Inspection Report Summary
The most recent inspection on April 16, 2025 found substantiated complaints but no deficiencies were cited. Earlier inspections showed some deficiencies primarily related to dietary service practices, including improper preparation of pureed foods and sanitation issues, as well as unsafe mechanical lift transfers resulting in a resident fall with injury. Prior reports also noted lapses in infection control, medication management, and fire safety compliance, with all previously cited deficiencies corrected upon follow-up surveys. Complaint investigations were mostly unsubstantiated, though some complaints were substantiated without resulting deficiencies, and one substantiated abuse incident in early 2017 led to staff disciplinary actions. The facility appears to have addressed prior deficiencies effectively, with recent surveys showing no new citations and corrections verified during follow-ups.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
136 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 136
Deficiencies: 0
Apr 16, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00248496, GA00250218, and GA00253140.
Findings
The complaints were substantiated but no deficiencies were cited during the survey.
Complaint Details
Complaints GA00248496, GA00250218, and GA00253140 were substantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
May 31, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 137
Deficiencies: 0
May 30, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 7, 2024 Recertification Survey.
Findings
All deficiencies cited as a result of the April 7, 2024 Recertification Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 137
Deficiencies: 0
May 30, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 7, 2024 Recertification Survey.
Findings
All deficiencies cited in the prior April 7, 2024 Recertification Survey were found to be corrected during the revisit survey.
Inspection Report
Renewal
Census: 134
Deficiencies: 3
Apr 7, 2024
Visit Reason
The inspection was a Licensure Survey conducted from April 5, 2024 through April 7, 2024 to assess compliance with licensure requirements.
Findings
The facility was found deficient in dietary service practices including failure to follow puree food recipes, improper hand hygiene and sanitation in the dietary department, and failure to discard expired emergency food supplies. Additionally, the facility failed to ensure safe mechanical lift transfers, resulting in a resident fall with rib fractures.
Deficiencies (3)
| Description |
|---|
| Dietary staff did not follow recipes for preparing puree food items, affecting 14 residents. |
| Failure to ensure safe transfer of one resident using a mechanical lift, resulting in fall and rib fractures. |
| Failure to document receive dates on food items, failure to wash hands after entering kitchen and between touching dirty/clean dishes, failure to discard food past best by date, and failure to properly sanitize dishware. |
Report Facts
Residents affected by puree food preparation deficiency: 14
Residents requiring mechanical lift transfer: 25
Residents consuming oral diet: 134
Expired emergency food cans: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook FF | Dietary Cook | Observed not measuring ingredients and not sanitizing blender between puree food preparations |
| Dietary Manager | Dietary Manager | Stated expectation that dietary staff follow recipes and properly wash hands and sanitize equipment |
| Resident R100 | Resident | Resident who fell from mechanical lift and sustained rib fractures |
| Certified Nursing Assistant BB | CNA | Failed to properly attach sling to mechanical lift causing resident fall; resigned without notice |
| Certified Nursing Assistant AA | CNA | Assisted with mechanical lift transfer during resident fall incident |
| Director of Nursing | Director of Nursing | Confirmed resident fall details and mechanical lift investigation |
| Dietary Aide EE | Dietary Aide | Observed not washing hands after entering kitchen and between handling dirty and clean dishes |
Inspection Report
Routine
Census: 138
Deficiencies: 4
Apr 7, 2024
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities, including review of resident care and facility practices.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to submit Level II PASARR screenings for two residents, an unsafe mechanical lift transfer resulting in resident injury, improper preparation of pureed food items, and multiple sanitation and food safety violations.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to submit Level II PASARR screening for two residents with mental disorders. | SS=D |
| Failed to ensure safe transfer using mechanical lift, resulting in resident fall and rib fractures. | SS=G |
| Failed to follow recipes for preparing pureed food items, compromising nutritive value and flavor. | SS=D |
| Failed to document receive dates on food items, ensure handwashing, discard expired food, and properly sanitize dishware to prevent cross contamination. | SS=F |
Report Facts
Residents requiring mechanical lift assistance: 25
Residents affected by pureed diet deficiency: 14
Residents census: 138
Fractured ribs: 3
Medication dosage: 100
Medication dosage: 150
Pureed chicken recipe amount: 5
Pureed chicken broth amount: 2.125
Pureed chicken thickener amount: 1.333
Pureed rice servings: 48
Pureed rice preparation: 10
Expired emergency food cans: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in mechanical lift fall incident for not properly attaching sling; resigned without notice. |
| Dietary Cook FF | Dietary Cook | Observed not measuring ingredients for pureed food and not sanitizing blender between uses. |
| Dietary Aide EE | Dietary Aide | Observed not washing hands after entering kitchen and between handling dirty and clean dishes. |
| Director of Nursing | Director of Nursing (DON) | Confirmed deficiencies related to PASARR screenings and mechanical lift fall. |
| Social Service Director CC | Social Service Director | Interviewed regarding PASARR process and resident screenings. |
| Social Service Director DD | Social Service Director | Described responsibilities including PASARR submissions and psychiatric services. |
| Administrator | Facility Administrator | Acknowledged PASARR deficiencies and planned follow-up. |
| Dietary Manager | Dietary Manager (DM) | Interviewed about food preparation, handwashing, and expired food issues. |
Inspection Report
Life Safety
Census: 110
Capacity: 150
Deficiencies: 3
Apr 6, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to ensure the laundry room door self-closes and latches, improper use and placement of power strips at the 4th floor nurses station, and lack of approved signage for oxygen storage rooms on all four floors.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Laundry room door failed to self-close and positively latch, affecting staff and corridor safety. | SS= D |
| Power strips were not used properly according to UL listing and were found laying on the floor at the 4th floor nurses station. | SS= D |
| Oxygen storage rooms on all four floors lacked approved signage as required. | SS= D |
Report Facts
Certified beds: 150
Census: 110
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to laundry room door, power strips, and oxygen storage signage during facility tour |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 0
Jan 16, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00230203.
Findings
The complaint #GA00230203 was unsubstantiated with no deficiencies cited during the survey.
Complaint Details
Complaint #GA00230203 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 127
Inspection Report
Abbreviated Survey
Census: 138
Deficiencies: 0
Dec 27, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00241693 and GA00241359.
Findings
No deficiencies were cited related to the complaints investigated during this survey.
Complaint Details
The survey was complaint-related for complaints GA00241693 and GA00241359; no deficiencies were found related to these complaints.
Inspection Report
Abbreviated Survey
Census: 132
Deficiencies: 0
Oct 27, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate four complaints (#GA00233258, #GA00233870, #GA00237103, and #GA00238022).
Findings
Complaint #GA00238022 was substantiated with no deficiencies cited. Complaints #GA00233258, #GA00233870, and #GA00237103 were unsubstantiated with no deficiencies cited.
Complaint Details
Four complaints were investigated; one complaint (#GA00238022) was substantiated with no deficiencies cited, and three complaints (#GA00233258, #GA00233870, #GA00237103) were unsubstantiated with no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Jul 19, 2022
Visit Reason
A revisit was conducted to verify correction of deficiencies cited during the 5/19/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 5/19/22 Recertification Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Jul 19, 2022
Visit Reason
A Revisit Survey was conducted on 7/19/22 to verify correction of deficiencies cited during the 5/19/22 Recertification Survey.
Findings
All deficiencies cited as a result of the 5/19/22 Recertification Survey were found to be corrected.
Inspection Report
Renewal
Deficiencies: 2
May 19, 2022
Visit Reason
The inspection was a Licensure Survey conducted from May 17, 2022 through May 19, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to maintain an effective Infection Control Program, including improper disinfection of a multi-use glucometer and inadequate hand hygiene by nursing staff. Additionally, the facility failed to assess two residents for safe self-administration of medications and improperly left medications at bedside. Nursing staff also did not adhere to professional standards during medication administration.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to disinfect multi-use blood glucometer between residents and failure to perform hand hygiene during medication pass. | SS= D |
| Failure to assess residents for ability to safely self-administer medications and leaving medications at bedside; failure to maintain professional nursing standards during medication administration. | SS= D |
Report Facts
Number of residents observed for glucometer use: 2
Number of nurses observed for hand hygiene during medication pass: 4
Number of residents not assessed for self-administration: 2
Dates of inspection: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to disinfect glucometer and perform hand hygiene during blood sugar testing. |
| LPN CC | Licensed Practical Nurse | Observed handling medications without hand hygiene or gloves during medication administration. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for hand hygiene and medication administration standards. |
| LPN DD | Licensed Practical Nurse | Interviewed stating medications should never be left at bedside for self-administration. |
| LPN II | Licensed Practical Nurse | Interviewed stating medications are never supposed to be left at resident's bedside. |
Inspection Report
Life Safety
Census: 115
Capacity: 150
Deficiencies: 0
May 19, 2022
Visit Reason
The visit was a Life Safety Code survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found in compliance with the Life Safety Code requirements. The emergency preparedness program was reviewed and found compliant with 42 CFR 483.73. The 3rd floor was not surveyed due to housing of COVID patients; only floors 1, 2, and 4 were surveyed.
Report Facts
Stories: 4
Construction Type: 2
Census: 115
Certified Beds: 150
Inspection Report
Routine
Census: 110
Deficiencies: 0
Feb 21, 2022
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 §483.73 and in substantial compliance with 42 CFR §483.80 infection control regulations. No deficiencies were cited.
Report Facts
Facility census: 110
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00215851 and #GA00218589.
Findings
The complaints #GA00215851 and #GA00218589 were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00215851 and #GA00218589 were investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Feb 17, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 28, 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
Routine
Census: 97
Deficiencies: 0
Jan 26, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 114
Deficiencies: 1
Dec 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations due to failure of two of six environmental service staff to be knowledgeable about and allow the necessary contact time for cleaning chemicals to be effective against bacteria and viruses such as COVID-19.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two of six housekeeper/environmental service staff were not knowledgeable about the required contact time for cleaning chemicals to be effective against bacteria and viruses such as COVID-19. | SS= D |
Report Facts
Census: 114
Contact time: 30
Contact time: 10
Contact time: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EVS DD | Environmental Service Staff | Interviewed about cleaning products and contact times; found not knowledgeable about required contact times |
| Hskpr KK | Housekeeper | Interviewed and observed using cleaning products; unaware of proper contact times and did not attend relevant in-service trainings |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 2, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00207810, #GA00205720, and #GA00204043.
Findings
Complaints #GA00207810 and #GA00204043 were unsubstantiated with no regulatory violations cited. Complaint #GA00205720 was substantiated but no regulatory violations were cited.
Complaint Details
Complaint #GA00205720 was substantiated; complaints #GA00207810 and #GA00204043 were unsubstantiated.
Inspection Report
Routine
Census: 113
Deficiencies: 0
Jun 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on June 25-26, 2020.
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 to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 5, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00198425 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00198425 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Census: 134
Deficiencies: 0
Mar 26, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Standard Survey from 2019-01-28 to 2019-01-31.
Findings
All deficiencies cited in the prior Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 19, 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 deficiencies had been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 14, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to follow care plans for residents and failure to ensure sanitary food service practices.
Findings
The facility failed to follow the care plan for resident #49, resulting in a fall with injury, and failed to develop a care plan for resident #94 regarding the use of a travel neck pillow. Additionally, the facility failed to ensure food was served in a sanitary manner for six residents on the secured unit.
Complaint Details
The investigation was complaint-related, focusing on care plan adherence and sanitary food service practices. Substantiation status is not explicitly stated.
Deficiencies (3)
| Description |
|---|
| Failure to follow the care plan for resident #49, resulting in a fall causing a midline laceration and cervical fracture. |
| Failure to develop a care plan for resident #94 for the use of a travel neck pillow for proper head positioning. |
| Failure to ensure food was served in a sanitary manner for six residents on the secured unit, including failure of the Activity Director to perform hand hygiene between assisting residents. |
Report Facts
Sample size: 26
Residents affected: 6
Residents in secured unit: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA FF | Certified Nursing Assistant | Named in the finding related to failure to follow care plan for resident #49 and failure to seek help during resident's fall |
| Registered Nurse Charge Nurse AA | Registered Nurse Charge Nurse | Interviewed regarding care plan adherence and food service hygiene |
| CNA EE | Certified Nursing Assistant | Interviewed about care requirements for resident #49 |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan for resident #94 |
| OT BB | Occupational Therapist | Completed interdisciplinary communication memo regarding travel neck pillow for resident #94 |
| Activity Director | Activity Director and Certified Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene during meal service |
Inspection Report
Routine
Census: 130
Deficiencies: 5
Jan 28, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and to investigate further due to identified noncompliance and resident harm.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including failure to follow care plans resulting in resident injury, inadequate care planning for specialized needs, failure to prevent falls, and lapses in infection control practices such as improper hand hygiene during meal service.
Severity Breakdown
G: 2
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to follow care plan for resident #49 resulting in a fall causing a midline laceration and C1 vertebral fracture. | G |
| Failure to develop a care plan for resident #94 for use of a travel neck pillow for proper head positioning. | D |
| Failure to assess and provide treatment for resident #94's neck positioning leading to improper neck flexion. | D |
| Failure to provide adequate supervision and accident prevention during bed bath for resident #49 resulting in fall and injury. | G |
| Failure to ensure proper hand hygiene by staff during meal service, including failure to perform hand hygiene after assisting residents with dressing and hygiene tasks. | D |
Report Facts
Resident census: 130
Sample size: 26
Residents affected: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA FF | Certified Nursing Assistant | Named in fall incident involving resident #49 and failure to follow care plan and call for assistance |
| Registered Nurse Charge Nurse AA | Registered Nurse Charge Nurse | Involved in fall incident investigation and interviews regarding resident #49 |
| CNA EE | Certified Nursing Assistant | Interviewed about care for resident #49 and combative behavior |
| OT BB | Occupational Therapist | Provided therapy and assessment for resident #94 and recommended discontinuing travel neck pillow |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding care plans, fall incident, and therapy for residents #49 and #94 |
| Licensed Practical Nurse HH | Licensed Practical Nurse | Present after fall incident for resident #49 and interviewed about care |
| Activity Director (AD) | Activity Director and Certified Nursing Assistant | Observed failing to perform hand hygiene during meal service |
Inspection Report
Life Safety
Census: 130
Capacity: 150
Deficiencies: 1
Jan 28, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to maintain the sprinkler system, specifically multiple yellow tags on sprinkler system control valves indicating sprinkler head replacement was needed but not completed, potentially placing residents and staff at risk during a fire.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain the sprinkler system and correct multiple yellow tags on sprinkler system control valves denoting sprinkler head replacement. | SS=F |
Report Facts
Census: 130
Certified Beds: 150
Staff at risk: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of yellow tags on sprinkler system control valves during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2018
Visit Reason
A complaint survey was conducted to investigate complaints GA 00191077 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA 00191077 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 10, 2018
Visit Reason
A complaint survey was conducted on 5/10/18 - 5/11/18 to investigate complaint #GA00187445 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00187445 was investigated and found to have no deficiencies.
Inspection Report
Routine
Census: 128
Deficiencies: 0
Feb 15, 2018
Visit Reason
A standard survey was conducted at A.G. Rhodes Home Wesley Woods from February 12, 2018 through February 15, 2018 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 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 131
Capacity: 150
Deficiencies: 0
Feb 12, 2018
Visit Reason
A 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 in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 23, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00178703 at AG Rhodes Wesley Woods.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Regulations with no deficiencies cited.
Complaint Details
Investigation of complaint GA00178703 determined the complaint was unsubstantiated as no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
May 15, 2017
Visit Reason
A follow up was conducted on 5/15/17 to the recertification survey to verify correction of previous deficiencies.
Findings
The deficiencies identified in the prior recertification survey were corrected as of the follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 131
Capacity: 150
Deficiencies: 1
Mar 21, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to complete the annual sprinkler inspection within 12 months, as evidenced by an inspection tag dated 03/16/2016, placing residents and staff at risk in the event of a fire.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete the annual sprinkler inspection prior to 12 months. | SS= D |
Report Facts
Census: 131
Total Capacity: 150
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding overdue sprinkler inspection |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 28, 2017
Visit Reason
The visit was a Health Revisit conducted to determine if the deficiencies cited during a prior Abbreviated Survey on 2017-01-25 had been corrected.
Findings
It was determined that the deficiencies cited during the Abbreviated Survey conducted on 2017-01-25 had been corrected as of the Health Revisit on 2017-02-28.
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 25, 2017
Visit Reason
An Abbreviated Survey was conducted on January 25, 2017, to investigate substantiated complaints GA00170914 and GA00170855 related to alleged resident mistreatment at the facility.
Findings
The facility was found not in substantial compliance with Federal and State Long Term Care Requirements due to an incident where a resident with advanced dementia was pulled backward in his wheelchair by a CNA. The incident was witnessed but not reported timely by another CNA. The facility confirmed the abuse via surveillance footage and took disciplinary actions including termination of the responsible CNA and warning of the witness CNA for delayed reporting.
Complaint Details
Complaints GA00170914 and GA00170855 were substantiated. The incident involved a resident (R#1) with advanced dementia who was pulled backward in his wheelchair by CNA FF on 12/26/16. The incident was witnessed by CNA AA who did not report it until 1/12/17. The Director of Nursing confirmed the incident after reviewing surveillance footage. CNA FF was terminated and CNA AA was disciplined for failure to timely report the abuse.
Severity Breakdown
Level G: 1
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from abuse when a CNA pulled a resident backward in his wheelchair by his shirt, causing agitation and potential harm. | Level G |
| Failure to immediately report a witnessed incident of staff to resident abuse, resulting in delayed reporting by 17 days. | Level D |
Report Facts
Days delay in reporting abuse: 17
Number of shifts worked by CNA FF after incident: 10
Date of incident: Dec 26, 2016
Date of survey: Jan 25, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA FF | Certified Nursing Assistant | Responsible for pulling resident backward in wheelchair; terminated for mistreatment |
| CNA AA | Certified Nursing Assistant | Witnessed abuse but delayed reporting by 17 days; received disciplinary warning |
| Director of Nursing | Director of Nursing | Reviewed surveillance footage and confirmed abuse incident |
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