Inspection Report Summary
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 9 years)
Deficiencies (over 9 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
75 residents
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Routine
Deficiencies: 4
Date: Jul 2, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration, pharmaceutical services, drug regimen management, and infection prevention and control at Resorts at Pooler Inc nursing facility.
Findings
The facility failed to follow physician orders for blood pressure monitoring prior to medication administration, failed to ensure timely availability of physician-ordered antibiotics, administered blood pressure medication despite parameters to hold it, and failed to implement enhanced barrier precautions during wound care, all with potential for minimal harm to a few residents.
Deficiencies (4)
Failed to follow physician's order to obtain blood pressure prior to administration of blood pressure medication for one resident.
Failed to ensure a physician-ordered antibiotic was available for timely administration for one resident.
Failed to follow parameters order for blood pressure medication resulting in unnecessary medication administration for one resident.
Failed to place a resident with an open wound in Enhanced Barrier Precautions and failed to follow infection control guidelines during dressing change.
Report Facts
Residents reviewed for medication administration: 16
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication doses not documented as given: 3
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 3 | Admitted not taking blood pressure prior to medication administration and confirmed order entry error | |
| Regional Director of Nursing (RDON) | Stated nurse should have followed physician's order for blood pressure monitoring | |
| Pharmacist | Explained delay in antibiotic delivery due to unconfirmed order | |
| Licensed Practical Nurse (LPN) 3 | Called pharmacy to obtain antibiotic and confirmed order in electronic record | |
| Director of Nursing (DON) | Described medication order confirmation process and expectations for nurses | |
| Licensed Practical Nurse (LPN) 1 | Observed performing dressing change without gown and acknowledged error | |
| Director of Nursing (DON) | Observed lack of gown use during wound care and stated staff should follow enhanced barrier precautions |
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00253214.
Complaint Details
Complaint GA00253214 was substantiated with no regulatory violations cited.
Findings
The complaint GA00253214 was substantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 26, 2024
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Deficiencies: 0
Date: Aug 1, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Resorts at Pooler Inc, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
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.
Deficiencies (2)
Dirty linen room door adjacent to the nursing station did not positively latch upon self-closing.
Oxygen cylinders were placed outside of the facility in an unsecured location.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings related to the dirty linen room door and oxygen cylinder storage during the tour. |
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 0
Date: Jul 31, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/16/2024 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 5
Date: Jun 16, 2024
Visit Reason
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)
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: 77
Residents reviewed for bed hold information: 6
Residents with missing bed hold info: 4
Employees reviewed for background checks: 10
Employees 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 |
| Human Resources | Human Resources | Interviewed regarding employee background checks |
Inspection Report
Routine
Census: 76
Deficiencies: 6
Date: Jun 16, 2024
Visit Reason
A standard survey was conducted from June 14 through June 16, 2024, including investigation of Complaint Intake Number GA00246840, which was unsubstantiated.
Complaint Details
Complaint Intake Number GA00246840 was investigated in conjunction with the standard survey and was found to be 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.
Deficiencies (6)
Failure to ensure unauthorized medications at bedside were safely stored and failure to obtain physician order for self-administration of medications for one resident.
Failure to ensure resident rooms were clean, homelike, and in good repair on two of three halls.
Failure to provide bed hold information in writing at time of transfer or within 24 hours for four residents.
Failure to submit PASARR Level II for one resident after new mental illness diagnosis and failure to implement PASARR recommendations for another resident.
Failure to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy.
Failure to maintain an effective infection prevention and control program with ongoing surveillance and use of McGeer criteria for infection tracking.
Report Facts
Facility census: 76
Residents reviewed for bed hold policy: 6
Residents with bed hold policy failure: 4
Residents with PASARR issues: 2
Residents receiving oxygen therapy with unsafe equipment storage: 2
Facility 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
Routine
Deficiencies: 6
Date: Jun 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident environment, bed hold policies, PASRR screening, respiratory care, and infection control.
Findings
The facility was found deficient in several areas including unsafe medication storage and lack of physician orders for self-administration, unsanitary and poorly maintained resident rooms, failure to provide written bed hold information at transfer, failure to submit and implement PASRR Level II screenings and recommendations, unsafe storage of oxygen equipment, and inadequate infection prevention and control program implementation.
Deficiencies (6)
Failed to ensure unauthorized medications at the bedside were safely stored and failed to obtain a physician order for self-administration of medications for one resident.
Failed to ensure resident rooms were clean, homelike, and in good repair on two of three halls, placing residents at risk of unsanitary living environment.
Failed to provide bed hold information in writing at the time of transfer or within 24 hours for four residents, risking denial of re-admission and loss of resident's home.
Failed to submit for a PASRR Level II for one resident after new mental illness diagnosis and failed to implement PASRR Level II recommendations for another resident.
Failed to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy, increasing risk of respiratory infection.
Failed to maintain an effective infection prevention and control program with ongoing surveillance, recognition, investigation, and control of infection, increasing exposure risk to communicable illnesses.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 77
Residents affected: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding medication self-administration and bed hold policy |
| Director of Nursing | Director of Nursing | Interviewed regarding medication self-administration, bed hold policy, oxygen equipment storage, infection control, and PASRR screening |
| LPN/Unit Manager BB | LPN/Unit Manager | Interviewed regarding medication self-administration and bed hold policy |
| Housekeeping Supervisor | Interviewed regarding room cleaning and maintenance staffing | |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance logbook and repair priorities |
| Administrator | Administrator | Interviewed regarding facility repairs and bed hold policy |
| Social Service Director | Social Service Director | Interviewed regarding PASRR Level II submission and psychiatric services |
| Unit Manager DD | Unit Manager | Interviewed regarding psychiatric services for resident with PASRR Level II |
| Infection Control Preventionist CC | Infection Control Preventionist | Interviewed regarding infection control program and use of McGeer criteria |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 16, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, resident environment, bed hold policies, PASRR screenings, respiratory care, and infection control at Resorts at Pooler Inc nursing home.
Findings
The facility was found deficient in multiple areas including failure to ensure safe medication self-administration and storage, inadequate cleanliness and maintenance of resident rooms, failure to provide written bed hold information at transfer, failure to submit and implement PASRR Level II screenings and recommendations, unsafe storage of oxygen equipment, and lack of effective infection prevention and control program using McGeer criteria.
Deficiencies (6)
Failed to ensure unauthorized medications at bedside were safely stored and failed to obtain physician order for self-administration of medications for one resident.
Failed to ensure resident rooms were clean, homelike, and in good repair on two of three halls.
Failed to provide bed hold information in writing at time of transfer or within 24 hours for four residents.
Failed to submit PASRR Level II for one resident after new mental illness diagnosis and failed to implement PASRR Level II recommendations for another resident.
Failed to ensure oxygen equipment was safely stored for two residents receiving oxygen therapy.
Failed to maintain an effective infection prevention and control program demonstrating ongoing surveillance, recognition, investigation, and control of infection using McGeer criteria.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding medication self-administration and bed hold policy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication self-administration, bed hold policy, oxygen equipment storage, infection control program, and PASRR screenings |
| LPN/Unit Manager BB | LPN/Unit Manager | Interviewed regarding medication self-administration and bed hold policy |
| Housekeeping Supervisor | Interviewed regarding room cleaning and staffing | |
| Maintenance Director | Interviewed regarding maintenance log and repairs | |
| Administrator | Interviewed regarding maintenance and bed hold policy | |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASRR screening submissions and psychiatric services |
| Unit Manager DD | Unit Manager | Interviewed regarding psychiatric services for resident with PASRR Level II |
| Infection Control Preventionist CC | Infection Control Preventionist | Interviewed regarding infection control program and use of McGeer criteria |
Inspection Report
Life Safety
Census: 76
Capacity: 122
Deficiencies: 4
Date: Jun 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.
Deficiencies (4)
Dirty linen room door adjacent to the nursing station did not positively latch upon closing.
Fire sprinkler heads throughout the facility had accumulated dust and debris and other foreign objects attached.
Extension cord was used as a permanent power supply for a freezer in the kitchen mechanical room.
Medical oxygen cylinders were placed outside the facility in an unsecured location.
Report Facts
Census: 76
Total Capacity: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the tour of the facility on 6/15/2024 |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
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.
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.
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.
Report Facts
Complaint Intake Numbers Investigated: 12
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 30, 2024
Visit Reason
Annual survey inspection of Resorts at Pooler Inc to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Jan 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.
Inspection Report
Re-Inspection
Census: 75
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 11/22/22 Complaint Survey.
Findings
All deficiencies cited as a result of the 11/22/22 Complaint Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 2
Date: Nov 22, 2022
Visit Reason
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)
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: 20
Residents reviewed: 3
Residents 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 |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Nov 22, 2022
Visit Reason
An abbreviated survey was conducted to investigate multiple complaint intake numbers related to the facility.
Complaint Details
Complaint intake numbers #GA00225056, GA00226506, GA00226549, GA00226750, GA00226970 and GA00228076 were investigated. Complaints #GA00225056, GA00226750, GA00226970 and GA00228076 were substantiated with deficiencies.
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).
Deficiencies (3)
Failure to develop or update the care plan of one resident related to wound type, location, and treatment.
Failure to ensure two residents received necessary wound treatment and services consistent with professional standards.
Failure to document Activities of Daily Living (ADL) care for three residents and medication administration for four residents.
Report Facts
Missing medication administration dates: 40
Missing ADL documentation days: 10
Missed wound treatment opportunities: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Assistant Director of Nursing | Confirmed care plan deficiencies and documentation issues related to wound care for Resident #1. |
| Director of Nursing | Director of Nursing | Confirmed inability to follow wound care patterns and missing wound care documentation for Residents #1 and #4. |
| KK | Regional Director | Indicated lack of ADL documentation records for most residents and inability to explain the absence. |
| Administrator | Administrator | Acknowledged gaps in wound care documentation and ADL documentation history; discussed ongoing education and efforts to improve. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2022
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 the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2022
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 the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2022
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 the follow-up survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 17, 2022
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
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Jun 15, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00224265 and GA00224572.
Complaint Details
The complaints GA00224265 and GA00224572 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Date: Jun 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: 0
Date: Jun 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.
Inspection Report
Renewal
Deficiencies: 1
Date: Apr 22, 2022
Visit Reason
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)
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: 9
Observation date: Apr 19, 2022
Observation 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 |
Inspection Report
Routine
Census: 73
Deficiencies: 2
Date: Apr 22, 2022
Visit Reason
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.
Complaint Details
Complaint Intake Numbers GA00219900, GA00222732, GA00222853, and GA00222914 were investigated in conjunction with the standard survey.
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.
Deficiencies (2)
Failure to ensure the planned menu was followed related to portion sizes for nine residents with physician's orders for a pureed diet.
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.
Report Facts
Resident census: 73
Number of residents not vaccinated: 16
Number 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 Safety
Census: 74
Capacity: 122
Deficiencies: 1
Date: Apr 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.
Deficiencies (1)
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.
Report Facts
Number of egress doors with deficient locking: 5
Resident census: 74
Total certified beds: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding electrical locking devices during facility tour |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 19, 2022
Visit Reason
The inspection was conducted to assess compliance with nutritional needs and infection prevention and control protocols, including COVID-19 related measures, at the facility.
Findings
The facility failed to ensure that the planned menu was followed for nine residents on pureed diets, with discrepancies in portion sizes served versus menu specifications. Additionally, the facility failed to implement an effective infection prevention and control program, including failure to screen visitors for COVID-19 and failure to encourage mask use and social distancing among unvaccinated residents during the COVID-19 pandemic.
Deficiencies (2)
Failure to ensure the planned menu was followed related to portion sizes for nine residents on pureed diets.
Failure to implement an infection prevention and control program, including failure to screen visitors for COVID-19 and failure to encourage mask use and social distancing among unvaccinated residents.
Report Facts
Residents affected: 9
Residents not vaccinated: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR | Dietary Manager | Provided menu extensions and information about portion sizes |
| TT | Consultant Registered Dietitian | Provided expectations regarding menu and portion size adherence |
| AA | Infection Control Preventionist | Reported non-compliance with mask use and screening procedures |
| DON | Director of Nursing | Acknowledged failure to screen visitors and discussed facility routines and vaccination status |
Inspection Report
Renewal
Capacity: 75
Deficiencies: 2
Date: Mar 3, 2022
Visit Reason
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)
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: 74
Total licensed capacity: 75
Missed dialysis appointments for resident #5: 4
Missed dialysis appointments for resident #8: 2
Missed 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 | |
| Certified Nursing Assistant FF | CNA | Reported transportation problems causing missed dialysis appointments |
| Director of Nursing | DON | Confirmed transportation issues and described nurse responsibilities for managing missed dialysis appointments |
| Medical Director | Notified of missed dialysis appointments and discussed clinical implications | |
| Administrator | Confirmed transportation issues and backup transport arrangements |
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 4
Date: Mar 3, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from March 1 to March 3, 2022, investigating multiple complaints, some substantiated, related to facility deficiencies.
Complaint Details
The survey investigated complaints GA00219665 (unsubstantiated), GA00220357, and GA00221644 (both substantiated with 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.
Deficiencies (4)
Failed to ensure transportation was provided for three of four dialysis residents for scheduled treatments.
Failed to prepare residents' nutritional meals as directed by Registered Dietician, affecting 74 of 75 residents receiving an oral diet.
Failed to implement a corrective action plan addressing transportation of residents to scheduled appointments.
Failed to ensure 100% of staff were fully or partially vaccinated against COVID-19.
Report Facts
Missed dialysis appointments: 9
Staff vaccination rate: 80.5
Total staff: 87
Vaccinated staff: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transportation issues and QAPI plan. |
| Medical Director | Medical Director | Interviewed about missed dialysis appointments and transportation reliability. |
| Administrator | Facility Administrator | Interviewed confirming transportation and vaccination issues. |
| Dietary Manager | Dietary Manager | Interviewed about meal preparation and freezer malfunction. |
| Registered Dietician | Registered Dietician (RD) | Interviewed about communication and nutritional adequacy. |
| Regional Administrator | Regional Administrator | Interviewed regarding dietary staffing and meal concerns. |
| Certified Nursing Assistant FF | Certified Nursing Assistant (CNA) | Interviewed about transportation problems for dialysis residents. |
| Unit Manager | Unit Manager | Interviewed about scheduling appointments and transportation. |
| Maintenance Director | Maintenance Director | Interviewed about freezer malfunction. |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an investigation of Complaint Intake Number GA00211013.
Complaint Details
Complaint Intake Number GA00211013 was investigated and found to be unsubstantiated with no deficiencies.
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.
Report Facts
Total census: 66
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
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.
Complaint Details
Complaint #GA00208530 was unsubstantiated with no deficiencies.
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.
Report Facts
Total census: 66
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00210308.
Complaint Details
Complaint #GA00210308 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the investigation.
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
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.
Report Facts
Total census: 78
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00210165.
Complaint Details
Complaint #GA00210165 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint #GA00210165 was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA000208619 and GA00208754.
Complaint Details
Complaints #GA000208619 and GA00208754 were investigated and found not substantiated.
Findings
The complaints #GA000208619 and GA00208754 were not substantiated and no regulatory violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint # GA00207376.
Complaint Details
Complaint # GA00207376 was investigated and found to be unsubstantiated without deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Date: Jul 14, 2020
Visit Reason
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.
Report Facts
Total census: 82
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 16, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00198441, GA00201037, GA00201477, and GA00202087 from January 13, 2020 to January 16, 2020.
Complaint Details
The complaints GA00198441, GA00201037, GA00201477, and GA00202087 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were identified.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
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
Routine
Census: 75
Deficiencies: 4
Date: Feb 7, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, pain management, infection control, and care planning at Resorts at Pooler Inc nursing home.
Findings
The facility failed to ensure proper PASARR Level II screening for one resident, did not follow the pain management plan for one resident including failure to assess pain every shift, and failed to prevent cross contamination of laundry affecting all residents.
Deficiencies (4)
Failed to ensure a PASARR Level II screening for one resident with major depressive disorder and psychotic features.
Failed to follow the plan of care related to pain management for one resident, including failure to assess pain every shift and missing orders on the Medication Administration Record.
Failed to complete a pain assessment every shift for one resident requiring such services.
Failed to assure cross contamination prevention in laundry handling, including soiled laundry touching staff uniforms and clean linens being contaminated by falling on the floor.
Report Facts
Facility census: 75
Sample size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in pain management deficiency related to pain assessments and medication administration |
| Director of Nursing | Director of Nursing (DON) | Discussed issues with pharmacy orders and pain management deficiencies |
| Social Service Director | Social Service Director (SSD) | Interviewed regarding PASARR screening procedures |
| Administrator | Administrator | Interviewed regarding staff expectations for PASRR form reviews |
| EE | Laundry Aide | Observed and interviewed regarding laundry handling deficiencies |
| Environmental Coordinator | Environmental Coordinator | Interviewed regarding laundry handling policies and PPE use |
Inspection Report
Life Safety
Census: 75
Capacity: 122
Deficiencies: 3
Date: Feb 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.
Deficiencies (3)
The door to the boiler room was stuck open and lacked a latching mechanism, failing to meet NFPA 101, 2012 Edition requirements.
The facility failed to maintain smoke compartment separation walls; points of connection above acoustic ceilings were not sealed to prevent fire and smoke passage.
The facility failed to provide annual inspections of all fire doors as required by NFPA 101, 2012 Edition and NFPA 80, 2010 Edition.
Report Facts
Residents at risk: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the facility tour. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 7, 2018
Visit Reason
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.
Complaint Details
Complaint Intake Number GA00190056 was investigated and found to be unsubstantiated.
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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 7, 2018
Visit Reason
A revisit survey was conducted on 8/6/18 through 8/7/18 in conjunction with investigation of Complaint Intake Number GA00190056.
Complaint Details
Complaint Intake Number GA00190056 was investigated and found to be unsubstantiated.
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 12, 2018
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.
Inspection Report
Routine
Census: 71
Deficiencies: 0
Date: Mar 15, 2018
Visit Reason
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 Safety
Census: 70
Capacity: 88
Deficiencies: 3
Date: Mar 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.
Deficiencies (3)
Patient room corridor door to room A16 was obstructed by a resident's bed preventing it from closing as required by NFPA 101.
Combustible storage (waste cooking oil receptacle) was maintained beneath an exterior porch greater than 2 feet not protected by the fire sprinkler system.
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.
Report Facts
Census: 70
Total Capacity: 88
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the inspection but no full name provided |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 27, 2017
Visit Reason
An unannounced complaint survey was conducted to investigate Complaint intake number #GA00179149.
Complaint Details
Complaint intake number #GA00179149 was investigated and found unsubstantiated with no deficiencies cited.
Findings
The complaints were found to be unsubstantiated and no deficiencies were cited during the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 3, 2017
Visit Reason
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 Safety
Census: 75
Capacity: 122
Deficiencies: 0
Date: Jun 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 12, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00174717 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00174717 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey conducted between 5/11/17 and 5/12/17 at The Place at Pooler.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 15, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaints 167330, 161982, 166198, 161488, and 172196 at The Place in Pooler.
Complaint Details
The survey was complaint-related, investigating multiple complaints as listed, with findings indicating substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
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