compliance with licensure requirements.
Findings
The facility failed to ensure that the planned menu was followed regarding portion sizes for nine residents with physician's orders for a pureed diet. Observations on 04/19/2022 and 04/20/2022 revealed that portions served did not match the menu extensions, particularly for pureed diets, including missing pureed bread.
Deficiencies (1)
Description
The facility failed to ensure the planned menu was followed related to portion sizes for nine residents that had physician's orders for a pureed diet.
Report Facts
Number of residents affected: 9Observation date: Apr 19, 2022Observation date: Apr 20, 2022
Employees Mentioned
Name
Title
Context
RR
Dietary Manager
Provided menu extensions and stated staff were supposed to look at the menu extension book
SS
Cook
Described portion sizes served during lunch meal on 04/20/2022
TT
Consultant Registered Dietitian
Explained expectations for following menu and portion sizes
A standard survey was conducted from 4/19/2022 through 4/22/2022, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to follow planned menus for pureed diets and failure to implement an effective infection prevention and control program, specifically inadequate COVID-19 visitor screening and lack of mask encouragement for unvaccinated residents.
Complaint Details
Complaint Intake Numbers GA00219900, GA00222732, GA00222853, and GA00222914 were investigated in conjunction with the standard survey.
Severity Breakdown
SS=E: 2
Deficiencies (2)
Description
Severity
Failure to ensure the planned menu was followed related to portion sizes for nine residents with physician's orders for a pureed diet.
SS=E
Failure to implement an infection prevention and control program to prevent transmission of COVID-19 and other infections, including failure to screen visitors for COVID-19 and failure to encourage mask use and social distancing among unvaccinated residents.
SS=E
Report Facts
Resident census: 73Number of residents not vaccinated: 16Number of residents observed on pureed diet: 9
Employees Mentioned
Name
Title
Context
RR
Dietary Manager
Interviewed regarding menu extensions and portion sizes.
SS
Cook
Interviewed regarding portion sizes served during lunch meals.
TT
Consultant Registered Dietitian
Interviewed regarding expectations for menu and portion size adherence.
AA
Infection Control Preventionist
Interviewed regarding infection control practices and mask use compliance.
Director of Nursing
Interviewed regarding COVID-19 screening and mask use policies; name not fully provided.
Inspection Report Life SafetyCensus: 74Capacity: 122Deficiencies: 1Apr 21, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance because the electrical locking devices on all five egress doors failed to unlock upon activation of the smoke detection system and sprinkler waterflow, potentially placing all 74 residents at risk during an emergency.
Severity Breakdown
SS=F: 1
Deficiencies (1)
Description
Severity
Electrical locks on egress doors did not fail safely upon loss of power and were not programmed to unlock upon activation of smoke detection and sprinkler systems.
SS=F
Report Facts
Number of egress doors with deficient locking: 5Resident census: 74Total certified beds: 122
Employees Mentioned
Name
Title
Context
Staff M
Confirmed findings regarding electrical locking devices during facility tour
A Licensure Survey was conducted from March 1, 2022, through March 3, 2022, to assess compliance with licensure requirements for the facility.
Findings
The facility failed to prepare residents' nutritional meals as directed by the Registered Dietician, affecting 74 of 75 residents receiving an oral diet. Additionally, the facility failed to ensure transportation for three of four dialysis residents to their scheduled treatments, resulting in missed appointments and potential adverse outcomes.
Deficiencies (2)
Description
Facility failed to prepare residents' nutritional meals as directed by Registered Dietician, affecting 74 of 75 residents receiving an oral diet.
Facility failed to ensure transportation was provided for three of four dialysis residents for scheduled treatments at their designated treatment centers.
Report Facts
Residents affected by dietary deficiency: 74Total licensed capacity: 75Missed dialysis appointments for resident #5: 4Missed dialysis appointments for resident #8: 2Missed dialysis appointments for resident #10: 3
Employees Mentioned
Name
Title
Context
Regional Administrator
Revealed facility is visited weekly by himself and Regional Nurse Consultant; discussed dietary staffing and meal preparation issues
Dietary Manager
Explained meal substitutions and freezer malfunction affecting meal preparation
Maintenance Director
Reported freezer malfunction and repair call
Registered Dietician
Not aware of freezer issue until the week of survey; communicated remotely with facility
Unit Manager
Responsible for scheduling appointments and transportation for residents
An Abbreviated/Partial Extended Survey was conducted from March 1 to March 3, 2022, investigating multiple complaints, some substantiated, related to facility deficiencies.
Findings
The facility was found deficient in ensuring reliable transportation for dialysis residents, preparing nutritional meals as directed by the Registered Dietician, implementing a QAPI plan addressing transportation issues, and achieving 100% COVID-19 staff vaccination compliance.
Complaint Details
The survey investigated complaints GA00219665 (unsubstantiated), GA00220357, and GA00221644 (both substantiated with deficiencies).
Severity Breakdown
Level E: 2Level F: 1Level D: 1
Deficiencies (4)
Description
Severity
Failed to ensure transportation was provided for three of four dialysis residents for scheduled treatments.
Level E
Failed to prepare residents' nutritional meals as directed by Registered Dietician, affecting 74 of 75 residents receiving an oral diet.
Level F
Failed to implement a corrective action plan addressing transportation of residents to scheduled appointments.
Level E
Failed to ensure 100% of staff were fully or partially vaccinated against COVID-19.
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of Complaint Intake Number GA00211013.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations. The complaint was unsubstantiated with no deficiencies identified.
Complaint Details
Complaint Intake Number GA00211013 was investigated and found to be unsubstantiated with no deficiencies.
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on January 4 and January 5, 2021. Additionally, an Abbreviated/Partial Extended Survey investigating complaint #GA00210726 was initiated and concluded during this period.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations. The complaint #GA00208530 was unsubstantiated with no deficiencies.
Complaint Details
Complaint #GA00208530 was unsubstantiated with no deficiencies.
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and 42 CFR 483.80 infection control regulations and had implemented recommended practices to prepare for COVID-19.
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess 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 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing recommended practices to prepare for COVID-19.
An abbreviated/partial extended survey was conducted to investigate complaints GA00198441, GA00201037, GA00201477, and GA00202087 from January 13, 2020 to January 16, 2020.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were identified.
Complaint Details
The complaints GA00198441, GA00201037, GA00201477, and GA00202087 were investigated and found to be unsubstantiated with no deficiencies.
A revisit survey was conducted to verify correction of deficiencies cited in the initial survey dated February 7, 2019.
Findings
All deficiencies cited in the initial survey were found to be corrected during the revisit survey.
Inspection Report Life SafetyCensus: 75Capacity: 122Deficiencies: 3Feb 6, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 Edition standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain the boiler room door properly, failure to maintain smoke compartment separation walls, and failure to conduct annual inspections of fire doors as required by NFPA standards.
Severity Breakdown
D: 1F: 2
Deficiencies (3)
Description
Severity
The door to the boiler room was stuck open and lacked a latching mechanism, failing to meet NFPA 101, 2012 Edition requirements.
D
The facility failed to maintain smoke compartment separation walls; points of connection above acoustic ceilings were not sealed to prevent fire and smoke passage.
F
The facility failed to provide annual inspections of all fire doors as required by NFPA 101, 2012 Edition and NFPA 80, 2010 Edition.
F
Report Facts
Residents at risk: 30
Employees Mentioned
Name
Title
Context
Staff M confirmed findings during the facility tour.
A revisit survey was conducted on 8/6/18 through 8/7/18 in conjunction with Complaint Intake Number GA00190056 to verify correction of previous deficiencies.
Findings
All deficiencies cited as a result of the 6/12/18 Abbreviated/Partial Extended Survey were found to be corrected. The complaint was unsubstantiated.
Complaint Details
Complaint Intake Number GA00190056 was investigated and found to be unsubstantiated.
A standard survey was conducted at The Place at Pooler from March 12, 2018 through March 15, 2018 to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Inspection Report Life SafetyCensus: 70Capacity: 88Deficiencies: 3Mar 13, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements at 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements due to multiple deficiencies including obstructed patient room corridor door, combustible storage beneath an exterior porch not protected by sprinklers, and damaged or painted sprinkler heads on the covered driveway canopy.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Patient room corridor door to room A16 was obstructed by a resident's bed preventing it from closing as required by NFPA 101.
SS= D
Combustible storage (waste cooking oil receptacle) was maintained beneath an exterior porch greater than 2 feet not protected by the fire sprinkler system.
SS= D
Fire sprinkler system was not maintained free from foreign material, paint, or physical damage; three concealed sprinkler heads on the covered driveway canopy were damaged or had painted and caulked cover plates.
SS= D
Report Facts
Census: 70Total Capacity: 88Deficiencies cited: 3
Employees Mentioned
Name
Title
Context
Staff M confirmed findings during the inspection but no full name provided
A follow-up to the recertification survey of June 8, 2017, was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of July 23, 2017.
Inspection Report Life SafetyCensus: 75Capacity: 122Deficiencies: 0Jun 5, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements for participation in Medicare/Medicaid and related fire safety standards.