Inspection Reports for Social Circle Nsg & Rehab Ctr
671 NORTH CHEROKEE ROAD, SOCIAL CIRCLE, GA, 30025
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 29, 2025, identified multiple deficiencies including medication cart security, glucometer disinfection, enteral feeding administration, documentation of personal care, call light functionality, and maintenance of flooring to preserve a home-like environment. Earlier inspections showed a pattern of similar issues related to medication management, infection control, resident care documentation, and environmental maintenance, with no fines or license actions listed in the available reports. A complaint investigation conducted concurrently with the latest survey was substantiated, confirming these deficiencies but no immediate jeopardy findings or enforcement actions were noted. Prior complaint investigations were mostly unsubstantiated, except for a substantiated case in November 2022 involving failure to protect residents from abuse, which was addressed in subsequent surveys. The facility’s inspection history shows recurring issues in care and environment maintenance without clear improvement in recent surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
15.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
224% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
56 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Social Circle Nursing and Rehab Center from May 27, 2025 through May 29, 2025 to determine compliance with State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to secure medication carts properly, improper disinfection of glucometers, failure to administer enteral feedings as ordered, incomplete documentation of personal care, malfunctioning call lights, and missing floor tiles affecting the home-like environment.
Deficiencies (6)
Failed to properly secure a medication cart when not in use or clearly visible to personnel and failed to date an opened eye drop medication to determine discard date.
Failed to properly disinfect a glucometer before use for one resident, risking infection.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident receiving tube feeding.
Failed to document personal, bowel, and bladder care for one resident in the medical record.
Failed to keep one call light in working condition in one of 18 rooms on North Hall, risking delayed response and injury.
Failed to maintain a home-like environment by not replacing missing floor tiles in three rooms on North and South Hall.
Report Facts
Facility census: 56
Residents with glucometer checks: 8
Residents sampled for documentation: 28
Rooms with call light issues: 1
Rooms with missing floor tiles: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication cart security and glucometer disinfection findings |
| Director of Nursing | Director of Nursing | Provided expectations on medication cart locking, glucometer cleaning, and tube feeding monitoring |
| Unit Manager | Unit Manager | Confirmed open eye drop bottle and documentation expectations |
| CNA CC | Certified Nursing Assistant | Reported on documentation practices and call light testing |
| Maintenance Director | Maintenance Director | Confirmed call light malfunction and missing floor tiles, described repair plans |
| Administrator | Administrator | Reinforced call light repair expectations and acknowledged missing floor tiles impact |
| Infection Perfectionist Nurse | Infection Preventionist Nurse | Provided protocol for glucometer disinfection and stated alcohol wipes should not be used |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
A standard survey was conducted from May 27 through May 29, 2025, in conjunction with Complaint Intake Number GA00253953, which was substantiated with deficiency. The visit aimed to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00253953 was investigated in conjunction with the standard survey and was found substantiated with deficiency.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to maintain a home-like environment due to missing floor tiles in resident rooms, failure to administer enteral tube feedings according to physician orders, improper medication cart security and medication dating, failure to document personal and continence care, inadequate disinfection of glucometers, and a non-functioning call light in one resident room.
Deficiencies (6)
Failed to maintain a home-like environment by not replacing missing floorboards in three resident rooms.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident receiving tube feeding.
Failed to properly secure a medication cart and ensure eye drop medication was dated appropriately.
Failed to document personal, bowel, and bladder care for one resident.
Failed to properly disinfect a glucometer before use for one resident.
Failed to keep one call light in working condition in one resident room.
Report Facts
Facility census: 56
Rooms with missing floorboards: 3
Residents sampled: 28
Residents with glucometer checks: 8
Rooms on North Hall: 18
Tube feeding hours: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in medication cart security and glucometer disinfection findings. |
| CC | Certified Nursing Assistant (CNA) | Named in call light testing and documentation findings. |
| Maintenance Director | Interviewed regarding missing floor tiles and call light issues. | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding tube feeding administration, medication cart security, glucometer disinfection, and call light issues. |
| Infection Perfectionist Nurse | Infection Preventionist Nurse | Interviewed regarding glucometer disinfection procedures. |
| Unit Manager | Interviewed regarding medication cart and documentation expectations. | |
| Administrator | Interviewed regarding call light maintenance and facility expectations. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Social Circle Nursing and Rehab Center from May 27, 2025 through May 29, 2025 to determine compliance with State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to secure medication carts properly, improper disinfection of glucometers, failure to administer enteral feedings according to physician orders, incomplete documentation of personal care, malfunctioning call lights, and missing floor tiles in resident rooms affecting the home-like environment.
Deficiencies (6)
Failed to properly secure a medication cart when not in use or clearly visible to personnel administering medication and failed to date an eye drop medication appropriately.
Failed to properly disinfect a glucometer before use for one resident, risking infection.
Failed to administer nutritional enteral feedings and hydration according to current physician orders for one resident receiving tube feeding.
Failed to document personal, bowel, and bladder care for one resident in the medical record.
Failed to keep one call light in working condition in one out of 18 rooms on North Hall.
Failed to maintain a home-like environment by not replacing missing floor tiles in three rooms on North and South Hall.
Report Facts
Facility census: 56
Residents with glucometer checks: 8
Residents sampled for documentation: 28
Rooms with call light issues: 1
Rooms with missing floor tiles: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in medication cart security and glucometer disinfection findings |
| Director of Nursing | Director of Nursing (DON) | Provided expectations and interviews regarding medication cart security, glucometer disinfection, and tube feeding administration |
| Unit Manager | Unit Manager | Confirmed open eye drop bottle and discussed documentation expectations |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Interviewed regarding documentation practices and call light testing |
| Maintenance Director | Maintenance Director | Confirmed call light malfunction and missing floor tiles, discussed maintenance priorities |
| Administrator | Administrator | Reinforced call light repair expectations and acknowledged missing floor tiles impact |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided protocol for glucometer disinfection and stated nurses should not use alcohol wipes |
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
A standard survey was conducted from May 27 through May 29, 2025, including investigation of Complaint Intake Number GA00253953, which was substantiated with deficiency.
Complaint Details
Complaint Intake Number GA00253953 was investigated in conjunction with the standard survey and was found substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a home-like environment due to missing floor tiles in resident rooms, failure to administer enteral feedings according to physician orders, improper medication cart security and medication dating, failure to document personal and continence care, inadequate glucometer disinfection, and a non-functioning call light in one resident room.
Deficiencies (6)
Failed to maintain a home-like environment by not replacing missing floorboards in three resident rooms.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident receiving tube feeding.
Failed to properly secure a medication cart and ensure eye drop medication was dated appropriately.
Failed to document personal, bowel, and bladder care for one resident.
Failed to properly disinfect a glucometer before use for one resident.
Failed to keep one call light in working condition in one resident room.
Report Facts
Facility census: 56
Number of rooms with missing floorboards: 3
Number of sampled residents with undocumented care: 1
Number of medication carts with deficiencies: 1
Number of residents with glucometer disinfection deficiency: 1
Number of rooms with non-functioning call light: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in medication cart security and glucometer disinfection findings. |
| CC | Certified Nursing Assistant (CNA) | Mentioned in relation to call light testing and documentation of resident care. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding tube feeding administration, medication cart security, glucometer disinfection, and call light issues. |
| Maintenance Director | Maintenance Director | Interviewed regarding missing floor tiles and call light malfunction. |
| Unit Manager | Unit Manager (UM) | Interviewed regarding medication cart and documentation deficiencies. |
| Infection Perfectionist Nurse | Infection Preventionist (IP) Nurse | Interviewed regarding proper glucometer disinfection procedures. |
| Administrator | Administrator | Interviewed regarding expectations for call light maintenance and overall facility compliance. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was conducted as a State Licensure survey at Social Circle Nursing and Rehab Center from May 27, 2025 through May 29, 2025 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to properly secure medication carts, improper disinfection of glucometers, failure to administer enteral feedings according to physician orders, incomplete documentation of personal care, nonfunctional call light in one resident room, and failure to maintain a home-like environment due to missing floor tiles in several rooms.
Deficiencies (6)
Failed to properly secure a medication cart when not in use or clearly visible to personnel and failed to date eye drop medication to determine discard date.
Failed to properly disinfect a glucometer before use for one resident, risking infection.
Failed to administer nutritional enteral feedings and hydration according to current physician orders for one resident receiving tube feeding.
Failed to document personal, bowel, and bladder care for one resident in the medical record.
Failed to keep one call light in working condition in one room, risking delayed response and resident safety.
Failed to maintain a home-like environment by not replacing missing floor tiles in three resident rooms.
Report Facts
Facility census: 56
Residents with glucometer checks: 8
Residents receiving tube feeding: 2
Residents sampled for documentation review: 28
Rooms with missing floor tiles: 3
Rooms with call light issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in findings related to medication cart security and glucometer disinfection |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication cart locking, glucometer cleaning, and tube feeding monitoring |
| Unit Manager | Unit Manager | Confirmed open eye drop bottle and discussed documentation expectations |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Interviewed about documentation practices and call light testing |
| Maintenance Director | Maintenance Director | Confirmed call light malfunction and missing floor tiles, described maintenance priorities |
| Administrator | Administrator | Reinforced expectations for call light repairs and tile maintenance |
| Infection Perfectionist Nurse | Infection Preventionist Nurse | Provided protocol for glucometer disinfection and stated alcohol wipes should not be used |
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
A standard survey was conducted from May 27 through May 29, 2025, including investigation of Complaint Intake Number GA00253953, which was substantiated with deficiency.
Complaint Details
Complaint Intake Number GA00253953 was investigated in conjunction with the standard survey and was found substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a home-like environment due to missing floor tiles in resident rooms, failure to administer enteral feedings according to physician orders, improper medication cart security and medication dating, failure to document personal and continence care, improper disinfection of glucometers, and a non-functioning call light in one resident room.
Deficiencies (6)
Failed to maintain a home-like environment by not replacing missing floorboards in three resident rooms.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident receiving tube feeding.
Failed to properly secure a medication cart and ensure eye drop medication was dated appropriately.
Failed to document personal, bowel, and bladder care for one resident.
Failed to properly disinfect a glucometer before use for one resident.
Failed to keep one call light in working condition in one resident room.
Report Facts
Facility census: 56
Rooms with missing floorboards: 3
Residents sampled for documentation: 28
Shifts with missing documentation: 16
Glucometers on medication cart: 2
Rooms on North Hall: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Named in findings related to medication cart security and glucometer disinfection. |
| CC | Certified Nursing Assistant (CNA) | Mentioned in relation to call light testing and documentation practices. |
| Maintenance Director | Confirmed missing floor tiles and call light issues, described maintenance workload. | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding tube feeding administration, medication cart security, glucometer disinfection, and call light expectations. |
| Unit Manager | Confirmed medication cart and documentation issues. | |
| Infection Perfectionist Nurse | Provided protocol for glucometer disinfection. | |
| Administrator | Reinforced expectations for call light maintenance and timely repairs. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at Social Circle Nursing and Rehab Center.
Findings
The facility was cited for multiple deficiencies including failure to secure medication carts properly, improper dating of opened eye drop medication, inadequate disinfection of glucometers, failure to administer enteral feedings as ordered, incomplete documentation of personal care, nonfunctional call light in one resident room, and failure to maintain a home-like environment due to missing floor tiles in several rooms.
Deficiencies (6)
Failed to properly secure a medication cart when not in use or clearly visible to personnel and failed to date an opened eye drop medication.
Failed to properly disinfect a glucometer before use for one resident, risking infection.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident receiving tube feeding.
Failed to document personal, bowel, and bladder care for one resident in the medical record.
Failed to keep one call light in working condition in one resident room, risking delayed response and injury.
Failed to maintain a home-like environment by not replacing missing floor tiles in three resident rooms.
Report Facts
Facility census: 56
Residents sampled for documentation deficiency: 28
Rooms with missing floor tiles: 3
Rooms with call light issues: 1
Residents with glucometer checks: 8
Residents receiving tube feeding: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in findings related to unsecured medication cart and improper glucometer disinfection |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding medication cart security, glucometer cleaning, tube feeding monitoring, and call light expectations |
| Unit Manager | Unit Manager | Confirmed open eye drop bottle and discussed documentation expectations |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Interviewed regarding documentation practices and call light testing |
| Maintenance Director | Maintenance Director | Confirmed call light malfunction and missing floor tiles, described maintenance priorities |
| Administrator | Facility Administrator | Reinforced call light repair expectations and acknowledged missing floor tiles impact on home-like environment |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Provided interview on proper glucometer disinfection procedures |
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
A standard survey was conducted from May 27 through May 29, 2025, including investigation of Complaint Intake Number GA00253953, which was substantiated with deficiency.
Complaint Details
Complaint Intake Number GA00253953 was investigated in conjunction with the standard survey and was found substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a home-like environment due to missing floor tiles, failure to administer enteral feedings per physician orders, improper medication cart security and medication dating, failure to document personal and continence care, improper glucometer disinfection, and a non-functioning call light in one resident room.
Deficiencies (6)
Failed to maintain a home-like environment by not replacing missing floorboards in three rooms (North-8A, North-18B, South-21B).
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident (R33).
Failed to properly secure medication cart and failed to date eye drop medication appropriately for one medication cart (North Hall).
Failed to document personal, bowel, and bladder care for one resident (R160).
Failed to properly disinfect a glucometer before use for one resident (R22).
Failed to keep one call light in working condition in one room (North 3-B).
Report Facts
Facility census: 56
Number of rooms with missing floorboards: 3
Number of sampled residents with documentation issues: 28
Number of shifts with missing documentation: 16
Number of medication carts with security issues: 1
Number of glucometers on cart: 2
Number of rooms with non-functioning call light: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed missing floor tiles and described maintenance workload and repair plans. | |
| Administrator | Acknowledged missing tiles affect home-like atmosphere and emphasized call light repair importance. | |
| Director of Nursing (DON) | Confirmed tube feeding not administered, medication cart security expectations, and call light reporting procedures. | |
| LPN BB | Licensed Practical Nurse | Observed not locking medication cart and improper glucometer disinfection. |
| CNA CC | Certified Nursing Assistant | Confirmed call light not working and explained documentation practices. |
| Unit Manager | Confirmed medication cart issues and documentation expectations. | |
| Infection Preventionist Nurse | Described proper glucometer disinfection protocol. | |
| Maintenance Director | Explained call light malfunction due to mismatched connections. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at Social Circle Nursing and Rehab Center.
Findings
The facility was found deficient in multiple areas including medication cart security, proper dating of opened medications, glucometer disinfection, administration of enteral feedings, documentation of personal care, call light functionality, and maintenance of flooring to preserve a home-like environment.
Deficiencies (6)
Failed to properly secure a medication cart when not in use or clearly visible to personnel administering medication and failed to ensure an eye drop medication was dated appropriately when opened.
Failed to properly disinfect a glucometer before use for one resident, risking infection.
Failed to administer nutritional enteral feedings and hydration according to current physician orders for one resident receiving tube feeding.
Failed to document personal, bowel, and bladder care for one resident in the medical record.
Failed to keep one call light in working condition in one room, risking delayed response and injury.
Failed to maintain a home-like environment by not replacing missing floorboards in three rooms.
Report Facts
Facility census: 56
Rooms with missing floorboards: 3
Rooms with call light issues: 1
Residents with glucometer checks: 8
Residents sampled for documentation: 28
Residents with documentation failure: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in findings related to medication cart security and glucometer disinfection |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding medication cart locking, glucometer cleaning, tube feeding monitoring, and call light expectations |
| Unit Manager | Unit Manager | Confirmed open eye drop bottle and discussed documentation expectations |
| Infection Perfectionist Nurse | Infection Preventionist Nurse | Provided protocol for glucometer disinfection and stated nurses should not use alcohol wipes |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Interviewed about documentation practices and call light testing |
| Maintenance Director | Maintenance Director | Confirmed call light issues and missing floor tiles, described maintenance priorities and repair plans |
| Administrator | Facility Administrator | Reinforced call light repair expectations and acknowledged impact of missing floor tiles on home-like environment |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 6
Date: May 29, 2025
Visit Reason
A standard survey was conducted from May 27 through May 29, 2025, including investigation of Complaint Intake Number GA00253953, which was substantiated with deficiency.
Complaint Details
Complaint Intake Number GA00253953 was investigated in conjunction with the standard survey and was found substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a home-like environment due to missing floor tiles, failure to administer enteral feedings per physician orders, improper medication cart security and medication dating, failure to document personal and continence care, improper glucometer disinfection, and a non-functioning call light in one resident room.
Deficiencies (6)
Failed to maintain a home-like environment by not replacing missing floorboards in three rooms.
Failed to administer nutritional enteral feedings and hydration according to physician orders for one resident.
Failed to properly secure medication cart and ensure eye drop medication was dated appropriately.
Failed to document personal, bowel, and bladder care for one resident.
Failed to properly disinfect a glucometer before use for one resident.
Failed to keep one call light in working condition in one resident room.
Report Facts
Facility census: 56
Rooms with missing floorboards: 3
Residents sampled for documentation: 28
Shifts with missing documentation: 16
Glucometers on medication cart: 2
Call light rooms: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Confirmed missing floor tiles and discussed repair plans | |
| Administrator | Acknowledged missing tiles and call light repair expectations | |
| Director of Nursing (DON) | Confirmed tube feeding not administered, medication cart security expectations, and glucometer cleaning protocols | |
| LPN BB | Licensed Practical Nurse | Observed not locking medication cart and improper glucometer disinfection |
| CNA CC | Certified Nursing Assistant | Confirmed call light not working and discussed documentation practices |
| Unit Manager | Confirmed medication cart and documentation expectations | |
| Infection Preventionist Nurse | Explained proper glucometer disinfection procedures | |
| Maintenance Director | Explained call light malfunction due to mismatched connections |
Inspection Report
Life Safety
Census: 56
Capacity: 65
Deficiencies: 2
Date: May 28, 2025
Visit Reason
The 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 deficiencies including lack of emergency lighting in the kitchen area and patient room doors failing to properly close, affecting one of four smoke compartments.
Deficiencies (2)
Facility failed to have emergency lighting in the kitchen area.
Facility failed to have the patient room doors properly closing in Room 5.
Report Facts
Certified beds: 65
Census: 56
Inspection Report
Abbreviated Survey
Census: 60
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaint GA00246006 was substantiated. Complaints GA00253500, GA00248094, GA00247060, GA00246419, GA00245810, and GA00243243 were unsubstantiated.
Findings
Complaint GA00246006 was substantiated, while the other complaints were unsubstantiated. No deficiencies were cited related to any of the complaints.
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00242427.
Complaint Details
Complaint GA00242427 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint GA00242427 was unsubstantiated with no regulatory violations cited during the survey.
Inspection Report
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Social Circle Nursing & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 29, 2023 Recertification Survey.
Findings
All deficiencies cited in the October 29, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 19, 2023
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The Emergency Preparedness Program was reviewed and found to be in substantial compliance with regulatory requirements. All previously cited deficiencies were corrected.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 8
Date: Oct 29, 2023
Visit Reason
The inspection was a State Licensure survey conducted at Social Circle Nursing and Rehabilitation Center from October 27, 2023 through October 29, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to maintain resident dignity by not providing dignity bags for catheter drainage, failure to implement stop dates for psychotropic medications, medication storage and labeling issues, failure to follow care plan interventions for PICC line care and contracture management, safety issues with laundry equipment, infection control lapses including hand hygiene and laundry practices, and failure to properly label and date opened food items in the kitchen.
Deficiencies (8)
Failed to maintain dignity by not providing a dignity bag for a resident's Foley catheter drainage bag, which was uncovered and visible from the hall.
Failed to ensure stop dates were implemented for psychotropic medications for two residents.
Failed to ensure medication carts and treatment carts were locked when not in use, insulin was dated appropriately, and expired medications were discarded properly.
Failed to follow care plan interventions for PICC line care and failed to develop a care plan to treat and prevent contractures for one resident.
Failed to ensure essential laundry equipment was in proper working order; water leak behind industrial washer.
Failed to prevent possible cross-contamination during laundry services and failed to ensure hand hygiene during medication administration.
Failed to ensure PICC line dressing was changed every seven days as required.
Failed to ensure opened food items were labeled, dated, and appropriately stored in kitchen refrigerators and freezers.
Report Facts
Facility census: 61
Number of residents reviewed for unnecessary medications: 6
Number of residents reviewed for care plans: 27
Number of residents affected by food labeling deficiency: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Acknowledged medication cart should be locked when not in use |
| CC | Licensed Practical Nurse (LPN) | Observed with medication cart and PICC line care; verified insulin vial opening date |
| EE | Licensed Practical Nurse (LPN) | Unaware medication treatment cart was unlocked |
| BB | Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene during medication administration |
| MM | Certified Nursing Assistant (CNA) | Reported lack of care plan for resident contracture management |
| JJ | Registered Nurse (RN), Unit Manager | Discussed PICC line dressing change responsibilities |
| OO | Nurse Practitioner (NP) | Discussed PICC line dressing change frequency and infection prevention |
| AA | Cook | Acknowledged food items were not labeled or dated |
| DON | Director of Nursing | Confirmed expectations for dignity bags, medication stop dates, care plan adherence, hand hygiene, and PICC line dressing changes |
| DM | Dietary Manager | Acknowledged food labeling and storage deficiencies |
| Maintenance Director | Reported awareness of laundry washer leak and awaiting replacement part | |
| Administrator | Verified laundry washer leak and discussed repair plans | |
| Pharmacist FF | Pharmacist | Discussed medication cart audits and insulin discard policies |
Inspection Report
Routine
Census: 61
Deficiencies: 11
Date: Oct 29, 2023
Visit Reason
A standard survey was conducted at Social Circle Nursing and Rehabilitation Center from October 27, 2023, to October 29, 2023, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident dignity, advance directives, care planning, medication management, infection control, and equipment maintenance. Deficiencies included failure to provide dignity bags for catheterized residents, lack of physician orders for code status, incomplete care plans, improper medication storage and labeling, inadequate infection control practices, and a leaking industrial washer in the laundry.
Deficiencies (11)
Failure to maintain dignity by ensuring a dignity bag was provided for a resident with an indwelling catheter.
Failure to obtain and/or transcribe a physician's order for code status for one resident.
Failure to ensure care plan interventions were followed for a resident with a PICC line and failure to develop a comprehensive care plan to treat and prevent contractures for another resident.
Failure to ensure a physician's order was in place for care of a PICC line and failure to document care of the PICC line.
Failure to provide restorative services to a resident with limited range of motion and contractures.
Failure to ensure respiratory nasal cannula tubing was dated when changed, oxygen concentrator filters were maintained sanitary, and proper storage of nasal cannula when not in use for residents receiving oxygen therapy.
Failure to ensure psychotropic medications had a stop date not to exceed 14 days for two residents.
Failure to ensure medication and treatment carts were locked when not in use, insulin was dated appropriately, and expired medications were discarded.
Failure to ensure opened food items were labeled, dated, and appropriately stored in the kitchen and food storage areas.
Failure to practice acceptable infection control practices including hand hygiene during medication administration, proper laundry workflow to prevent cross-contamination, and timely dressing changes for a PICC line.
Failure to ensure essential laundry equipment was in proper working order as evidenced by a water leak behind an industrial washer.
Report Facts
Residents receiving oxygen therapy: 3
Residents reviewed for restorative services: 27
Residents reviewed for unnecessary psychotropic medications: 6
Residents receiving psychotropic medications without stop date: 2
Residents present during inspection: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Named in findings related to PICC line care and medication cart observations. |
| RN JJ | Registered Nurse Unit Manager | Named in findings related to PICC line dressing and oxygen therapy observations. |
| DON | Director of Nursing | Named in multiple findings related to oversight of care plans, infection control, and medication management. |
| LPN DD | Licensed Practical Nurse | Observed leaving medication cart unlocked. |
| LPN EE | Licensed Practical Nurse | Observed leaving treatment cart unlocked. |
| Laundry Supervisor | Named in findings related to laundry equipment and workflow. | |
| Maintenance Director | Named in findings related to laundry washer leak. | |
| Administrator | Named in findings related to laundry equipment and restorative services. | |
| Pharmacist FF | Pharmacist | Named in medication management and audit process. |
Inspection Report
Life Safety
Census: 61
Capacity: 65
Deficiencies: 2
Date: Oct 28, 2023
Visit Reason
The Life Safety Code Survey was 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 due to improper use of flammable foam to seal AC penetrations on an exterior wall and a smoke door in the south hallway that did not close properly, potentially placing residents at risk from fire and smoke spread.
Deficiencies (2)
Use of improper rated materials (flammable foam) to seal around AC connections at the right outside exterior wall.
Failure to maintain smoke door closing properly at the south hallway; door was bowed and needed adjusting.
Report Facts
Resident count at risk: 60
Resident count at risk: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews regarding deficiencies. |
Inspection Report
Abbreviated Survey
Census: 60
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00227862 and #GA00229939 were substantiated with no deficiencies. Complaints #GA00229044, #GA00231896, #GA00233285, and #GA00238515 were unsubstantiated.
Findings
Complaints #GA00227862 and #GA00229939 were substantiated with no deficiencies found. Complaints #GA00229044, #GA00231896, #GA00233285, and #GA00238515 were unsubstantiated.
Report Facts
Complaints investigated: 6
Facility census: 60
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a survey completed at the facility.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Date: Jan 18, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 11/23/22 Complaint Survey.
Complaint Details
This revisit survey followed a complaint survey conducted on 11/23/22. All deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited in the previous complaint survey were found to be corrected during this revisit survey.
Report Facts
Census: 56
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Date: Nov 23, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint intake GA00229858 regarding allegations of sexual abuse by one resident towards others.
Complaint Details
Complaint number GA00229858 was substantiated with deficiencies related to sexual abuse allegations involving residents #1, #2, and #3.
Findings
The facility failed to protect two residents from sexual abuse by another resident, failed to report allegations of abuse to the State Survey Agency timely, and failed to investigate the allegations of abuse. Multiple staff and resident interviews confirmed inappropriate behavior by the accused resident, and the facility administration was unaware of some incidents.
Deficiencies (3)
Failed to ensure two residents were protected from sexual abuse by another resident.
Failed to report allegations of abuse to the State Survey Agency within required timeframes.
Failed to investigate allegations of abuse for two residents.
Report Facts
Facility census: 59
BIMS score: 5
BIMS score: 12
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant (CNA) | Reported resident #1's inappropriate behavior and aggression when redirected |
| BB | Housekeeper | Witnessed resident #1's inappropriate behavior and reported to nurses and administrative staff |
| CC | Housekeeper | Observed resident #1 entering other resident rooms uninvited and redirecting him |
| DD | Licensed Practical Nurse (LPN) | Observed resident #1 placing hands beneath covers of resident #2 and reported to Director of Nursing |
| Director of Nursing (DON) | Director of Nursing | Received reports of resident #1's behavior and was interviewed about awareness of incidents |
| Administrator | Administrator | Interviewed regarding awareness of resident #1's behavior and efforts to find alternative placement |
Inspection Report
Deficiencies: 0
Date: Sep 9, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 0
Date: Sep 9, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 7/21/22 recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Renewal
Deficiencies: 1
Date: Jul 21, 2022
Visit Reason
The inspection was a Licensure Survey conducted from July 19, 2022 through July 21, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to maintain cleanliness of the kitchen grease trap, resulting in a buildup of black, greasy substance that posed potential health and safety hazards to residents and staff. Interviews revealed lack of maintenance scheduling and communication regarding the grease trap cleaning responsibilities.
Deficiencies (1)
Facility failed to maintain cleanliness of the kitchen grease trap, exposing residents and staff to potential health and safety hazards.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Food Manager | Certified Food Manager (CFM) | Interviewed regarding condition of grease trap and cleaning responsibilities. |
| Maintenance Director | Maintenance Director | Interviewed about grease trap cleaning responsibilities and maintenance scheduling. |
| Administrator | Administrator | Interviewed about maintenance responsibilities for grease trap cleaning. |
| Cook | Cook | Interviewed about grease trap condition and typical buildup. |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 2
Date: Jul 21, 2022
Visit Reason
A standard survey was conducted from 7/19/22 through 7/21/22, including investigation of Complaint Intake Number GA00225705, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00225705 was investigated in conjunction with the standard survey. The complaint involved failure to provide SNFABN notices to residents discharged from Medicare Part A services but remaining in the facility.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, including failure to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two residents discharged from Medicare Part A services but remaining in the facility, and failure to maintain cleanliness of the kitchen grease trap, exposing residents and staff to potential health and safety hazards.
Deficiencies (2)
Failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two residents discharged from Medicare Part A services but remaining in the facility.
Failed to maintain cleanliness of the kitchen grease trap, with black, greasy substance buildup and leakage onto the floor.
Report Facts
Resident census: 51
Residents discharged from Medicare Part A without SNFABN: 2
Date of Medicare Part A discharge for R#52: Mar 9, 2022
Date of Medicare Part A discharge for R#11: May 4, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding SNFABN distribution policy and procedures | |
| Administrator | Interviewed regarding expectations for SNFABN distribution | |
| Certified Food Manager | Interviewed about grease trap condition and cleaning responsibility | |
| Maintenance Director | Interviewed about grease trap maintenance and cleaning schedule | |
| Cook | Interviewed about grease trap condition and buildup |
Inspection Report
Life Safety
Census: 51
Capacity: 65
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The visit was conducted as a Life Safety Code survey to assess compliance with fire safety and related regulations at Social Circle Nursing and Rehab.
Findings
The facility was found to be in compliance with the requirements for participation in Medicare/Medicaid under 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 Edition. Five rooms in the North Hall were not surveyed due to COVID patients, but daily life safety assessments were documented.
Inspection Report
Deficiencies: 0
Date: Jul 18, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Jul 18, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the complaint survey conducted on 2022-06-02.
Findings
All deficiencies cited in the previous complaint survey were found to be corrected during this revisit survey.
Report Facts
Census: 51
Inspection Report
Renewal
Deficiencies: 1
Date: Jun 2, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from May 22, 2022 through June 2, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to implement a respiratory care plan intervention by not obtaining a physician order for oxygen use for one of three sampled residents with asthma and COPD. The Director of Nursing confirmed that care plans should be followed and updated as needed.
Deficiencies (1)
Failure to implement a respiratory care plan intervention of obtaining a physician order for oxygen use for one resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed on 6/1/2022 confirming the respiratory care plan and intervention. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00211410 and #GA00211346.
Complaint Details
Complaints #GA00211410 and #GA00211346 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00204989, #GA00205309, #GA00206201, #GA00207228, #GA00207473, #GA00208622, and #GA00208796 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 55
Deficiencies: 0
Date: Oct 28, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the August 12, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 1
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on August 11-12, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH) to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with 42 CFR §483.80 infection control regulation due to failure to properly contain COVID-19 for four of six sampled residents on the COVID/Observation Unit. Specifically, a Certified Nursing Assistant failed to perform hand hygiene after removing PPE and before donning new gloves.
Deficiencies (1)
Failure to properly contain COVID-19 for four of six sampled residents on the COVID/Observation Unit due to inadequate hand hygiene by staff after PPE removal and before donning new gloves.
Report Facts
Total census: 56
Sampled residents with deficiency: 4
Date of positive COVID-19 test: Jul 27, 2020
Date of positive COVID-19 test: Jul 29, 2020
Date of hand hygiene competency validation: Aug 7, 2020
Date of PPE skills competency checklist: Jul 20, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed failing to perform hand hygiene after PPE removal and before donning new gloves |
| Infection Preventionist Nurse | Interviewed and stated staff needed to disinfect hands prior to putting on PPE |
Inspection Report
Routine
Census: 61
Deficiencies: 0
Date: Jul 22, 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 §483.80 infection control regulations and had implemented recommended practices to prepare for COVID-19.
Report Facts
Census: 61
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints # GA00200057, GA00202422, and GA00203032.
Complaint Details
Complaint # GA00202422 was substantiated; complaints # GA00200057 and GA00203032 were not substantiated.
Findings
Complaints GA00200057 and GA00203032 were not substantiated, while complaint GA00202422 was substantiated. No deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
A complaint survey was conducted on 6/12/19 to investigate complaint GA00196852 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00196852 was investigated and no deficiencies were found, indicating compliance with applicable requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
A follow-up to the Recertification survey conducted from 1/22/19 through 1/26/19 was performed from 3/18/19 through 3/21/19 to verify correction of previous deficiencies. Additionally, an Abbreviated/Partial Extended survey was conducted to investigate complaint #GA00195166.
Complaint Details
Complaint #GA00195166 was investigated during the revisit survey with no deficient practice cited.
Findings
All deficiencies from the prior recertification survey had been corrected, and the facility was in substantial compliance as of 3/11/19. The complaint investigation found no deficient practices.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 21, 2019
Visit Reason
An unannounced abbreviated survey was conducted from 3/18/19 through 3/21/19 to investigate complaint #GA00195166, along with a revisit survey to the Recertification survey of 1/22/19 through 1/26/19.
Complaint Details
Complaint #GA00195166 was investigated and no deficient practice was found.
Findings
No deficient practice was cited for the complaint portion of the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 60
Deficiencies: 9
Date: Jan 26, 2019
Visit Reason
A standard survey was conducted at Social Circle Nursing & Rehab Center from 1/22/19 to 1/26/19 to assess compliance with Medicare/Medicaid regulations and evaluate resident care and facility operations.
Findings
The survey identified multiple deficiencies including failure to promptly notify family of resident condition changes, failure to protect a resident from staff abuse, inaccurate resident assessments, insufficient nursing staff to complete medication passes timely, elevated hot water temperatures in resident bathrooms, incomplete infection control surveillance and reporting, and failure to properly post nurse staffing information.
Deficiencies (9)
Failure to promptly notify family of a resident's pressure sore and treatment change.
Failure to protect a resident from abuse by a Certified Nursing Assistant who removed the resident's call light and placed it out of reach.
Failure to accurately document dementia diagnosis and discharge status in resident assessments.
Failure to implement care plan interventions to prevent falls and evaluate their effectiveness for a resident with multiple falls.
Failure to anchor Foley catheter tubing to resident's leg to prevent tension and discomfort.
Insufficient nursing staff to complete medication passes within required timeframes on the rehabilitation unit.
Failure to post actual hours worked by licensed and unlicensed nursing staff and actual resident census on daily staffing sheets.
Failure to provide evidence of infection control surveillance data analysis and response to infection clusters and outbreaks.
Failure to provide documented education to resident or representative prior to refusal of influenza and pneumococcal vaccines.
Report Facts
Resident census: 60
Resident census: 63
Water temperature: 124
Water temperature: 123.8
Water temperature: 125.6
Water temperature: 123.5
Falls: 7
Medication scheduled time: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in abuse finding for removing resident call light and suspended pending investigation |
| LPN GG | Licensed Practical Nurse | Nurse on duty during call light incident, interviewed about abuse allegation |
| RN Supervisor DD | Registered Nurse Supervisor | Received family complaint about call light removal, reported incident |
| LPN MM | Licensed Practical Nurse | Named in medication pass delay finding |
| CNA CC | Certified Nursing Assistant | Named in Foley catheter anchoring deficiency |
Inspection Report
Routine
Census: 60
Deficiencies: 4
Date: Jan 26, 2019
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations including administration, infection control, nursing care, physical plant standards, and patient safety at Social Circle Nursing & Rehab Center.
Findings
The facility failed to promptly notify a resident's family of a new pressure ulcer and treatment, did not adequately analyze infection control data or respond to infection clusters, failed to implement care plans related to falls, medication administration, and catheter care, and did not maintain hot water temperatures within safe limits, failing to monitor and communicate elevated water temperatures effectively.
Deficiencies (4)
Failure to promptly notify family of a resident's new pressure ulcer and treatment.
Failure to provide evidence that infection control surveillance data was accurately recorded, analyzed, and responded to for infection clusters.
Failure to implement care plans related to falls, medication administration, and Foley catheter anchoring.
Failure to maintain hot water temperatures at or below 110 degrees Fahrenheit in resident bathrooms and common shower, and failure to monitor and communicate elevated water temperatures.
Report Facts
Facility census: 60
Sample size: 34
Pressure ulcer wound measurement: 1.5
Pressure ulcer wound measurement: 0.5
Pressure ulcer wound measurement: 0.1
Falls documented: 5
Medications scheduled at 9:00 a.m.: 9
Urine volume: 1000
Hot water temperatures: 124
Hot water temperatures: 123.8
Hot water temperatures: 125.6
Residents independently mobile: 26
Residents with BIMS score below 8: 8
Residents independently mobile in rooms with hot water >120F: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse, Treatment Nurse | Interviewed regarding resident R 'A' skin condition and treatment |
| LPN FF | Licensed Practical Nurse, Treatment Nurse | Measured and confirmed open area on resident R 'A' gluteal cleft |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding notification expectations, falls, and water temperature issues |
| LPN Infection Control Coordinator | Licensed Practical Nurse, Infection Control Coordinator | Interviewed about infection control surveillance and outbreak response |
| LPN MM | Licensed Practical Nurse | Named by resident R 'B' regarding late medication administration |
| Certified Nursing Assistant (CNA) CC | Certified Nursing Assistant | Interviewed about Foley catheter anchoring for resident #59 |
| Maintenance Director | Maintenance Director | Interviewed regarding water temperature monitoring and valve replacement |
| Administrator | Facility Administrator | Interviewed regarding water temperature issues and communication |
| CNA KK | Certified Nursing Assistant | Interviewed about notification of elevated water temperatures |
| Maintenance Assistant LL | Maintenance Assistant | Interviewed about water temperature checks |
Inspection Report
Life Safety
Census: 62
Capacity: 65
Deficiencies: 7
Date: Jan 22, 2019
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 improper maintenance of the fire alarm system, lack of sprinkler protection in some closets, corridor doors not closing and latching properly, unprotected penetrations in rated ceilings, failure to maintain rated doors, improper use of portable space heaters, and lack of a remote annunciator for the emergency generator.
Deficiencies (7)
Fire alarm system breaker has no lock and is not identified as required.
Closet inside the Staff Break Area is not protected by the fire sprinkler system.
Corridor doors to Wound Care, Kitchen, Soiled Utility rooms do not close and latch; North Hall cross corridor doors blocked from closing by storage, eliminating smoke compartment.
Unprotected penetrations in the rated ceiling in the IT Room.
No routine inspections of rated doors; fire doors damaged in laundry area.
Portable space heater located in Resident Ambassador's Office (removed at time of inspection).
No annunciator for the emergency generator.
Report Facts
Residents at risk: 62
Certified beds: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour and inspection. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 26, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00190251 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00190251 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 22, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00189471 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00189471 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
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 had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 59
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 2/1/18.
Findings
All deficiencies cited as a result of the Recertification survey of 2/1/18 were corrected.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Mar 21, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies related to the facility's Emergency Preparedness Plan.
Findings
The facility's Emergency Preparedness Plan was found not to be in substantial compliance as it did not address all identified hazards and not all staff had been trained and tested, placing 59 residents at risk in the event of an emergency.
Deficiencies (1)
The Emergency Preparedness Plan did not address all identified hazards and not all staff have been trained and tested.
Report Facts
Residents at risk: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings related to Emergency Preparedness Plan deficiencies. |
Inspection Report
Routine
Census: 59
Deficiencies: 7
Date: Feb 1, 2018
Visit Reason
A standard survey was conducted at Social Circle Health Nursing and Rehab Center from January 29, 2018 to February 1, 2018 to assess compliance with Medicare/Medicaid regulations and facility standards.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to document Quality Improvement Organization information on Medicare Non-Coverage notices, incomplete comprehensive care plans for multiple residents, failure to prevent and treat pressure ulcers, lack of restorative therapy services as ordered, inadequate bowel and bladder assessments and interventions, failure to provide therapeutic diets and assistance with eating, and failure to maintain infection control practices for a resident in isolation.
Deficiencies (7)
Failure to document Quality Improvement Organization (QIO) name and toll-free number on Medicare Non-Coverage notices for three residents.
Failure to develop comprehensive care plans for six residents with various needs including pressure ulcers, dialysis, nutrition, and restorative services.
Failure to prevent and treat multiple pressure ulcers for two residents, including inadequate wound assessment, delayed treatment, and improper use of pressure reduction devices.
Failure to provide restorative therapy services as ordered for one resident with limited range of motion.
Failure to have physician order for Foley catheter and to assess and provide toileting program for two residents.
Failure to provide physician ordered therapeutic diet and assistance with eating for two residents.
Failure to maintain infection control practices for a resident in isolation for possible clostridium difficile infection, including staff entering isolation room without PPE.
Report Facts
Resident census: 59
Weight loss: 6.89
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 5
Weight: 142
Weight: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Entered isolation room without PPE for resident in contact isolation |
| Unit Manager | Interviewed regarding air mattress setup, care plans, and infection control | |
| Director of Nursing | Interviewed regarding policies for turning/repositioning, catheter use, and infection control | |
| Registered Dietician | Interviewed regarding dietary needs and education for resident with gastric bypass | |
| Physical Therapist | Reported discontinuation of PT and referral to restorative therapy | |
| Licensed Practical Nurse | Restorative Therapy Coordinator | Reported resident was on restorative therapy only for upper extremities |
| Wound Care Physician | Provided wound care and debridement for resident with pressure ulcers | |
| Wound Nurse | Provided wound care and interviewed regarding air mattress and skin committee |
Inspection Report
Routine
Census: 21
Deficiencies: 2
Date: Feb 1, 2018
Visit Reason
The inspection was conducted to evaluate compliance with infection control practices, comprehensive care planning, and nursing care standards at the Social Circle Nursing & Rehab Center.
Findings
The facility failed to maintain proper infection control practices for a resident in isolation for possible clostridium difficile and failed to develop comprehensive care plans for six residents with various medical and care needs including pressure ulcers, dialysis, nutrition, range of motion limitations, and bowel/bladder functioning.
Deficiencies (2)
Failure to ensure infection control practices to prevent infection and cross contamination for a resident in isolation for possible clostridium difficile.
Failure to develop comprehensive care plans for six residents addressing pressure ulcers, dialysis, nutrition, range of motion, and bowel/bladder care.
Report Facts
Sample size: 21
Pressure ulcers: 3
Weight: 142
MDS Brief Interview for Mental Status score: 6
MDS Brief Interview for Mental Status score: 4
MDS Brief Interview for Mental Status score: 15
Foley catheter size: 18
Foley catheter volume: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed not wearing PPE in isolation room for Resident #147 |
| Unit Manager | Interviewed regarding infection control expectations and care plan development | |
| MDS Coordinator | Interviewed regarding care plan development and dialysis care planning | |
| Physical Therapy staff | Physical Therapist | Interviewed regarding restorative therapy services for Resident #17 |
| Licensed Practical Nurse | Restorative Therapy Coordinator | Interviewed regarding restorative therapy services for Resident #17 |
Inspection Report
Life Safety
Census: 59
Capacity: 65
Deficiencies: 10
Date: Jan 30, 2018
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements, including deficiencies in the emergency preparedness plan, fire alarm system installation and initiation, sprinkler system maintenance, fire extinguisher maintenance, corridor doors, electrical systems, HVAC maintenance, generator maintenance, and oxygen cylinder storage.
Deficiencies (10)
Emergency Preparedness Plan was not site specific and did not address all identified hazards.
Fire alarm system pull stations mounted too high, no pull station within 5 feet of main egress, pull station obstructed at reception desk, and no visual notification device in conference room.
Facility failed to properly maintain corridor smoke detectors; smoke detector located in HVAC supply air stream.
Fire sprinkler system deficiencies including painted heads, dust loaded heads, outdated gauge, no data plate on sprinkler system, and sprinkler heads installed outside listing in attic.
Fire extinguishers mounted too high throughout the facility.
Corridor door to laundry will not close properly.
Electrical system deficiencies including flexible power cord running through wall, open junction box, damaged receptacle, and improperly installed flexible metal cable.
HVAC systems not serviced as required.
Facility failed to conduct required monthly 30-minute minimum load run on generator; no runs conducted in approximately 9 months.
Oxygen cylinders not properly secured.
Report Facts
Residents at risk: 59
Certified beds: 65
Months generator load test missing: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during observations and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 30, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181144 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00181144 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Social Circle Nursing and Rehab.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00178560 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00178560 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 8/17/17 to 8/18/17.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 26, 2017
Visit Reason
A follow-up survey was conducted on 4/26/17 to the recertification survey conducted on 3/2/17.
Findings
All deficiencies identified in the prior recertification survey had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 21, 2017
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 had been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint GA00173610.
Complaint Details
Complaint GA00173610 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint GA00173610 was unsubstantiated and no deficiencies were found during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 4, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00173362.
Complaint Details
Complaint GA00173362 was investigated and found to be unsubstantiated.
Findings
The complaint GA00173362 was found to be unsubstantiated during the survey.
Inspection Report
Life Safety
Census: 58
Capacity: 65
Deficiencies: 12
Date: Feb 28, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including improperly secured exit doors, failure to maintain exit and emergency lighting, improperly installed smoke detectors, inadequate fire sprinkler system coverage and maintenance, damaged rated ceilings, electrical system deficiencies, incomplete fire drills on all shifts, use of prohibited portable space heaters, failure to properly test the emergency generator, and lack of required oxygen storage signage.
Deficiencies (12)
Facility failed to properly secure exit doors, placing residents at risk in an emergency.
Facility failed to properly maintain exit and exit directional lighting; exit signs not tested monthly.
Facility failed to properly maintain emergency lighting; emergency lights not tested monthly.
Smoke detectors not properly installed; one located within 3 feet of HVAC supply.
Facility not properly protected by fire sprinkler system; uncovered combustible construction areas and sprinkler heads improperly located or maintained.
Facility failed to properly maintain fire sprinkler system; heads painted, dusty, wiring issues, and items hung on piping.
Facility failed to properly maintain rated smoke barrier walls and ceilings; damage and unprotected penetrations observed.
Facility failed to properly maintain electrical system; missing junction box covers, missing knockout, unprotected splices, and use of extension cords as permanent wiring.
Facility failed to conduct quarterly fire drills on all shifts; missing drills for third shift first quarter and second shift fourth quarter.
Portable space heaters used in facility areas not meeting requirements.
Facility failed to properly test emergency generator; monthly load runs less than required 30 minutes for multiple months.
Facility failed to properly identify oxygen storage locations; required signage missing.
Report Facts
Census: 58
Total Capacity: 65
Months with generator runs less than 30 minutes: 6
Fire drills missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff interviewed and confirmed findings during facility tour and record review |
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