Inspection Reports for Sandy Springs Center for Nursing and Healing

The facility failed to maintain a sanitary, clean, and homelike environment due to unclean floors, lingering foul odors, and stained furniture. Additionally, a medication cart was found unlocked and unattended, posing a risk of unauthorized access. The facility also failed to properly clean one of the ice machines, which had visible dirt and debris, with unclear responsibility for its maintenance.

The facility was found deficient in multiple areas including failure to complete PASARR assessments for residents with serious mental disorders, incomplete care plans addressing weight loss, late medication administration, inadequate activities of daily living care, missed antibiotic doses, failure to perform weekly weights after significant weight loss, and poor infection control practices including lack of PPE and improper peri-care. Additionally, the kitchen was not maintained in a sanitary manner with food temperature and dishwashing issues.

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.

The facility failed to complete required preadmission screening assessments (PASARR) for some residents, did not develop complete care plans addressing weight loss, administered medications late, failed to provide consistent activities of daily living care, missed doses of prescribed antibiotics, failed to perform weekly weights after significant weight loss, did not maintain kitchen sanitation standards, and failed to ensure proper infection prevention and control practices including PPE availability and use.

Multiple complaint intake numbers were investigated in conjunction with the standard survey, indicating complaint-related triggers for the visit.

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.

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.

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.

The facility was found deficient in multiple areas including failure to provide adequate linens, failure to prevent resident-to-resident abuse, failure to notify ombudsman of resident transfers, failure to develop comprehensive care plans, failure to provide scheduled showers, failure to properly assess and monitor pressure ulcers, failure to ensure safe mechanical lift transfers, failure to ensure staff competency in mechanical lifts, failure to maintain medication availability, failure to monitor psychotropic medication use, failure to properly label and store medications and supplies, failure to maintain food service safety standards, failure to clean CPAP equipment, and failure to maintain an effective quality assurance program.

The facility was found deficient in multiple areas including failure to provide adequate linens, failure to prevent resident-to-resident abuse, failure to notify ombudsman of transfers, failure to notify residents of bed-hold policies, failure to refer for PASARR Level II screening, failure to develop comprehensive care plans especially for transfers and catheter care, failure to provide scheduled showers, failure to properly assess and monitor pressure ulcers, failure to ensure adequate supervision to prevent accidents, failure to ensure CNA competency in mechanical lift transfers, failure to maintain medication availability, failure to maintain proper medication labeling and storage, failure to clean and store CPAP equipment properly, failure to monitor and document behaviors for residents on psychotropic medications, failure to maintain an effective quality assurance program, and failure to maintain food service safety standards.

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.

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.

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.

The facility was found deficient in ensuring proper assessment and physician orders for resident self-administration of medications, failure to post survey results accessibly, failure to report an allegation of abuse, failure to assist a resident in obtaining prescribed glasses, and failure to maintain food service equipment and prevent staff food storage in resident refrigerators.