Inspection Report Summary
The most recent inspection on March 19, 2024, found that all previously cited Life Safety Code deficiencies had been corrected. Earlier inspections showed a mixed pattern, with some deficiencies noted in life safety code compliance and food service practices, but these issues were addressed in subsequent revisit surveys. Main themes of past deficiencies included fire safety system maintenance, smoke barrier penetrations, and dietary labeling and hygiene. Complaint investigations over the years were mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. The facility’s record indicates improvement over time, with recent surveys showing compliance and correction of prior issues.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
41 residents
Based on a February 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Deficiencies: 0
Mar 19, 2024
Visit Reason
A Life Safety Code Revisit (Desk Review) was conducted to verify correction of previously cited survey tags.
Findings
The revisit found that all previously cited survey tags have been corrected.
Inspection Report
Renewal
Deficiencies: 0
Feb 18, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Stevens Park Health and Rehabilitation.
Findings
No State Health deficiencies were cited during the survey conducted from February 16 through February 18, 2024.
Inspection Report
Routine
Census: 41
Deficiencies: 0
Feb 18, 2024
Visit Reason
A standard survey was conducted from February 16, 2024, through February 18, 2024, including investigation of Complaint Intake Number GA00241881.
Findings
The complaint intake was unsubstantiated, and the facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Complaint Details
Complaint Intake Number GA00241881 was investigated and found to be unsubstantiated.
Inspection Report
Life Safety
Census: 41
Capacity: 50
Deficiencies: 3
Feb 17, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with life safety code requirements, including failure to provide all staff with codes to electronic magnetic locks on exit doors in Patient Wing 200, failure to seal a penetration in the smoke barrier in Wing 100, and failure to properly identify empty oxygen cylinders in Wing 100. All violations were confirmed by staff and corrected before survey completion.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide a code to the electronic magnetic lock for the exit door within egress path to all staff members in Patient Wing 200. | SS= D |
| Failed to seal penetration within the smoke barrier in Wing 100. | SS= D |
| Failed to properly identify empty oxygen cylinders in Wing 100. | SS= D |
Report Facts
Census: 41
Total Capacity: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to electronic lock codes, smoke barrier penetration, and oxygen cylinder identification |
Inspection Report
Routine
Census: 39
Deficiencies: 0
Aug 30, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess 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 and 42 CFR §483.80 Infection Control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 39
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Aug 15, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/19/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 6/19/22 Recertification Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Aug 15, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/19/22 Recertification Survey.
Findings
All deficiencies cited in the prior 6/19/22 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 35
Capacity: 42
Deficiencies: 0
Jun 28, 2022
Visit Reason
The visit was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey to ensure compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The Emergency Preparedness Program was found to be in compliance with 42 CFR § 483.73, and the facility was found in compliance with the Life Safety Code requirements for participation in Medicare/Medicaid.
Inspection Report
Routine
Census: 38
Deficiencies: 2
Jun 19, 2022
Visit Reason
The inspection was a state licensure survey conducted from June 17, 2022 through June 19, 2022 to assess compliance with physical plant standards and other regulatory requirements.
Findings
The facility failed to label and date opened food items in the walk-in refrigerator and failed to ensure dietary staff wore hair nets during food preparation and meal service, potentially affecting 37 of 38 residents receiving an oral diet.
Deficiencies (2)
| Description |
|---|
| Failure to label and date opened food items in the walk-in refrigerator. |
| Dietary staff, including the Certified Dietary Manager, did not wear hair nets during food preparation and meal service. |
Report Facts
Residents affected: 37
Residents present: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Named in findings related to not wearing hair net during food preparation and meal service |
Inspection Report
Routine
Census: 24
Deficiencies: 0
Jan 12, 2021
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 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 23, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00201950, GA00206321, GA00205341, and GA00207446.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints #GA00201950, GA00206321, GA00205341, and GA00207446 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 32
Deficiencies: 0
Aug 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on August 6-7, 2020 by Ascellon on behalf of the Georgia Department of Community Health to assess compliance with COVID-19 related regulations.
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 CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Census: 32
Inspection Report
Routine
Census: 25
Deficiencies: 0
Jun 2, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR 483.83 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 30, 2019
Visit Reason
An unannounced complaint survey was conducted to investigate complaint #GA00200178.
Findings
No deficiencies were cited at the time of the complaint investigation survey.
Complaint Details
Complaint #GA00200178 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 1, 2019
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 during the follow-up survey.
Inspection Report
Life Safety
Census: 39
Capacity: 42
Deficiencies: 6
Sep 10, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain fire barriers, fire alarm system components, sprinkler system maintenance, portable fire extinguishers, and smoke barriers, which could place all 39 residents and staff at risk in the event of fire.
Severity Breakdown
SS=F: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain holes in hazardous areas compromising fire barriers. | SS=F |
| Failed to maintain the fire alarm system and its components. | SS=F |
| Smoke detector in kitchen dish room located within 3 feet of HVAC discharge. | SS=F |
| Failed to maintain the fire sprinkler system and its components; discrepancies in inspection tags and missing list of sprinkler heads in spare box. | SS=F |
| Failed to maintain the hood fire suppression system and its components; inspection tag not checked monthly. | SS=F |
| Failed to maintain fire walls; visible open penetrations above 300 hall fire doors. | SS=F |
Report Facts
Census: 39
Total Capacity: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00195627, GA00195743, and GA00196011.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Complaint Details
The investigation of complaints GA00195627, GA00195743, and GA00196011 was unsubstantiated with no deficiencies.
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 0
Sep 17, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from July 23, 2018 through July 26, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 42
Capacity: 42
Deficiencies: 0
Jul 24, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan met the necessary standards.
Report Facts
Certified beds: 42
Census: 42
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186419 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00186419 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2018
Visit Reason
A complaint investigation for GA00185881 was conducted.
Findings
The complaint investigation was found to be unsubstantiated with no deficiencies cited.
Complaint Details
Complaint investigation GA00185881 was unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 27, 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 survey tags have been corrected.
Inspection Report
Life Safety
Census: 47
Capacity: 50
Deficiencies: 9
Sep 5, 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 failure to maintain self-closing doors, sprinkler system components, fire walls, smoke/fire doors, electrical safety, portable space heater control, and proper storage of oxygen cylinders. These deficiencies could place all 47 residents at risk in the event of fire.
Severity Breakdown
D: 5
E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Door closer missing from kitchen entry door from dining room area. | D |
| Sprinkler head wrench missing from sprinkler box in sprinkler riser room. | D |
| Failed to completely identify PIV and FDC for sprinkler system with signage. | D |
| Door to 300 hall wheelchair storage room would not close and latch securely against smoke or fire. | D |
| Rated fire walls not properly sealed where open penetrations existed and not sealed with proper rated materials in main electrical and compressor rooms. | E |
| Failed to maintain smoke/fire doors; main electrical room rated door and door closer removed leaving room open to unprotected areas. | E |
| Extension cord found in service in Admissions Office; electrical panel at kitchen exterior exit door lacks circuit identifications. | D |
| Non-compliant electrical space heater found in use in Activity Director's Office. | E |
| Oxygen storage room lacked separation and labeled areas for empty and full cylinders. | E |
Report Facts
Residents at risk: 47
Certified beds: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour. |
Inspection Report
Routine
Census: 45
Deficiencies: 0
Sep 3, 2017
Visit Reason
A standard survey was conducted at Stevens Park Health and Rehabilitation Center from September 2, 2017 through September 3, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 7, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00177844 at Stevens Park Health and Rehabilitation.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations 42 CFR, Part 483, Subpart B for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA00177844 determined the facility was in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 21, 2017
Visit Reason
An abbreviated/partial extended survey was conducted to investigate Complaint Number GA00176251.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint Number GA00176251 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 22, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate complaints #GA00171252 and #GA00166374 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with no deficiencies written during the complaint survey.
Complaint Details
The survey was conducted in response to complaints #GA00171252 and #GA00166374. The facility was found to be in substantial compliance with no deficiencies.
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