Inspection Reports for Sandy Springs Center for Nursing and Healing
1500 S Johnson Ferry Rd NE, Sandy Springs, GA 30319, GA, 30319
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 3, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Sandy Springs Center for Nursing and Healing LLC following a survey completed on June 3, 2025.
Findings
The report contains initial comments but does not specify any deficiencies or findings.
Inspection Report
Follow-Up
Census: 141
Deficiencies: 0
Jun 3, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification in conjunction with a Complaint Investigation survey concluded on April 10, 2025.
Findings
All deficiencies cited as a result of the prior Recertification and Complaint Investigation survey were found to be corrected.
Inspection Report
Life Safety
Deficiencies: 0
Apr 25, 2025
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected at the time of the revisit.
Inspection Report
Annual Inspection
Deficiencies: 4
Apr 10, 2025
Visit Reason
A State Licensure survey was conducted from 3/10/2025 through 4/10/2025 to determine compliance with State Long Term Care Requirements for Sandy Springs Center for Nursing and Healing LLC.
Findings
The facility was found deficient in infection control practices including lack of Personal Protective Equipment (PPE) availability for residents on Enhanced Barrier Precautions, failure to maintain proper peri-care technique, failure to perform weekly weights after significant weight loss, failure to implement dietician recommendations, failure to provide Activities of Daily Living (ADL) care, and failure to maintain sanitary kitchen conditions including improper food temperatures, inadequate hairnet use, and improper dishwasher sanitization.
Deficiencies (4)
| Description |
|---|
| Failure to ensure PPE was available for residents on Enhanced Barrier Precautions and failure to maintain infection control during peri-care. |
| Failure to perform weekly weights after significant weight loss and failure to implement dietician recommendations for nutrition. |
| Failure to provide Activities of Daily Living (ADL) care for two residents, including inconsistent peri-care documentation and care. |
| Failure to maintain kitchen sanitation including lack of foot-pedal trash cans, improper food holding temperatures, improper hairnet use, presence of acrylic nails on dietary staff, and dishwasher not reaching required sanitization temperatures. |
Report Facts
Weight loss percentage: 5.2
Weight loss percentage: 8.48
Number of residents affected by kitchen sanitation deficiencies: 146
Dates with missing peri-care documentation for resident R4: 30
Dates with missing peri-care documentation for resident R "A": 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| VV | Certified Nursing Assistant (CNA) | Unaware of Enhanced Barrier Precautions requirements and did not don PPE while caring for residents overnight. |
| UU | Licensed Practical Nurse (LPN) | Night nurse unaware of Enhanced Barrier Precautions requirements and did not don PPE while caring for residents overnight. |
| XX | Regional Housekeeping/Laundry Director | Replaced Alcohol Based Hand Rub dispensers and ordered new foam action dispensers. |
| JJ | Certified Nursing Assistant (CNA) | Performed peri-care on resident R4 improperly and reported peri-care charting practices. |
| BB | Certified Nursing Assistant (CNA) | Assisted with peri-care on resident R4 and reported peri-care charting practices. |
| ADON | Assistant Director of Nursing/Infection Preventionist | Responsible for infection control oversight and weight data entry; unaware of blanks in peri-care documentation. |
| WW | Dietary Aide | Reported lack of foot-pedal trash cans in kitchen. |
| EE | Cook/Aid | Reported dishwasher temperature issues and food temperature monitoring practices. |
| DM | Dietary Manager | Observed wearing acrylic nails and uncertain about policy on nails. |
| CRD | Consultant Registered Dietician | Confirmed weight loss issues, dietician recommendations, and expectations for kitchen sanitation and staff hygiene. |
Inspection Report
Routine
Census: 146
Deficiencies: 9
Apr 10, 2025
Visit Reason
A standard survey was conducted from 3/10/2025 through 4/10/2025, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Findings
The facility was found noncompliant with Medicare/Medicaid regulations, with deficiencies including failure to complete PASARR assessments for residents with serious mental disorders, failure to address weight loss in care plans, medication administration errors, failure to provide adequate ADL care, failure to administer antibiotics as ordered, failure to perform weekly weights after significant weight loss, kitchen sanitation issues, inaccurate medical record documentation postmortem, and infection control lapses including lack of PPE and improper peri-care technique.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, indicating complaint-related triggers for the visit.
Severity Breakdown
A: 1
D: 6
E: 1
F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to complete PASARR assessments for two residents with serious mental disorders or intellectual disabilities. | D |
| Failed to address weight loss in care plans for two residents despite documented weight loss. | D |
| Failed to administer scheduled medications within 60 minutes before or after scheduled time for one resident. | D |
| Failed to provide Activities of Daily Living care for two residents, including inconsistent peri-care and documentation. | D |
| Failed to ensure Vancomycin antibiotic was administered as ordered for one resident, missing three doses without documentation or physician notification. | D |
| Failed to perform weekly weights after significant weight loss and failed to implement dietician recommendation for one resident. | D |
| Failed to maintain kitchen sanitation including improper food temperatures, lack of foot-pedal trash cans, improper hairnet use, acrylic nails on staff, and dishwasher not meeting temperature requirements. | F |
| Medical record contained inaccurate information documenting morphine and lorazepam administration postmortem for one resident. | A |
| Failed to ensure Personal Protective Equipment was available and used for residents on Enhanced Barrier Precautions, failed to maintain functioning alcohol-based hand rub dispensers, and failed to maintain infection control during peri-care. | E |
Report Facts
Resident census: 146
Weight loss percentage: 5.2
Weight loss percentage: 8.48
Missed medication doses: 3
Medication administration times: 12
Food temperatures: 131
Dishwasher temperature: 141
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN YY | Licensed Practical Nurse | Documented administration of morphine and lorazepam postmortem for Resident R157. |
| Director of Nursing | Interviewed regarding medication administration errors, infection control, and PPE availability. | |
| Social Services Director | Interviewed regarding PASARR assessments for residents R74 and R31. | |
| Consultant Registered Dietician | Interviewed regarding weight monitoring and dietician recommendations. | |
| Assistant Director of Nursing | Interviewed regarding infection prevention and weight monitoring. | |
| Certified Nursing Assistant JJ | Observed performing peri-care with improper infection control technique. | |
| Certified Nursing Assistant BB | Observed assisting with peri-care and interviewed about documentation practices. | |
| Dietary Manager | Observed with acrylic nails and interviewed about kitchen sanitation policies. | |
| Regional Consultant | Observed kitchen food temperatures and staff hairnet use. |
Inspection Report
Life Safety
Census: 146
Capacity: 165
Deficiencies: 2
Mar 10, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failures in assuring smoke containment within one of eight smoke compartments. Deficiencies included missing and broken ceiling tiles in several areas and a gap around a corridor door knob allowing smoke passage.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Missing and broken ceiling tiles in laundry, housekeeping closet, and riser/mechanical room that do not resist smoke passage. | E |
| Corridor door with a gap around the door knob allowing smoke passage near the conference room by the front entrance. | D |
Report Facts
Smoke compartments affected: 1
Census: 146
Total licensed beds: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 3/10/2025 |
Inspection Report
Abbreviated Survey
Census: 144
Deficiencies: 0
Aug 27, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00249971 and GA00249937.
Findings
No deficiencies were cited related to the complaints, and the complaints were found to be unsubstantiated.
Complaint Details
Complaints GA00249971 and GA00249937 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 7, 2023
Visit Reason
A revisit survey was conducted on 7/7/23 to investigate Complaint Intake Numbers GA00236065, GA00236065, and GA00235543 in conjunction with this revisit survey.
Findings
No deficient practice was identified related to the complaint investigation. All deficiencies cited as a result of the 5/7/23 Recertification and Complaint Survey were found to be corrected.
Complaint Details
Complaint Intake Numbers GA00236065, GA00236065, GA00235543 were investigated and no deficient practice was identified related to the complaint investigation.
Report Facts
Complaint Intake Numbers: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 7, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate specific complaint numbers GA00236065, GA00235543, and GA00235381.
Findings
The survey was completed with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Jul 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Sandy Springs Center for Nursing and Healing LLC, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 22, 2023
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
Life Safety
Census: 146
Capacity: 165
Deficiencies: 3
May 23, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related regulations for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with fire safety requirements, including loaded sprinkler heads in the laundry department, a damaged smoke barrier wall allowing smoke passage, and a missing electrical outlet cover in the riser/boiler room.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Loaded sprinkler heads found in laundry department (dryers and washer areas). | D |
| Smoke barrier wall above ceiling damaged by water leakage, not repaired, allowing smoke passage. | D |
| Missing electrical outlet cover in riser/boiler room. | D |
Report Facts
Smoke Compartments affected: 1
Stories: 2
Construction Type: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 5/23/23. |
Inspection Report
Routine
Deficiencies: 13
May 7, 2023
Visit Reason
A State Licensure survey was conducted from 5/1/23 through 5/7/23 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to notify residents and families of significant health changes, failure to notify ombudsman of transfers and discharges, failure to notify residents of bed-hold policies, medication availability issues, improper cleaning and storage of CPAP equipment, failure to provide scheduled showers, inadequate wound assessment and documentation, inaccurate medical record documentation related to medication indications, insufficient linens and towels availability, and food service safety violations including poor hand hygiene, inadequate sanitizer concentration in dish machine, expired food storage, insufficient hair restraints, and unclean microwave in the central supply room.
Deficiencies (13)
| Description |
|---|
| Failure to notify resident and family of significant changes to plan of treatment for wound care. |
| Failure to notify ombudsman in writing of resident transfers or discharges. |
| Failure to notify residents of bed-hold and reserve bed payment policy prior to hospital transfer. |
| Failure to ensure medications were available from pharmacy for medication administration. |
| Failure to clean and store CPAP equipment properly after use. |
| Failure to provide scheduled showers and failure to assess and monitor pressure ulcer. |
| Failure to maintain accurate medical record related to medication indication for Depakote. |
| Failure to provide sufficient linens, towels, and washcloths consistently. |
| Failure to perform hand hygiene between handling soiled and clean dishes. |
| Failure to maintain adequate sanitizer concentration in low temperature dish machine. |
| Failure to discard expired food items. |
| Failure to wear sufficient hair restraints in food preparation areas. |
| Failure to ensure microwave in central supply room was clean. |
Report Facts
Number of sampled residents: 57
Number of sampled residents with notification failure: 1
Number of sampled residents with ombudsman notification failure: 2
Number of sampled residents with bed-hold notification failure: 2
Number of sampled residents with medication availability issue: 1
Number of sampled residents with CPAP cleaning failure: 1
Number of sampled residents with shower/pressure ulcer deficiencies: 2
Number of sampled residents with inaccurate medication indication: 1
Number of halls with linen shortages: 3
Expired food item date: 2023.04
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LLL | Unit Manager | Interviewed regarding notification policies, CPAP cleaning, shower scheduling, linen availability, microwave cleaning |
| OOO | Licensed Practical Nurse (LPN), wound nurse | Interviewed regarding wound care and documentation |
| NNN | Registered Nurse (RN) | Interviewed regarding medication availability and microwave cleaning responsibility |
| AAA | Dietary Aide | Observed handling dishes without hand hygiene between dirty and clean sides |
| DD | Dietary Aide | Observed with insufficient hair restraint |
| MMM | Certified Nursing Assistant (CNA) | Interviewed regarding shower assistance and linen availability |
| Administrator | Interviewed regarding notification policies, medication indication, linen availability, food safety expectations | |
| DON | Director of Nursing | Interviewed regarding notification policies, wound care, linen availability, food safety expectations |
| DM | Dietary Manager | Interviewed regarding dish machine sanitizer concentration and hand hygiene |
| RD | Registered Dietitian | Interviewed regarding food safety and hand hygiene |
| LPN III | Licensed Practical Nurse | Interviewed regarding medication order entry and indication |
| LPN WWW | Licensed Practical Nurse | Interviewed regarding medication use and indication |
| Laundry Associate | Interviewed regarding linen availability and laundry operations | |
| Cook BB | Cook | Observed not wearing hair restraint while washing dishes |
| Central Supply Manager | Interviewed regarding microwave cleaning responsibility |
Inspection Report
Abbreviated Survey
Census: 136
Deficiencies: 16
May 7, 2023
Visit Reason
A standard survey was conducted from 5/1/23 through 5/7/23, including investigation of multiple complaint intake numbers. The visit included assessment of compliance with Medicare/Medicaid regulations and review of resident care and facility operations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to ensure safe mechanical lift transfers, inadequate notification and documentation of resident care changes, insufficient linen availability, failure to notify the ombudsman of resident transfers, incomplete care plans, failure to monitor psychotropic medication effects, expired medications and supplies in medication rooms, and improper food safety and sanitation practices. Immediate Jeopardy was identified related to unsafe mechanical lift transfers and was removed after corrective actions.
Complaint Details
The survey included investigation of multiple complaint intake numbers (GA00233232, GA00232701, GA00232139, GA00231783, and GA00234934). Immediate Jeopardy was identified related to unsafe mechanical lift transfers on 5/3/23 and was removed on 5/6/23 after corrective actions.
Severity Breakdown
Immediate Jeopardy: 3
Severity D: 10
Severity E: 2
Deficiencies (16)
| Description | Severity |
|---|---|
| Unsafe mechanical lift transfers resulting in resident sliding from wheelchair to floor due to improper sling placement and staff competency deficiencies. | Immediate Jeopardy |
| Failure to notify resident and family of significant changes to plan of treatment related to wound care. | Severity D |
| Failure to provide sufficient linens, towels, and washcloths consistently to residents. | Severity E |
| Failure to protect residents from physical abuse by another resident, including inadequate supervision and investigation. | Severity D |
| Failure to notify ombudsman in writing of resident transfers or discharges, including emergency hospital transfers. | Severity D |
| Failure to notify residents of bed-hold and reserve bed payment policy prior to hospital transfers. | Severity D |
| Failure to refer resident for Level II PASARR evaluation after diagnosis of major depressive disorder. | Severity D |
| Failure to develop accurate baseline care plans addressing psychotropic and diuretic medications and skin integrity issues. | Severity D |
| Failure to develop comprehensive care plans addressing mechanical lift transfers and indwelling catheter care; Immediate Jeopardy related to mechanical lift transfers. | Immediate Jeopardy |
| Failure to provide scheduled showers and document resident preferences and refusals. | Severity D |
| Failure to assess and monitor pressure ulcer with appropriate documentation and wound physician follow-up. | Severity D |
| Failure to provide adequate supervision during mechanical lift transfers resulting in resident fall; staff competency deficiencies in mechanical lift use. | Immediate Jeopardy |
| Failure to ensure timely availability of prescribed medications from pharmacy. | Severity D |
| Failure to monitor and document targeted behaviors for residents prescribed psychotropic medications. | Severity E |
| Failure to perform hand hygiene between handling soiled and clean dishes; failure to maintain sanitizer concentration in dish machine; expired food items and medications found in storage; inadequate hair restraints worn by kitchen staff; dirty microwave in central supply room. | Severity D |
| Failure to clean and store CPAP equipment properly, including cleaning mask and tubing and use of distilled water in humidifier chamber. | Severity D |
Report Facts
Resident census: 136
Deficiencies cited: 3
Medication administration dates: 20
Number of staff re-educated: 59
Mechanical lift competency checklist steps failed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nursing Assistant | Named in unsafe mechanical lift transfer and competency failure |
| CNA TT | Certified Nursing Assistant | Named in unsafe mechanical lift transfer and competency failure |
| LPN OOO | Licensed Practical Nurse | Wound nurse who failed to document wound assessments |
| LPN XXX | Licensed Practical Nurse | Named in fall incident with resident R#69 |
| LPN III | Licensed Practical Nurse | Named in fall incident investigation and education |
| DA AA | Dietary Aide | Named in failure to perform hand hygiene between handling soiled and clean dishes |
| DM | Dietary Manager | Named in dish machine sanitizer concentration failure |
| UM LLL | Unit Manager | Named in failure to clean CPAP equipment |
| SDC | Staff Development Coordinator | Named in mechanical lift training and competency education |
| DON | Director of Nursing | Named in oversight of mechanical lift transfers and fall investigations |
| Administrator | Facility Administrator | Named in oversight and response to multiple deficiencies |
Inspection Report
Abbreviated Survey
Census: 122
Deficiencies: 0
Nov 15, 2022
Visit Reason
An abbreviated survey was conducted to investigate multiple complaints identified by their codes, initiated on September 1, 2022, and concluded on November 15, 2022.
Findings
All complaints investigated during the survey were unsubstantiated with no regulatory violations cited.
Complaint Details
Complaints GA00223004, GA00223403, GA00223413, GA00224683, GA00225264, GA00225812, and GA00227014 were unsubstantiated with no regulatory violations cited.
Report Facts
Resident Census: 122
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Jul 18, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00225915 and GA00225959.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00225915 and GA00225959 were investigated and found to be unsubstantiated with no regulatory violations.
Inspection Report
Routine
Census: 119
Deficiencies: 0
Mar 29, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 3/21/22 to 3/29/22, including investigation of complaint intake numbers GA00221581 and GA0021459.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations, and the complaints investigated were found to be unsubstantiated.
Complaint Details
Complaint Intake numbers GA00221581 and GA0021459 were investigated and found to be unsubstantiated.
Report Facts
Census: 119
Inspection Report
Deficiencies: 0
Mar 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of Sandy Springs Center for Nursing and Healing LLC.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 29, 2022
Visit Reason
A revisit survey was conducted from 3/21/2022 to 3/29/2022 to investigate Complaint Intake numbers GA00221581 and GA00221459 and to perform a Focused Infection Control survey.
Findings
The revisit survey revealed that all citations related to the Complaint survey of 2/2/2022 had been corrected.
Complaint Details
Complaint Intake numbers GA00221581 and GA00221459 were investigated during the revisit survey.
Loading inspection reports...
