Inspection Reports for Southern Pines Senior Living
423 Covington Ave, Thomasville, GA 31792, United States, GA, 31792
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Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Mar 28, 2025
Visit Reason
A revisit was conducted at Southern Pines to verify correction of deficiencies cited during the recertification survey conducted on February 2, 2025.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected during this revisit.
Inspection Report
Deficiencies: 0
Mar 28, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the facility Southern Pines, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Annual Inspection
Deficiencies: 5
Feb 2, 2025
Visit Reason
A State Licensure survey was conducted at Southern Pines from January 31, 2025, through February 2, 2025, to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to provide transfer and bed hold notices for hospital transfers for two residents, improper preparation of pureed food compromising nutritional value, lack of a comprehensive care plan for psychotropic medication use for one resident, and multiple dietary service violations related to food storage, labeling, and sanitation.
Deficiencies (5)
| Description |
|---|
| Failure to provide transfer notices for two residents (R50 and R62) upon hospital transfer. |
| Failure to provide bed hold notices for two residents (R50 and R62) upon hospital transfer. |
| Dietary staff pureed fried fish with bread slices, compromising nutritive value for eight residents on pureed diets. |
| Lack of a comprehensive person-centered care plan for psychotropic medication use for one resident (R12). |
| Failure to discard leftover and expired food, label and date leftover foods, remove dented cans, maintain cleanliness of storage areas, and prevent wet nesting of steam table pans, risking foodborne illness for 56 of 58 residents. |
Report Facts
Residents reviewed for hospital transfers: 2
Residents receiving pureed diet: 8
Residents reviewed for psychotropic medication use: 5
Residents consuming oral diet: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Agency Licensed Practical Nurse (LPN) | Reported on transfer procedures and lack of bed hold notice provision. |
| Assistant Director of Nursing (ADON) | Reported on transfer procedures and lack of transfer and bed hold notices under previous ownership. | |
| Administrator | Reported former company did not provide transfer or bed hold notices. | |
| AA | Dietary Cook | Observed preparing pureed fried fish with bread slices. |
| Dietary Manager (DM) | Reported no recipe for pureed fried fish, improper food storage and sanitation issues. | |
| MDS Coordinator | Acknowledged lack of care plan for psychotropic medication use for resident R12. |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 6
Feb 2, 2025
Visit Reason
A standard annual survey was conducted at Southern Pines from January 31, 2025, through February 2, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with several Medicare/Medicaid regulations including failure to provide transfer and bed hold notices for hospital transfers, lack of comprehensive care plan for psychotropic medication use, improper preparation of pureed foods, poor food storage and sanitation practices, and failure to conduct annual review of infection control policies.
Severity Breakdown
SS= D: 3
SS= F: 2
SS= C: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure transfer notices were provided for two residents transferred to hospital, risking uninformed rights about hospital transfer and return. | SS= D |
| Failed to provide bed hold notices for two residents hospitalized, risking denial of re-admission and loss of room. | SS= D |
| Failed to develop a comprehensive person-centered care plan for psychotropic medication use for one resident. | SS= D |
| Dietary staff pureed fried fish with bread slices, compromising nutritive value for residents on pureed diets. | SS= F |
| Failed to discard expired/leftover food, label and date leftovers, remove dented cans, maintain cleanliness of storage areas, and prevent wet nesting of pans, risking foodborne illness. | SS= F |
| Failed to ensure annual review of Infection Control and Prevention Program policies, increasing risk of infectious disease exposure. | SS= C |
Report Facts
Facility census: 58
Residents reviewed for hospital transfers: 2
Residents reviewed for psychotropic medication use: 5
Residents receiving pureed diet: 8
Residents consuming oral diet: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Agency Licensed Practical Nurse (LPN) | Reported on transfer procedures and bed hold notice responsibility |
| Assistant Director of Nursing (ADON) | Reported on transfer and bed hold notice procedures and previous company practices | |
| R12 | Resident | Reviewed for psychotropic medication use without comprehensive care plan |
| AA | Dietary Cook | Observed preparing pureed fried fish with bread |
| DM | Dietary Manager | Interviewed regarding food preparation, storage, and sanitation deficiencies |
| Infection Preventionist (IP) | Reported on infection control program review status | |
| Director of Nurses (DON) | Unable to provide evidence of annual infection control policy review |
Inspection Report
Life Safety
Census: 59
Capacity: 66
Deficiencies: 0
Feb 1, 2025
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR § 483.73 for emergency preparedness and 42 CFR Subpart 483.90(a) for Life Safety from Fire, as well as the NFPA 101 Life Safety Code 2012 edition.
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 0
Dec 18, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00253149 and GA00245322.
Findings
The complaints GA00253149 and GA00245322 were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints GA00253149 and GA00245322 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Deficiencies: 0
Oct 18, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for the healthcare facility Southern Pines, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 0
Oct 18, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/20/2023 Recertification Survey and Complaint Investigation.
Findings
All deficiencies cited as a result of the 8/20/2023 Recertification Survey and Complaint Investigation were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 13, 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 by the surveyor.
Inspection Report
Life Safety
Census: 58
Capacity: 66
Deficiencies: 5
Aug 29, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with hazardous area enclosures, cooking facility protections, fire alarm system maintenance, smoke detector sensitivity testing, sprinkler system installation, spare sprinkler head supply, and smoke detection in corridor-open areas.
Severity Breakdown
E: 1
D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure storage was located in safe areas and two doors to storage areas did not resist passage of smoke, placing 33 of 66 residents at risk. | E |
| Cooking appliances were not properly aligned under the hood and suppression system, including a deep fryer on casters and a six burner range under two separate hoods. | D |
| Fire alarm system testing and maintenance records were not up to date; smoke detector sensitivity testing had not been performed in the past two years. | D |
| Failed to ensure a proper supply of spare sprinkler heads in the spare sprinkler cabinet; fewer than six of each type were available. | D |
| Failed to ensure two areas open to the corridor (activities room and physical therapy room) had proper smoke detection; barn doors partially closed openings leaving areas open to corridor. | D |
Report Facts
Residents at risk due to deficient storage door smoke resistance: 33
Total certified beds: 66
Current census: 58
Residents at risk due to deficient smoke detection in corridor-open areas: 33
Minimum required spare sprinkler heads per type: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 20, 2023
Visit Reason
A State Licensure survey was conducted at Southern Pines from August 18, 2023, through August 20, 2023, to assess compliance with state health regulations and nursing care standards.
Findings
The facility failed to assess the competency of nursing staff caring for implanted venous ports and failed to implement proper infection control practices during intravenous antibiotic administration for one resident. Deficiencies included improper handling of port needles, lack of sterile technique, missed antibiotic doses, and inadequate staff competency verification.
Deficiencies (2)
| Description |
|---|
| Failure to assess competency of nursing staff caring for implanted venous ports for one resident receiving IV antibiotics every four hours. |
| Failure to implement infection control practices during care of a resident receiving medications via a port and during needle device changes, risking cross contamination. |
Report Facts
IV antibiotic frequency: 4
Date of survey completion: Aug 20, 2023
Date of facility assessment: Jun 30, 2023
Time of missed antibiotic dose: 1353
IV tubing rate: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering IV antibiotics and handling port needle without proper sterile technique |
| RN BB | Registered Nurse | Observed Infection Preventionist and provided instruction on sterile technique |
| Infection Preventionist | Performed port dressing removal and attempted port access with improper sterile technique | |
| Director of Nursing | Director of Nursing | Interviewed regarding staff competency and port care procedures |
| Assistant Director of Nursing | Assistant Director of Nursing | Normally responsible for port needle changes and dressing changes; not working on 8/19/2023 |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 3
Aug 20, 2023
Visit Reason
A standard survey was conducted from August 18 through August 20, 2023, including investigation of Complaint Intake Numbers GA00235229 and GA00235881, which were found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to nursing staff competency in implanted venous port care, medication administration errors, and failure to implement proper infection control practices during intravenous antibiotic therapy for one resident.
Complaint Details
Complaint Intake Numbers GA00235229 and GA00235881 were investigated and found to be unsubstantiated.
Severity Breakdown
Level D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to assess competency of nursing staff caring for implanted venous ports for one resident receiving IV antibiotics. | Level D |
| Failure to ensure one resident was free of significant medication errors related to IV antibiotic administration. | Level D |
| Failure to implement infection control practices during care of resident receiving medications via a port and during needle device changes, risking cross contamination. | Level D |
Report Facts
Resident census: 59
Antibiotic doses given: 100
IV antibiotic frequency: 4
IV antibiotic treatment duration: 42
IV infusion rate: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering IV antibiotics and handling port needle without proper infection control |
| RN BB | Registered Nurse | Observed assisting Infection Preventionist and instructing on sterile technique |
| Director of Nursing | Director of Nursing | Interviewed regarding competency and medication administration issues |
| Infection Preventionist | Infection Preventionist Nurse | Observed performing port care and needle device changes with lapses in sterile technique |
| Assistant Director of Nursing | Assistant Director of Nursing | Normally responsible for port needle changes and dressing changes; noted lack of competency check-offs |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 23, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00231849, #GA00230730, and #GA00230260.
Findings
Complaint #GA00230730 was substantiated with no regulatory violations cited. Complaints #GA00231849 and #GA00230260 were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaint #GA00230730 was substantiated with no regulatory violations cited. Complaints #GA00231849 and #GA00230260 were unsubstantiated with no regulatory violations cited.
Inspection Report
Life Safety
Census: 39
Capacity: 66
Deficiencies: 0
Apr 20, 2022
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid related to Life Safety from Fire and the Emergency Preparedness Program.
Inspection Report
Renewal
Deficiencies: 0
Apr 17, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 4/15/2022 through 4/17/2022 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from 4/15/2022 through 4/17/2022.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Apr 17, 2022
Visit Reason
A standard survey was conducted from 4/15/2022 through 4/17/2022, including an investigation of Complaint Intake Number GA00222854 in conjunction with the standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. There were no deficiencies resulting from the facility's noncompliance related to the standard survey.
Complaint Details
Complaint Intake Number GA00222854 was investigated in conjunction with the standard survey; no deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00214790.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00214790 was investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Deficiencies: 0
Nov 3, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility Southern Pines, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 0
Nov 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey on 2020-08-24.
Findings
All deficiencies cited as a result of the 8/24/2020 complaint survey were found to be corrected.
Complaint Details
The revisit survey was conducted following a complaint survey; all cited deficiencies were corrected.
Inspection Report
Renewal
Deficiencies: 0
Aug 24, 2020
Visit Reason
A Licensure Survey was conducted from August 11, 2020 through August 24, 2020 to assess compliance for licensure renewal.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 24, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00203446 and GA00207299. Complaint GA00203446 was unsubstantiated, while complaint GA00207299 was substantiated with deficiencies related to abuse.
Findings
The facility failed to ensure that one resident (#1) was free from abuse by a Floor Technician, resulting in psychosocial harm related to fear of sexual abuse after multiple encounters in her room. The investigation included video surveillance, interviews, and record reviews, confirming inappropriate conduct and leading to the termination and criminal charges against the employee.
Complaint Details
Complaint GA00207299 was substantiated with deficiencies. Psychosocial harm was identified for resident #1 related to fear of sexual abuse after multiple encounters in her room with the alleged perpetrator, Floor Technician AA. The police were notified, and the employee was arrested and charged with criminal attempt to commit rape and elderly abuse.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident #1 was free from verbal, mental, sexual, or physical abuse by a Floor Technician. | G |
Report Facts
Date of incident: Jul 7, 2020
Date survey completed: Aug 24, 2020
Date of hire: Jul 1, 2020
Clock out time: 1532
Resident age: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Floor Technician AA | Housekeeping Staff | Alleged perpetrator in the abuse incident involving resident #1. |
| RN DD | Registered Nurse | Charge nurse on duty during the incident and involved in assessment and reporting. |
| CNA BB | Certified Nursing Assistant | Resident #1's CNA who witnessed and reported the incident. |
| CNA CC | Certified Nursing Assistant | Staff who observed the incident and assisted in reporting. |
| Housekeeping Supervisor | Supervised Floor Technician AA and intervened during the incident. | |
| Director of Nursing EE | Director of Nursing | Received report of the incident and involved in follow-up. |
| Detective FF | Law Enforcement Detective | Confirmed arrest and charges against Floor Technician AA based on investigation. |
Inspection Report
Routine
Census: 44
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Report Facts
Total census: 44
Inspection Report
Original Licensing
Capacity: 10
Deficiencies: 0
Jan 29, 2020
Visit Reason
An initial walk-through survey of the Mechanical Ventilation Unit at Southern Pines was conducted to assess compliance with State requirements.
Findings
The 10-bed Vent Unit was found to be in compliance with State requirements during the initial survey.
Inspection Report
Original Licensing
Deficiencies: 0
Jan 2, 2020
Visit Reason
The inspection was conducted as a relocation survey to provide an initial environment survey for the new Southern Pines facility, which is a replacement facility for Elberta Health Care.
Findings
No deficiencies were identified during the survey.
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