Inspection Report
Plan of Correction
Deficiencies: 0
Dec 27, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Sadie G. Mays Health & Rehabilitation Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 148
Deficiencies: 0
Dec 27, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the Recertification-Complaint Survey concluded on 2024-10-24.
Findings
All deficiencies cited in the prior Recertification-Complaint Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 26, 2024
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 deficiencies have been corrected.
Inspection Report
Original Licensing
Deficiencies: 2
Oct 24, 2024
Visit Reason
A Licensure Survey was conducted from 10/22/2024 through 10/24/2024 to assess compliance with licensure requirements and facility policies.
Findings
The facility failed to ensure proper sanitation and labeling of nebulizers, oxygen concentrator tubing, and bedpans; failed to properly clean and disinfect the medication cart and provide a clean barrier for accu-checks; and failed to provide preventative care consistent with professional standards for a resident at risk for skin breakdown related to repositioning.
Deficiencies (2)
| Description |
|---|
| Nebulizers were not bagged, dated, and labeled for two of three residents; oxygen concentrator tubing was undated and filter was dirty for one resident; bedpans were improperly stored unbagged and unlabeled; medication cart was not properly cleaned and no clean barrier was provided for accu-checks. |
| Preventative care for skin breakdown was inadequate for one resident at risk, with repositioning documented as incomplete. |
Report Facts
Repositioning opportunities: 96
Repositioning documented: 59
Sampled residents: 58
Residents with nebulizer issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| D Hall | Unit Manager | Interviewed regarding improper storage of bedpans. |
| MM | Licensed Practical Nurse (LPN) | Interviewed about monitoring and sanitation of oxygen concentrators and nebulizers. |
| MM | Director of Nursing (DON) | Interviewed about expectations for cleaning nebulizers and medication administration. |
| LL | Certified Nurse Assistant (CNA) | Interviewed about supervision and education on oxygen machines and nebulizers. |
Inspection Report
Annual Inspection
Census: 150
Deficiencies: 8
Oct 24, 2024
Visit Reason
A recertification survey was conducted from October 22, 2024 through October 24, 2024, including investigation of multiple substantiated complaints related to abuse and other regulatory compliance issues.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to timely report and thoroughly investigate abuse allegations, incomplete Minimum Data Set (MDS) assessments, lack of baseline care plans, inadequate preventative care for skin breakdown, improper infection control practices, malfunctioning call light system, and failure to maintain antibiotic stewardship documentation.
Complaint Details
Complaint Intake Numbers GA 00249231, GA00248869, GA00251060, GA00250242, GA00248615, and GA00250077 were investigated and all were substantiated.
Severity Breakdown
SS= D: 6
SS= F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to report allegations of sexual abuse timely for two residents. | SS= D |
| Failed to complete thorough investigations of abuse for three residents. | SS= D |
| Failed to ensure quarterly MDS assessments were completed for two residents. | SS= D |
| Failed to complete baseline care plan for one resident with a supra-pubic catheter. | SS= D |
| Failed to provide preventative care consistent with professional standards for one resident at risk for skin breakdown related to repositioning. | SS= D |
| Failed to ensure proper infection control practices including nebulizer and oxygen concentrator maintenance, bedpan storage, and medication administration procedures. | SS= F |
| Failed to maintain review and documentation of antibiotic prescribing practices and stewardship efforts for nine months. | SS= F |
| Failed to ensure one resident had a functioning call light system. | SS= D |
Report Facts
Residents present: 150
MDS assessments missed: 2
Repositioning opportunities: 96
Repositioning documented: 59
Months of antibiotic stewardship data missing: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse (LPN) | Documented abuse incidents involving resident R98 |
| CC | Licensed Practical Nurse (LPN) | Documented abuse incident involving residents R98 and R10 |
| Administrator | Abuse Coordinator responsible for reporting and investigation | |
| DON | Director of Nursing | Responsible for abuse investigations and staff education |
| NN | Minimum Data Set Coordinator/Licensed Practical Nurse (LPN) | Confirmed missing baseline care plan for resident R355 |
| OO | Minimum Data Set Coordinator | Confirmed missing MDS assessment for resident R405 |
| LL | Certified Nurse Assistant (CNA) | Described proper use and cleaning of oxygen machines and nebulizers |
| MM | Licensed Practical Nurse (LPN) | Described monitoring and cleaning of oxygen concentrators and nebulizers |
| D Hall | Unit Manager | Commented on improper storage of bedpans |
| Maintenance Director | Tested and confirmed malfunctioning call light system | |
| Infection Control Preventionist | Described infection control duties and antibiotic stewardship monitoring |
Inspection Report
Life Safety
Census: 151
Capacity: 206
Deficiencies: 3
Oct 23, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically related to the fire alarm system installation and sprinkler system maintenance. Deficiencies included undated fire alarm control panel batteries, a missing sprinkler escutcheon plate in the kitchen, and a spare sprinkler box lacking a sprinkler wrench.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire alarm control panel batteries were not dated with the manufacturer's date. | D |
| Sprinkler escutcheon plate missing in the kitchen near the dishwashing area. | D |
| Spare sprinkler box did not house a sprinkler wrench. | D |
Report Facts
Smoke compartments affected: 1
Census: 151
Total licensed beds: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm system and sprinkler system deficiencies during facility tour. |
Inspection Report
Re-Inspection
Census: 145
Deficiencies: 0
Aug 23, 2024
Visit Reason
A revisit survey was conducted from 8/22/2024 through 8/23/2024 to verify correction of deficiencies cited during the 6/26/2024 Complaint and Focused Infection Control Survey.
Findings
All deficiencies cited as a result of the 6/26/2024 Complaint and Focused Infection Control Survey were found to be corrected.
Complaint Details
The revisit survey was related to a complaint investigation conducted on 6/26/2024; all cited deficiencies were corrected.
Inspection Report
Complaint Investigation
Census: 150
Deficiencies: 13
Jun 26, 2024
Visit Reason
A Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended survey investigating multiple complaints initiated on 2024-05-02 and concluded on 2024-06-26.
Findings
The facility was found not in compliance with infection control regulations, with harm identified related to medication errors and pest infestation. Deficiencies were found in reasonable accommodations, safe environment, staff background checks, complaint reporting, care planning, ADL care, medication administration, staff licensure, infection control, COVID-19 vaccination consent, and pest control.
Complaint Details
The survey was initiated based on multiple complaint numbers including GA00236153, GA00236989, GA00238550, GA00238994, GA00239097, GA00239261, GA00239810, GA00241715, GA00241717, GA00243898, GA00244895, GA00246253, GA00247484, and GA00247622. Some complaints were substantiated with deficiencies, others were unsubstantiated or substantiated with no deficiencies.
Severity Breakdown
D: 5
E: 2
F: 2
G: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to provide reasonable accommodations for residents related to wheelchair accessibility and bathing preferences. | D |
| Failure to maintain a safe, clean, and comfortable environment including dirt buildup in air discharge grilles, holes in bathroom and resident rooms, and inadequate linen supply. | E |
| Failure to conduct criminal background checks for two registered nurses prior to employment. | D |
| Failure to report misappropriation of controlled drugs to the State Survey Agency. | D |
| Failure to develop comprehensive, person-centered care plans for multiple residents including ADLs, falls, fractures, oxygen use, and BiPAP/CPAP. | D |
| Failure to provide ADL care assistance to a resident resulting in unclean appearance and unmet hygiene needs. | D |
| Failure to provide adequate nursing care related to pain management, medication administration without physician order, and pest infestation in resident's room. | G |
| Failure to ensure timely renewal of CNA certifications resulting in staff working with expired certifications. | F |
| Failure to ensure resident was free from unnecessary psychotropic medication; Fluoxetine was administered for 48 weeks after discontinuation. | G |
| Failure to ensure staff licensure was current; RN worked with lapsed license. | D |
| Failure to maintain infection control standards including cleaning and disinfecting reusable items between residents and performing hand hygiene during medication administration. | F |
| Failure to obtain vaccination consent before administering COVID-19 vaccines to residents. | D |
| Failure to maintain an effective pest control program related to infestation of black gnats on one unit. | E |
Report Facts
Residents present: 150
Pain level: 7
Medication administration count: 57
Medication administration count: 5
CNA certification lapse duration: 6
CNA certification lapse duration: 1
RN worked with lapsed license: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN HH | Registered Nurse Supervisor | Worked with lapsed RN license |
| CNA TT | Certified Nursing Assistant | Worked 6 months with expired certification |
| CNA UU | Certified Nursing Assistant | Worked 1 month with expired certification |
| LPN NN | Licensed Practical Nurse | Administered Fluoxetine (Prozac) without physician order |
| Human Resources Director | Responsible for hiring and license verification | |
| Psychiatrist EEE | Psychiatrist | Discontinued Fluoxetine (Prozac) and prescribed alternative |
| Pharmacist | Confirmed pharmacy dispensed discontinued medication | |
| Maintenance Director QQ | Maintenance Director | Oversees pest control program |
| Unit Manager JJ | Unit Manager | Reported pest infestation |
| Director of Health Services | Oversight of nursing and infection control | |
| RN SS | Registered Nurse | Failed to clean equipment and perform hand hygiene |
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 9, 2023
Visit Reason
An Abbreviated Partial Extended survey was conducted to investigate complaints #GA00233964, #GA00233533, #GA00233350, and #GA00232277.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00233964, #GA00233533, #GA00233350, and #GA00232277 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Census: 147
Deficiencies: 0
Feb 9, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Survey investigating complaints #GA00229051, #GA00230754, and #GA00230883 was conducted.
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.
Complaint Details
Complaints #GA00229051, #GA00230754, and #GA00230883 were investigated and found to be unsubstantiated.
Report Facts
Total census: 147
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 15, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Sadie G. Mays Health & Rehabilitation Center following a survey completed on 11/15/2022.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Nov 15, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 19, 2022 Recertification with Complaints Survey.
Findings
All deficiencies cited in the prior August 19, 2022 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 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 during the Follow-Up Survey.
Inspection Report
Renewal
Deficiencies: 3
Aug 19, 2022
Visit Reason
A Licensure Survey was conducted from 8/15/22 through 8/19/22 to assess compliance with licensure requirements for Sadie G. Mays Health & Rehabilitation Center.
Findings
The survey identified deficiencies including failure to provide privacy curtains for two residents, failure to maintain a secure locked medication cart, and a medication error rate exceeding 5% due to incorrect administration and missed application of medications.
Deficiencies (3)
| Description |
|---|
| Facility failed to provide a privacy curtain to ensure personal privacy for two of 45 sampled residents (R#16 and R#47). |
| Facility failed to maintain a secure, locked medication cart for one out of six medication carts. |
| Facility failed to maintain a medication error rate of 5% or less, with two errors out of 27 opportunities observed during medication pass for two residents (R#105 and R#106). |
Report Facts
Residents sampled: 45
Medication carts: 6
Medication error rate: 7.4
Medication errors: 2
Medication opportunities: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN SS | Licensed Practical Nurse | Observed walking past unlocked medication cart and locking it |
| LPN TT | Licensed Practical Nurse | Observed leaving medication cart unlocked and behind curtain with resident |
| LPN UU | Licensed Practical Nurse | Interviewed about medication cart locking policy |
| LPN VV | Licensed Practical Nurse | Administered chewable aspirin instead of enteric coated aspirin |
| LPN JJ | Licensed Practical Nurse | Failed to apply diclofenac cream as ordered during medication administration |
| Director of Nursing | Director of Nursing | Provided expectations regarding privacy curtains and medication cart security |
| Administrator | Administrator | Provided expectations regarding privacy curtains and medication administration |
| Maintenance Director | Maintenance Director | Reported on privacy curtain track repair and reinstallation |
| Laundry Aide WW | Laundry Aide | Provided information about responsibility for hanging privacy curtains |
Inspection Report
Routine
Census: 142
Deficiencies: 4
Aug 19, 2022
Visit Reason
A standard survey was conducted from August 15, 2022 through August 19, 2022, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide privacy curtains for residents, failure to follow physician orders for oxygen administration, medication errors exceeding 5%, and unsecured medication carts.
Complaint Details
Complaint Intake Numbers GA00219180, GA00220142, GA00220212, GA00221658, GA00222055, GA00223943, GA00224349 were investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide a privacy curtain to ensure personal privacy for two residents. | SS= D |
| Failed to follow physician orders related to oxygen administration for two residents. | SS= D |
| Failed to maintain a medication error rate of 5% or less; two errors out of 27 opportunities (7.4% error rate). | SS= D |
| Failed to maintain a secure, locked medication cart; observed unlocked and unattended medication carts. | SS= D |
Report Facts
Resident census: 142
Medication error rate: 7.4
Medication error count: 2
Medication administration opportunities: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN VV | Licensed Practical Nurse | Administered chewable aspirin instead of enteric coated aspirin |
| LPN JJ | Licensed Practical Nurse | Forgot to apply diclofenac cream during medication administration |
| LPN SS | Licensed Practical Nurse | Observed medication cart unlocked and locked it |
| LPN TT | Licensed Practical Nurse | Observed with unlocked medication cart outside resident room |
| Director of Nursing | Director of Nursing | Stated expectation that medication carts be locked at all times and privacy curtains be maintained |
| Administrator | Administrator | Stated expectation that medication carts be secure and privacy curtains be replaced promptly |
Inspection Report
Routine
Census: 144
Capacity: 206
Deficiencies: 6
Aug 16, 2022
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program, Life Safety Code compliance, and related regulatory requirements.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements, including lack of documentation for emergency exercises and plan updates, and deficiencies in fire alarm system readiness, sprinkler system maintenance, electrical safety, and emergency power system testing.
Severity Breakdown
SS=F: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| No documentation available that the emergency preparedness plan included an organized full size or tabletop exercise and no physical record of training or documented 'after action' reports of any exercises. | SS=F |
| No documentation available showing that the emergency preparedness plan had been updated or approved in the last year. | SS=F |
| Facility fire alarm system was in trouble and silenced, affecting 1 of 4 smoke compartments. | SS=F |
| Fire sprinkler system 5-year inspection, testing, and maintenance was overdue by several months; missing sprinkler escutcheon plate near back door. | SS=F |
| Therapy tools (walkers) placed in front of electrical panel box and Multiple Outlet Power Supply device located on the floor in therapy center, creating electrical hazards. | SS=F |
| Emergency backup power system 4-hour load test required every three years was overdue. | SS=F |
Report Facts
Census: 144
Total Capacity: 206
Date of Survey: Aug 16, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed findings related to emergency preparedness plan documentation and exercise deficiencies. | ||
| Staff M | Confirmed findings related to fire alarm system trouble, sprinkler system deficiencies, electrical hazards, and emergency power system testing. |
Inspection Report
Abbreviated Survey
Census: 140
Deficiencies: 0
Aug 30, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a COVID-19 Focused Infection Control Survey to investigate multiple complaints and assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control. One complaint was unsubstantiated, and several complaints were substantiated with no deficiencies identified.
Complaint Details
Complaint #GA00216442 was unsubstantiated. Complaints #GA00216097, #GA00215471, #GA00215114, #GA00214588, #GA00213623, and #GA00212558 were substantiated with no deficiencies.
Report Facts
Resident Census: 140
Inspection Report
Abbreviated Survey
Census: 148
Deficiencies: 0
Feb 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted along with an Abbreviated/Partial Extended Survey investigating complaint numbers GA00211743 and GA00209935.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended COVID-19 practices. Complaint #GA00211743 was substantiated with no regulatory violations cited, and complaint #GA00209935 was unsubstantiated with no violations cited.
Complaint Details
Complaint #GA00211743 was substantiated with no regulatory violations cited. Complaint #GA00209935 was unsubstantiated with no regulatory violations cited.
Report Facts
Total census: 148
Inspection Report
Deficiencies: 0
Dec 22, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Sadie G. Mays Health & Rehabilitation Center following a survey completed on December 22, 2020.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 154
Deficiencies: 0
Dec 22, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of the 10/29/2020 Complaint and COVID-19 Infection Control Survey.
Findings
All deficiencies cited in the prior complaint and COVID-19 infection control survey were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a complaint investigation dated 10/29/2020.
Report Facts
Census: 154
Inspection Report
Original Licensing
Deficiencies: 3
Oct 29, 2020
Visit Reason
A Licensure Survey was conducted from 10/26/2020 through 10/29/2020 to assess compliance with licensure requirements for the facility.
Findings
The facility was found deficient in notifying the resident's responsible party of significant changes in condition, failure to follow transmission-based precautions on the COVID-19 isolation unit, and failure to maintain an effective pest control program with inadequate cleaning of soiled utility rooms.
Deficiencies (3)
| Description |
|---|
| Failure to notify the resident's Responsible Party (legal guardian) of a significant change in condition for Resident #3. |
| Failure to follow transmission-based precautions prior to entering and exiting the Level II COVID-19 isolation unit, including improper use of PPE by staff and transporters. |
| Failure to maintain an effective pest control program, including failure to clean and maintain three of four soiled utility rooms as recommended by pest control service provider. |
Report Facts
Residents on Level II unit: 11
Dates of Licensure Survey: Survey conducted from 2020-10-26 through 2020-10-29.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LL | Social Worker | Interviewed regarding Resident #3's legal guardian and notification requirements. |
| DHS | Director of Health Services | Interviewed regarding notification procedures and PPE requirements on Level II unit. |
| VV | Licensed Practical Nurse | Interviewed regarding notification of Responsible Party. |
| LL | Licensed Practical Nurse | Interviewed regarding notification of Responsible Party. |
| Licensed Practical Nurse | Observed and interviewed regarding PPE use and transport procedures on Level II unit. | |
| Employee II | Charge Nurse B-Hall | Interviewed regarding pest control issues and reporting. |
| Assistant Administrator | Interviewed regarding pest control service scheduling and communication. | |
| Environmental Director | Interviewed and observed regarding soiled utility rooms and pest control. |
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 4
Oct 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigations of multiple complaint intake numbers related to infection control and COVID-19 preparedness.
Findings
The facility was found not in compliance with infection control regulations and failed to implement CMS and CDC recommended practices for COVID-19. Several deficiencies were identified including failure to notify resident representatives of condition changes, failure to follow physician orders for weekly weights, failure to follow transmission-based precautions on a COVID-19 isolation unit, and failure to maintain an effective pest control program.
Complaint Details
Complaints #GA00205731, #GA00205019, #GA00204557, #GA00205619, #GA00205194, #GA00208808 were unsubstantiated. Complaints #GA00206402, #GA00205849, and #GA00206480 were substantiated with deficiencies related to infection control and COVID-19 preparedness.
Severity Breakdown
D: 2
E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify resident's Responsible Party (legal guardian) of a significant change in condition for Resident #3. | D |
| Failure to follow physician's orders for weekly weights for Resident #7, resulting in significant unmonitored weight loss. | D |
| Failure to follow transmission-based precautions on the Level II COVID-19 Person Under Investigation unit, including improper use of PPE by staff and transporters. | E |
| Failure to maintain an effective pest control program; soiled utility rooms were unclean with overflowing trash, flying insects, rodent traps obstructed, and structural damage. | E |
Report Facts
Total census: 140
Weight loss percentage: 19
Number of residents on Level II unit: 11
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 10, 2020
Visit Reason
The survey was initiated by desk review to investigate infection control concerns from multiple complaint investigations between April 21, 2020 and May 4, 2020, followed by onsite Covid-19 focused infection control survey and further onsite observations to address all allegations.
Findings
No findings of harm or immediate jeopardy were identified during desk reviews or onsite visits. The complaints were not substantiated and no regulatory violations were cited throughout the abbreviated/partial extended survey process.
Complaint Details
The survey investigated multiple complaints related to infection control concerns. The complaints were not substantiated.
Inspection Report
Routine
Census: 152
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 152
Deficiencies: 0
Jun 18, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00203901, GA00203912, and GA00203971, and a COVID-19 Focused Infection Control Survey was conducted on June 18, 2020.
Findings
Complaints GA00203901 and GA0020371 were partially substantiated with no deficiencies, complaint GA00203912 was unsubstantiated, and no deficiencies were cited during the COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints GA00203901 and GA0020371 were partially substantiated with no deficiencies; complaint GA00203912 was unsubstantiated.
Report Facts
Total census: 152
Inspection Report
Deficiencies: 0
Feb 25, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Sadie G. Mays Health & Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 188
Deficiencies: 0
Feb 25, 2020
Visit Reason
A revisit survey was conducted from 2/24/2020 through 2/26/2020 to investigate complaint intake numbers GA00202902 and GA00203091 and to verify correction of deficiencies cited in the 12/23/19 complaint survey.
Findings
All deficiencies cited as a result of the 12/23/19 complaint survey were found to be corrected. The complaint investigation found GA00202902 and GA00203091 to be unsubstantiated with no deficiencies.
Complaint Details
Complaint intake numbers GA00202902 and GA00203091 were investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Facility census: 188
Inspection Report
Re-Inspection
Census: 188
Deficiencies: 0
Feb 25, 2020
Visit Reason
A revisit survey was conducted on 2/26/2020 to investigate Complaint Intake Numbers GA00202902 and GA00203091 in conjunction with this revisit survey.
Findings
All deficiencies cited as a result of the 12/23/19 complaint survey were found to be corrected. The complaint investigation found both complaints unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00202902 and GA00203091 were investigated and found to be unsubstantiated.
Report Facts
Facility census: 188
Inspection Report
Complaint Investigation
Census: 184
Deficiencies: 0
Jan 17, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00202186 and GA00201806 and to determine compliance with Federal and State Long Term Care Requirements.
Findings
The complaints were found to be unsubstantiated and the facility was in substantial compliance with the applicable requirements.
Complaint Details
Complaints GA00202186 and GA00201806 were investigated and found to be unsubstantiated.
Report Facts
Resident Census: 184
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 23, 2019
Visit Reason
The inspection was conducted as a complaint survey to investigate alleged deficiencies at the facility.
Findings
No licensure deficiencies were identified during the complaint survey.
Complaint Details
The complaint survey found no licensure deficiencies; no substantiation of complaints was noted.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2019
Visit Reason
A complaint survey was conducted from 2019-06-10 to 2019-06-12 to investigate complaints #GA00196993 and #GA00196006 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted to investigate complaints #GA00196993 and #GA00196006; no deficiencies were found.
Inspection Report
Re-Inspection
Census: 187
Deficiencies: 0
Jun 12, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2019-04-19.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 4, 2019
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
Routine
Census: 194
Deficiencies: 11
Apr 19, 2019
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and requirements for long term care facilities.
Findings
The survey identified multiple deficiencies including failure to allow a resident to exercise voting rights, failure to provide scheduled showers due to lack of functional shower chairs, failure to provide written evidence of advance directive information, unsafe and unsanitary environment conditions, use of physical restraints without proper assessment, inaccurate assessments, incomplete baseline and comprehensive care plans, failure to provide adequate ADL care, failure to provide restorative services for range of motion, inadequate supervision during smoking breaks, food safety violations, and infection control issues related to labeling and storage of personal care equipment.
Severity Breakdown
SS= D: 9
SS= E: 2
SS= F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to allow one resident to exercise their right to vote in the November 2018 election. | SS= D |
| Facility failed to provide scheduled showers for six residents due to lack of functional reclining shower chairs or trolleys. | SS= D |
| Facility failed to provide written evidence that one resident was given information on and opportunity to formulate an advance directive. | SS= D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment in eight resident rooms and dining room ceiling tiles. | SS= E |
| Facility failed to ensure one resident was free from physical restraints; resident was observed with a seatbelt restraint without assessment or monitoring. | SS= D |
| Facility failed to ensure accuracy of assessments for three residents related to PASRR Level II status, restorative nursing program, and use of restraints. | SS= D |
| Facility failed to complete a baseline care plan for one resident and failed to develop comprehensive care plans addressing key needs for three residents. | SS= D |
| Facility failed to provide restorative services for splinting and range of motion consistently for two residents. | SS= D |
| Facility failed to provide adequate supervision during smoking breaks for two residents who had smoking materials in their possession and staff assisted in lighting cigarettes. | SS= D |
| Facility failed to ensure food safety including proper labeling and dating of opened food items, sanitary kitchen conditions, proper sanitizing in dishwashing, and proper food holding temperatures. | SS= F |
| Facility failed to maintain an effective infection control program related to labeling and storage of residents' personal care equipment in four resident rooms. | SS= D |
Report Facts
Resident census: 194
Restorative nursing documentation missing days: 62
Dishwasher sanitizing solution ppm: 0
Dishwasher sanitizing solution ppm: 300
Hot food temperature: 50
Cold food temperature: 55
Cold food temperature: 45
Refrigerator temperature: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| PP | Certified Nursing Assistant | Supervising residents during smoke break and failed to report residents with cigarettes in possession |
| DD | Dietary Cook | Observed with opened and undated food items in walk-in cooler and kitchen |
| EE | Dietary Cook | Observed improper use of three-compartment sink and failure to wear hair net |
| UU | Restorative Nursing Assistant | Responsible for applying splints and documenting restorative services but failed to document many days |
| BBB | Licensed Practical Nurse | Responsible for oversight of restorative nursing program but unable to ensure documentation |
| MM | Licensed Practical Nurse Unit Manager | Verified unsanitary resident pantry and assigned cleaning duties |
| ZZ | Registered Nurse Unit Manager | Verified unsanitary resident pantry and assigned cleaning duties |
| Infection Control Nurse | Conducts daily rounds to check for proper labeling and storage of personal care equipment | |
| ADHS | Assistant Director of Health Services | Responsible for smoking program and restorative nursing program oversight |
Inspection Report
Routine
Deficiencies: 7
Apr 19, 2019
Visit Reason
Routine inspection of Sadie G. Mays Health & Rehabilitation Center to assess compliance with healthcare facility regulations including infection control, nursing care, safety, environmental sanitation, and physical plant standards.
Findings
The inspection identified multiple deficiencies including improper infection control practices with unbagged and unlabeled resident care equipment, failure to follow smoking supervision policies, inadequate nursing care per care plans, improper use and monitoring of restraints, safety hazards in the facility, unsanitary environmental conditions, and food safety violations in the kitchen and resident pantries.
Deficiencies (7)
| Description |
|---|
| Unbagged and unlabeled bedpans, urinals, and bath basins found in resident bathrooms and rooms. |
| Resident observed smoking with unauthorized cigarettes and staff failed to intervene or report violation of smoking policy. |
| Resident care plans not followed including failure to provide assistance with grooming and use of splints as ordered. |
| Physical restraint used without physician order or assessment; resident unable to self-release seatbelt restraint. |
| Multiple safety hazards including loose electrical jack, dirty air conditioner vents, stained ceiling tiles, broken furniture, and debris from maintenance work. |
| Food safety violations including raw chicken soaking without running water, undated and unsealed food items in walk-in cooler, inadequate sanitizing solution in dishwashing sink, improper food temperatures, and unclean resident pantries with expired and unlabeled food. |
| Dietary staff observed not wearing required hair restraint in food preparation area. |
Report Facts
Deficiencies cited: 7
BIMS score: 13
BIMS score: 99
Sanitizer concentration: 0
Sanitizer concentration: 50
Sanitizer concentration: 300
Food temperature: 50
Food temperature: 55
Food temperature: 45
Dishwasher wash cycle temperature: 167
Dishwasher rinse cycle temperature: 174
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| PP | Certified Nursing Assistant | Supervised smoking break where resident was observed with unauthorized cigarettes and failed to intervene or report. |
| AA | Certified Nursing Assistant | Verified resident's nails were dirty and long; described duties including grooming and bathing. |
| BB | Unit Manager | Verified expectations for staff to provide grooming and nail care; acknowledged resident refusal of care. |
| UU | Restorative Nursing Assistant | Responsible for applying/removing splint; last applied splint on 3/30/19 but forgot to document. |
| RR | Staff | Reported resident with contractures not receiving restorative services after discharge from OT. |
| Resident Nurse Consultant | Stated resident could sometimes release restraint belt; no assessment done for restraint use. | |
| DD | Dietary Cook | Observed food safety violations in kitchen including raw chicken soaking and undated food items. |
| EE | Dietary Cook | Observed improper sanitizing solution levels and food temperatures; stated dishwasher technician visited. |
| FF | Dietary Aide | Observed improperly loading dish machine and rewashed trays. |
| MM | Unit Manager Licensed Practical Nurse | Verified concerns in resident pantry and cleaning responsibilities. |
| ZZ | Unit Manager Registered Nurse | Verified pantry cleaning responsibilities and procedures. |
| XX | Dietary Aide | Observed not wearing hair net or beard covering during food preparation. |
Inspection Report
Life Safety
Census: 193
Capacity: 206
Deficiencies: 2
Apr 4, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety and related National Fire Protection Association (NFPA) standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with the Life Safety Code requirements, specifically regarding smoke barrier construction and utilities safety. Deficiencies included penetrations in smoke/fire barriers above ceilings and blocked access to electrical panels, which could place residents and staff at risk.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Smoke barriers above ceilings at rated walls had penetrations at smoke doors in the A-Hall and D-Hall, compromising smoke resistance. | SS=E |
| Blocked access to an electrical panel in the kitchen due to a rack and presence of a multi-outlet power supply under a table in the marketing office, risking electrical shock. | SS=E |
Report Facts
Residents at risk: 100
Staff at risk: 6
Census: 193
Total capacity: 206
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00195049 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00195049 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00193780 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA00193780 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 27, 2018
Visit Reason
A complaint survey was conducted from 12/19/18 to 12/26/18 to investigate complaints GA00192617 and GA00193378 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted to investigate complaints GA00192617 and GA00193378; no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 27, 2018
Visit Reason
A desk revisit survey was conducted to verify correction of deficiencies cited during the complaint investigation survey on 2018-07-06.
Findings
All deficiencies cited as a result of the complaint investigation survey on 2018-07-06 were found to be corrected.
Complaint Details
This visit was a follow-up to a complaint investigation survey conducted on 2018-07-06.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 6, 2018
Visit Reason
A complaint survey was conducted to investigate an allegation of abuse involving a fractured left knee of Resident #1, to determine compliance with Federal and State Long Term Care Requirements.
Findings
The facility failed to report the alleged abuse causing the fractured left knee to the State Survey Agency within the required two-hour timeframe. Resident #1 was found to have a fractured left distal femur and tibia, and the facility delayed reporting the incident by two days. The involved CNAs were suspended pending investigation.
Complaint Details
The complaint investigation was triggered by allegation GA00189740 regarding abuse causing a fractured left knee of Resident #1. The allegation was substantiated as the facility admitted to missing the two-hour reporting window and initiated an investigation. The involved CNAs were suspended.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report alleged abuse involving a fractured left knee within the required two-hour timeframe. | SS=D |
Report Facts
Sample size: 3
Reporting delay: 2
BIMS score: 7
Incident date: Jun 29, 2018
Incident report date: Jul 2, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Accepted responsibility for missing the two-hour reporting window and initiated investigation |
| RN FF | Nursing Consultant | Confirmed corporate policy requires reporting suspected abuse within two hours and affirmed delay in reporting |
| Assistant Administrator | Assistant Administrator | Interviewed and stated lack of knowledge about two-hour reporting requirement |
Inspection Report
Re-Inspection
Census: 175
Deficiencies: 0
Apr 19, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/1/18 Recertification survey.
Findings
All deficiencies cited as a result of the 3/1/18 Recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 19, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 13, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00186052.
Findings
The complaint was substantiated but no deficiencies were cited during the survey.
Complaint Details
The complaint was substantiated with no deficiencies cited.
Inspection Report
Routine
Census: 180
Deficiencies: 5
Mar 1, 2018
Visit Reason
A standard survey was conducted from February 26, 2018 through March 1, 2018, including investigation of complaint intake numbers GA00185633 and GA00185664, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate resident assessments, failure to develop and implement comprehensive care plans for toileting programs, failure to provide scheduled showers for dependent residents, failure to provide services to maintain or restore bowel and bladder continence, and improper storage and labeling of medications including expired drugs.
Complaint Details
Complaint Intake Numbers GA00185633 and GA00185664 were investigated in conjunction with the standard survey.
Severity Breakdown
Level B: 1
Level D: 1
Level E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Inaccurate Minimum Data Set (MDS) assessments for Resident #145, incorrectly identifying a diagnosis of schizophrenia requiring a Level II PASARR screening that was not completed. | Level B |
| Failure to develop and implement toileting programs for residents incontinent of bowel and/or bladder (Residents #38, #105, #165, #127). | Level E |
| Failure to provide scheduled showers for Resident #127, who was dependent on staff for bathing and personal hygiene, missing 5 scheduled showers in February 2018. | Level D |
| Failure to provide services to maintain or restore bowel and bladder continence for Residents #38, #105, #127, and #165, including lack of toileting programs and inadequate incontinence care. | Level E |
| Failure to remove expired medications and improper storage of medications on four medication carts, including expired drugs and mixing of medications with different routes of administration in the same compartments. | Level E |
Report Facts
Resident census: 180
Sample size: 34
Scheduled showers missed: 5
Expired medication dates: 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse, Unit Manager for D Wing | Confirmed expired medications and improper medication storage; stated residents #38, #165, #127 had never been assessed for bowel and bladder retraining program |
| RN Acting Director of Nursing | Registered Nurse | Confirmed medication storage deficiencies and stated all residents should be assessed for toileting programs |
| CNA BB | Certified Nursing Assistant | Assigned to Resident #38; stated no toileting program was directed and confirmed delayed incontinence care |
| LPN FF | Licensed Practical Nurse | Stated restorative department responsible for toileting program assessments |
| RN M | Registered Nurse | Stated Resident #105 was incontinent and not on toileting program |
| LPN BB | Licensed Practical Nurse | Confirmed missing expiration date on aspirin bottle in medication cart |
| LPN DD | Licensed Practical Nurse | Confirmed improper medication storage mixing ointments with oral medications |
| LPN EE | Licensed Practical Nurse | Confirmed expired glucose testing solution and improper medication storage |
Inspection Report
Routine
Deficiencies: 2
Mar 1, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, and toileting programs, including review of Minimum Data Set (MDS) assessments and care plans for residents with incontinence issues.
Findings
The facility failed to ensure accurate resident assessments, as evidenced by incorrect diagnosis coding for one resident (R#145) leading to missing required screenings. Additionally, the facility did not develop or implement toileting programs for four of five sampled residents who were incontinent, resulting in inadequate management of bowel and bladder incontinence and potential risk to a larger resident population.
Deficiencies (2)
| Description |
|---|
| Incorrect diagnosis of schizophrenia for Resident #145 on multiple MDS assessments without required Level II PASARR screening. |
| Failure to develop, revise, and implement toileting programs for residents incontinent of bowel and/or bladder (Residents #38, #105, #127, #165). |
Report Facts
MDS assessments with incorrect diagnosis: 6
Residents sampled for toileting program deficiency: 4
Residents potentially affected by toileting program failure: 149
Residents potentially affected by toileting program failure: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Assigned to Resident #38; reported no toileting direction and delayed incontinence care. |
| FF | Licensed Practical Nurse | Unit A nurse's station; discussed toileting program assessments and restorative referrals. |
| CC | Licensed Practical Nurse | Unit Manager for D wing; stated residents #38, #165, #127 not assessed for toileting programs. |
| M | Registered Nurse Acting Director of Nursing | Confirmed residents should be assessed for toileting programs and toileting offered every two hours. |
| LVN | Certified Nursing Assistant | Reported Resident #105 mostly self-care but occasional accidents requiring cleanup. |
| Director of Social Services | Confirmed no Level II PASARR screening completed for Resident #145. | |
| MDS coordinator | Acknowledged coding error for schizophrenia diagnosis on Resident #145 MDS assessments. |
Inspection Report
Life Safety
Census: 180
Capacity: 206
Deficiencies: 4
Feb 26, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain optimum readiness of the fire sprinkler system, improper operation of corridor and smoke barrier doors, failure of fire doors to latch during alarm activation, and the presence of prohibited portable space heaters.
Severity Breakdown
E: 2
F: 1
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Loaded sprinkler heads identified in the lobby and dining hall, indicating failure to assure optimum readiness of the fire sprinkler system. | E |
| Several resident room doors would not close to latch in the closed position, compromising smoke resistance. | F |
| Fire doors on A-wing did not close and latch to stay closed on alarm activation. | D |
| Portable space heaters were located in the Assistant Dietician's Office and Admissions office, which is prohibited. | E |
Report Facts
Staff and residents at risk: 60
Staff and residents at risk: 34
Staff and residents at risk: 65
Staff and residents at risk: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews related to fire safety deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2018
Visit Reason
A complaint survey was conducted to investigate complaints GA00183559 and GA00184353 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiency was cited during the complaint survey.
Complaint Details
The survey was conducted in response to complaints GA00183559 and GA00184353; no deficiencies were found.
Inspection Report
Abbreviated Survey
Census: 178
Deficiencies: 0
Oct 17, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate allegations relating to quality of care and treatment at the facility.
Findings
The allegations relating to quality of care and treatment were found to be unsubstantiated during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 30, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00179070 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint investigation #GA00179070 was conducted and no deficiencies were found.
Inspection Report
Abbreviated Survey
Census: 181
Deficiencies: 0
Aug 24, 2017
Visit Reason
An abbreviated survey was conducted to investigate allegations relating to accidents at the facility.
Findings
The allegations relating to accidents were substantiated without deficiencies.
Complaint Details
Allegations relating to accidents were substantiated without deficiencies.
Report Facts
Resident Census: 181
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176786 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00176786 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 19, 2017
Visit Reason
A follow-up visit was conducted on 6/19/17 to verify correction of deficiencies identified in the prior recertification survey.
Findings
The follow-up survey found that the previously identified deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 12, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA 00175801 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Sadie G. Mays Health & Rehabilitation Center.
Complaint Details
Complaint #GA 00175801 was investigated and found to have no deficiencies.
Inspection Report
Life Safety
Census: 182
Capacity: 206
Deficiencies: 3
Apr 25, 2017
Visit Reason
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 with fire safety requirements, including failure to maintain kitchen hood fire prevention, corridor doors not positively latching, and uncovered voided circuit space in the kitchen electrical panel, placing staff and residents at risk.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Kitchen suppression Red Rubber Spray heads over cooking appliances were not in place to prevent grease accumulation. | SS= D |
| Resident room #D3 door would not close to positively latch to hold in the closed position. | SS= D |
| Voided Circuit space in the kitchen 'EK' electrical panel box was not covered as required. | SS= D |
Report Facts
Census: 182
Total Capacity: 206
Staff at risk: 12
Residents at risk: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to kitchen fire prevention, corridor door, and electrical panel deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 22, 2017
Visit Reason
A complaint investigation (GA00174096) was initiated and concluded on 4/22/17 to assess compliance with long term care requirements.
Findings
The facility was found to be in compliance with 42 CFR, Part 483, Subpart B for Long Term Care Requirements. No deficiencies were cited.
Complaint Details
Complaint investigation GA00174096 was conducted and the facility was found compliant with no deficiencies.
Loading inspection reports...
