Inspection Reports for
The Bell Minor Home
2200 OLD HAMILTON PLACE NE, GAINESVILLE, GA, 30507
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
161% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
97% occupied
Based on a April 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 101
Deficiencies: 18
Date: Apr 9, 2025
Visit Reason
A standard survey was conducted from 2025-03-25 through 2025-03-30, including investigation of multiple complaint intake numbers, some substantiated and some unsubstantiated, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. Several complaints were substantiated, including abuse, neglect, and quality of care issues. Immediate jeopardy was identified related to these complaints.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies including immediate jeopardy related to resident abuse, neglect, pressure ulcer care, medication management, and infection control. The immediate jeopardy was removed on 2025-03-31 after corrective actions, but the facility remains out of compliance while implementing systemic changes.
Deficiencies (18)
Failure to ensure residents were free from resident-to-resident abuse, neglect in identifying and reporting changes in condition, and failure to prevent development and provide timely treatment of pressure ulcers.
Failure to complete a Significant Change Minimum Data Set (MDS) Assessment following initiation of hospice services for one resident.
Failure to complete quarterly Minimum Data Set (MDS) assessments timely for three residents.
Failure to ensure accuracy of MDS assessments related to pressure ulcer coding for two residents.
Failure to develop a person-centered care plan related to a diabetic foot ulcer for one resident.
Failure to identify and notify medical provider of worsening skin condition for one resident, resulting in death.
Failure to provide showers as scheduled to one dependent resident, resulting in poor hygiene and odor.
Failure to prevent development of facility-acquired pressure ulcers and provide timely treatment per physician orders for two residents.
Failure to complete quarterly assessments for continued use and safety of bedrails for one resident.
Failure to have antibiotic and pain medications available to administer as ordered for three residents.
Failure to ensure timely physician response to pharmacist recommendations during monthly drug regimen reviews for four residents.
Failure to ensure residents were free from significant medication errors related to medication availability and administration for two residents.
Failure to ensure food was palatable, served at proper temperatures, and condiments were provided as per menu for five residents and resident council attendees.
Failure to ensure no more than a 14-hour gap between dinner and breakfast, with no substantial evening snack provided, creating potential for resident hunger.
Failure to maintain dumpster area in a sanitary manner to prevent pest harborage, with garbage strewn around the dumpster and parking lot for multiple days.
Failure to ensure infection control practices including proper use of personal protective equipment (PPE) for enhanced barrier precautions and availability of PPE outside resident rooms.
Failure to ensure the arbitration agreement presented to residents included a clause for mutually convenient venue selection.
Failure of facility administration to use resources to ensure residents attained and maintained their highest physical well-being, contributing to actual harm or death.
Report Facts
Residents present: 101
Deficiency counts: 16
Education completion: 71
Total employees: 75
Meal service time: 38
Meal gap hours: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Named in medication availability and administration issues |
| Director of Nursing | Director of Nursing | Named in multiple findings related to oversight and medication management |
| Regional Director of Clinical Operations | Regional Director of Clinical Operations | Named in oversight and root cause analysis |
| Dietary Manager | Dietary Manager | Named in food service and sanitation findings |
| Registered Dietitian 2 | Registered Dietitian | Named in food palatability and safety findings |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in infection control and nursing education |
| Pharmacist | Pharmacist | Named in medication regimen review and recommendations |
| Nurse Practitioner 1 | Nurse Practitioner | Named in medication availability and regimen review |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Named in infection control practices |
| Certified Nursing Assistant 8 | Certified Nursing Assistant | Named in infection control practices |
Inspection Report
Abbreviated Survey
Deficiencies: 11
Date: Mar 30, 2025
Visit Reason
The inspection was conducted due to multiple serious deficiencies including failure to notify medical providers of changes in resident conditions, neglect and abuse investigations, and concerns about pressure ulcer care and medication management.
Findings
The facility failed to timely notify medical providers of changes in residents' conditions, resulting in harm and death. Neglect and abuse were identified, including failure to protect a resident from roommate abuse. Nursing staff failed to properly assess and intervene in worsening skin conditions and pressure ulcers. Medication management was deficient with unavailable medications and delayed administration. Food service and infection control practices were substandard. The facility administration failed to ensure effective oversight and compliance with policies.
Deficiencies (11)
F580: The facility failed to timely notify medical providers and family of changes in condition for residents R159 and R9, resulting in death and actual harm.
F600: The facility failed to protect residents from neglect and abuse, including failure to protect R360 from abuse by roommate R46.
F658: Nursing staff failed to use professional judgment to identify and notify providers of worsening skin condition for resident R159.
F686: The facility failed to prevent pressure ulcers and provide timely, appropriate treatment for residents R104 and R2, contributing to worsening wounds and death.
F700: The facility failed to complete quarterly assessments for bedrail safety for resident R22, increasing risk of accidents.
F755: The facility failed to ensure antibiotic and pain medications were available and administered as ordered for residents R2, R78, and R10.
F756: The facility failed to ensure timely physician response to pharmacist recommendations for residents R2, R21, R77, and R63.
F804: The facility failed to ensure food was palatable, served at proper temperatures, and condiments were provided as per menu for residents including R72, R31, R10, R14, and R30.
F812: The facility failed to maintain sanitary conditions in the dumpster area, with garbage strewn around and dumpster doors left open, risking pest harborage.
F880: The facility failed to follow infection control practices for enhanced barrier precautions for residents R51 and R78, including lack of PPE use and availability.
F835: The facility administration failed to use resources effectively to ensure resident safety and quality care, contributing to actual harm and death.
Report Facts
Deficiencies cited: 5
Residents affected: 40
Residents in facility: 101
BIMS scores: 15
Medication doses missed: 6
Meal service time: 38
Temperature: 95
Temperature: 54
Temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Documented absence of pedal pulses for resident R159 without notifying medical provider |
| NP1 | Nurse Practitioner | Stated nursing staff should have notified provider of absent pedal pulses for R159 |
| NP2 | Nurse Practitioner | Confirmed nursing staff notified her of drainage but not other worsening conditions for R159 |
| DON | Director of Nursing | Expected nurses to notify provider of changes and complete alert charting |
| Administrator | Facility Administrator | Responsible for overall management and confirmed nursing failures |
| DM | Dietary Manager | Reported food complaints and verified food temperature and leftover policies |
| RD2 | Registered Dietitian | Stated dietary staff should not reuse leftovers and should offer salt and pepper |
| MD | Maintenance Director | Responsible for dumpster area maintenance and confirmed cleanup after surveyor notification |
| LPN4 | Licensed Practical Nurse | Observed not wearing gown during enhanced barrier precautions for R51 |
| ADON | Assistant Director of Nursing | Responsible for training nursing staff on policies including change in condition and infection control |
| RDCO | Regional Director of Clinical Operations | Reported concerns about physician response to pharmacist recommendations and infection control practices |
Inspection Report
Immediate Jeopardy
Deficiencies: 18
Date: Mar 30, 2025
Visit Reason
The inspection was conducted due to multiple serious deficiencies including failure to notify medical providers of changes in resident conditions, neglect and abuse, failure to provide adequate pressure ulcer care, and medication management issues.
Findings
The facility failed to timely notify medical providers of changes in residents' conditions, resulting in harm and death. Neglect and abuse were identified, including failure to protect a resident from roommate abuse. Pressure ulcer care was inadequate, leading to worsening wounds and death. Medication management was deficient with missed doses and unavailable medications. Food service was substandard with cold and bland food, and infection control practices were not consistently followed.
Deficiencies (18)
F580: The facility failed to timely notify medical providers and families of changes in residents' conditions, causing death and harm.
F600: The facility failed to protect residents from neglect and abuse, including failure to protect a resident from roommate abuse.
F658: Nursing staff failed to use professional judgment to identify and report worsening skin conditions for a resident.
F686: The facility failed to provide adequate pressure ulcer care and prevent new ulcers, contributing to resident death.
F835: The facility administration failed to use resources effectively, resulting in harm and death to residents.
F0637: The facility failed to complete a Significant Change Minimum Data Set assessment following hospice initiation for one resident.
F0638: The facility failed to ensure quarterly Minimum Data Set assessments were completed timely for three residents.
F0641: The facility failed to ensure accurate Minimum Data Set assessments for two residents related to pressure ulcers.
F0656: The facility failed to develop a person-centered care plan related to a diabetic foot ulcer for one resident.
F0677: The facility failed to provide showers as scheduled for one dependent resident, risking poor hygiene.
F0686: The facility failed to ensure timely availability and administration of antibiotic and pain medications for three residents.
F0755: The facility failed to ensure timely physician response to pharmacist recommendations for unnecessary medications for four residents.
F0760: The facility failed to ensure residents were free from significant medication errors including missed and refused doses.
F0804: The facility failed to ensure food was palatable, served at proper temperatures, and condiments were provided as directed.
F0812: The facility failed to maintain proper food service hygiene including hand hygiene and proper labeling of leftovers.
F0814: The facility failed to maintain the dumpster area in a sanitary manner to prevent pest harborage.
F0835: The facility failed to ensure quarterly assessments for bedrail safety were completed for one resident.
F0880: The facility failed to ensure proper infection control practices including use of personal protective equipment for residents on enhanced barrier precautions.
Report Facts
Length of time pressure ulcer left unassessed: 23
Length of time without wound care assessment: 21
Number of residents with missed quarterly MDS assessments: 3
Number of residents with delayed pharmacist recommendation responses: 4
Number of residents with missed medication doses: 2
Number of residents with food temperature below standard: 5
Number of residents with bed rail assessments missing: 1
Number of residents on enhanced barrier precautions without proper PPE use: 2
Number of residents with 15-hour gap between dinner and breakfast: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Documented resident R159 did not have palpable pedal pulses but did not notify medical provider |
| NP1 | Nurse Practitioner | Stated nursing staff should have notified provider when R159's pedal pulses were absent |
| NP2 | Nurse Practitioner | Confirmed nursing staff notified her of drainage but not other worsening conditions for R159 |
| NP3 | Nurse Practitioner | Denied family request to transfer R159 to hospital |
| LPN2 | Licensed Practical Nurse | Notified wound care provider late about worsening diabetic foot ulcer for R9 |
| DON | Director of Nursing | Expected nurses to notify physician of changes in condition and reported nursing failures |
| Administrator | Facility Administrator | Responsible for overall management; acknowledged nursing failures |
| RDCO | Regional Director of Clinical Operations | Informed of Immediate Jeopardy and nursing failures |
| DM | Dietary Manager | Reported food complaints and improper food handling |
| LPN4 | Licensed Practical Nurse | Reported medication delivery issues and improper PPE use |
| CNA3 | Certified Nursing Assistant | Reported abuse incident and PPE use |
| Unit Manager/IP2 | Unit Manager/Infection Preventionist | Reported insulin not administered due to stock issues |
Inspection Report
Life Safety
Census: 103
Capacity: 104
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, including issues with means of egress, hazardous area enclosures, combustible storage, and improper storage of oxygen cylinders. Multiple deficiencies were observed affecting one or more smoke compartments.
Deficiencies (4)
Failed to ensure all components of the means of egress were properly maintained, including an abrupt change in sidewalk elevation and a delayed egress door that failed to open.
Failed to ensure all exits were maintained free of obstructions; exit door near room #C1 was partially blocked by a chair.
Failed to ensure hazardous areas were properly enclosed and separated, including improper storage of combustible materials on patios of A Hall and B Hall.
Failed to ensure proper maintenance and storage of oxygen cylinders; full and empty cylinders were stored intermingled.
Report Facts
Census: 103
Total Capacity: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey M. Goodwin | Mentioned in citation text for Tag 0000, Regulation K307 | |
| Staff M | Staff interviewed and confirmed findings during the inspection |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 25, 2025
Visit Reason
The inspection was a State Licensure survey conducted from 3/25/2025 through 3/30/2025 to determine compliance with the State Long Term Care Requirements.
Findings
Multiple deficiencies were cited including failure to notify medical providers timely of changes in residents' conditions leading to adverse outcomes, inadequate dietary services including excessive meal gaps and poor food palatability, failure to follow infection control practices, failure to provide care according to care plans especially related to pressure ulcers, and unsanitary conditions in the kitchen and dumpster area.
Deficiencies (7)
Failure to ensure nursing staff used clinical judgment to notify medical provider of worsening skin condition for resident R159.
Failure to ensure no more than a 14-hour gap between dinner and breakfast for 99 of 101 residents.
Failure to ensure food was palatable for five sampled residents and those attending resident council meetings.
Failure to timely notify medical providers and family of changes in condition for residents R159 and R9.
Failure to follow infection control practices including proper use of enhanced barrier precautions and PPE availability for residents R51 and R78.
Failure to provide care and services to meet needs of residents R9, R23, R104, R2, and R307 related to diabetic foot ulcer care, shower provision, and prevention of facility-acquired pressure ulcers.
Failure to maintain and practice food service principles to prevent foodborne illness and maintain sanitary dumpster area.
Report Facts
Residents affected by meal gap: 99
Residents sampled for food palatability: 5
Leftover food use timeframe: 3
Pressure ulcer treatment missed dates: 20
Shower completion rate: 50
Garbage strewn area length: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Documented resident R159's pedal pulses absent but did not notify medical provider. |
| NP1 | Nurse Practitioner | Stated that had she been notified timely about R159's condition, she would have requested further assessment and hospital transfer. |
| NP2 | Nurse Practitioner | Confirmed nursing staff notified her late about R159's foot drainage and ordered antibiotics. |
| Director of Nursing | Director of Nursing | Expected nurses to notify providers of changes in condition and stated education was provided. |
| Dietary Manager | Dietary Manager | Acknowledged complaints about meal timing and food temperature; verified improper glove use by dietary aides. |
| Registered Dietitian 2 | Registered Dietitian | Stated dietary staff should not reuse foods and should offer salt and pepper. |
| LPN3 | Licensed Practical Nurse | Became wound nurse in February 2025; provided wound care and verified delayed wound provider notification. |
| Assistant Director of Nursing | Assistant Director of Nursing | Performed wound care for resident R104 and verified gaps in wound assessments. |
| Maintenance Director | Maintenance Director | Responsible for cleaning dumpster area; verified garbage accumulation and cleaned area after notification. |
Inspection Report
Abbreviated Survey
Census: 100
Deficiencies: 0
Date: Nov 13, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00252341, initiated on November 6, 2024, and continued through November 12 and 13, 2024.
Complaint Details
Complaint GA00252341 was investigated and found to be unsubstantiated.
Findings
The complaint GA00252341 was found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Bell Minor Home, indicating regulatory oversight and corrective actions following an inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Follow-Up
Census: 100
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in a prior complaint investigation survey concluded on September 9, 2024.
Complaint Details
This visit was a follow-up to a complaint investigation survey concluded on September 9, 2024. All cited deficiencies were corrected.
Findings
All deficiencies cited during the complaint investigation survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Deficiencies: 1
Date: Sep 9, 2024
Visit Reason
The inspection was conducted to ensure the nursing home maintained a safe and secure environment free from accident hazards, specifically focusing on accident prevention related to unlocked cabinets containing potentially hazardous items in shower rooms.
Findings
The facility failed to keep cabinets containing cleaning supplies, toiletries, and disposable razors locked in the shower rooms on A and B Halls, posing a potential harm risk to two of 15 sampled residents who wandered the facility. The facility's policy on maintaining shower room supplies was requested but not received prior to exit.
Deficiencies (1)
F 0689: The facility failed to ensure a safe environment by not keeping cabinets locked in shower rooms on A and B Halls containing cleaning supplies, toiletries, and disposable razors. This posed potential harm to two residents who wandered the facility.
Report Facts
Residents sampled: 15
Residents affected: 2
Residents not receiving showers: 3
Residents who wander: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Verified cabinet on A Hall was unlocked and lock was broken | |
| Certified Medical Assistant (CMA-Tech) | Verified cabinet on B Hall was unlocked and no lock was present | |
| Director of Nursing (DON) | Provided information about residents not receiving showers and cabinet lock status | |
| Assistant Director of Nursing (ADON) | Interviewed regarding shower room cabinet security | |
| Minimum Data Set (MDS) Coordinator | Interviewed regarding residents' shower status | |
| Administrator | Provided information about wandering residents and policy request |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 9, 2024
Visit Reason
The inspection was conducted as a State Licensure survey from August 28, 2024 through September 9, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to timely report an allegation of verbal abuse by a staff member, failure to provide a nourishing and well-balanced diet due to non-receipt of food orders caused by non-payment, and failure to maintain a safe environment by not keeping shower room cabinets locked containing hazardous items.
Deficiencies (3)
Failure to report an allegation of verbal abuse by a staff member to the State Survey Agency within the required time frame.
Failure to provide each resident with a nourishing, palatable, well-balanced diet due to non-receipt of two food orders in August 2024 caused by non-payment of past invoices, potentially affecting 101 residents.
Failure to ensure a safe and secure environment by not keeping cabinets locked in the shower rooms on A and B Halls containing cleaning supplies, toiletries, and disposable razors, potentially harming two residents who wander the facility.
Report Facts
Residents potentially affected by dietary deficiency: 101
Deficiency sample size: 15
Dietary budget: 5096
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Verified unlocked cabinet in shower room on A Hall. |
| CC | Certified Medical Assistant (CMA-Tech) | Verified unlocked cabinet in shower room on B Hall. |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 4
Date: Sep 9, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from August 28, 2024 through September 9, 2024 to investigate multiple complaints regarding verbal abuse and other concerns at The Bell Minor Home.
Complaint Details
The complaint investigation was triggered by multiple complaint intake numbers. Two complaints were substantiated with deficiencies cited, including verbal abuse by the DON towards resident R5 and failure to report the abuse timely. Other complaints were unsubstantiated.
Findings
The facility was found to have substantiated deficiencies related to verbal abuse between the Director of Nursing (DON) and a resident, failure to report the verbal abuse allegation timely to the State Survey Agency, unsecured cabinets in shower rooms posing accident hazards, and failure to provide residents with a nourishing diet due to non-receipt of food orders caused by non-payment.
Deficiencies (4)
Facility failed to protect one resident's right to be free from verbal abuse by facility staff, involving the DON and resident R5 using racial slurs and yelling at each other.
Facility failed to report an allegation of verbal abuse by a staff member to the State Survey Agency within the required time frame.
Facility failed to ensure a safe and secure environment by not keeping cabinets locked in shower rooms containing cleaning supplies and razors, potentially harming residents who wander.
Facility failed to provide residents with a nourishing, palatable, well-balanced diet due to two food orders in August 2024 not received because of non-payment for past invoices, potentially affecting 101 residents.
Report Facts
Residents present: 99
Residents affected by verbal abuse deficiency: 1
Residents potentially harmed by unlocked cabinets: 2
Residents potentially affected by dietary deficiency: 101
Dietary budget: 5096
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in verbal abuse incident with resident R5 |
| Administrator | Facility Administrator | Reported verbal abuse incident to the state and suspended the DON |
| Dietary Manager | Dietary Manager (DM) | Responsible for placing food orders; involved in dietary deficiency |
| Registered Dietician | Registered Dietician (RD) | Interviewed regarding dietary issues |
| Regional Director of Dietary Services | Regional Director of Dietary Services | Contract company representative interviewed about food supply issues |
| Social Service Director | Social Service Director (SSD) | Attended meeting regarding verbal abuse incident |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
An Abbreviated/Partial Extended survey was conducted to investigate multiple complaints against the facility.
Complaint Details
The survey investigated complaints GA00245699, GA00243904, GA00243664, GA00243188, GA00245622, GA00245737, and GA00245256, all of which were unsubstantiated.
Findings
No deficiencies were cited for the investigated complaints and all complaints were found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 02/12/2024 and 02/18/2024 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 01/29/2024 and 02/04/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Census: 94
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00242979 and GA00243019.
Complaint Details
The survey investigated complaints GA00242979 and GA00243019 and found no deficiencies related to these complaints.
Findings
No deficiencies were cited related to the complaints GA00242979 and GA00243019.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Bell Minor Home, indicating regulatory oversight and corrective actions following an inspection.
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
Follow-Up
Census: 91
Deficiencies: 0
Date: Jan 11, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the November 16, 2023 Recertification Survey.
Findings
All deficiencies cited in the November 16, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
A life safety Code revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the revisit survey.
Inspection Report
Life Safety
Census: 96
Capacity: 104
Deficiencies: 3
Date: Nov 17, 2023
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and electrical safety standards.
Findings
The facility was found not in substantial compliance with fire safety and electrical safety requirements, including an obstructed fire extinguisher in the kitchen, open breaker slots on electrical panel K1, and the use of power extension cords and multi-plug adapters as fixed wiring in the server room.
Deficiencies (3)
Obstructed fire extinguisher in the kitchen area.
Open breaker slots on electrical panel K1 creating a shock hazard.
Use of power extension cords and multi-plug adapters as fixed wiring in the server room, creating a fire hazard.
Report Facts
Census: 96
Total Capacity: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident care, medication administration, infection control, safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to update care plans, follow physician orders, maintain bedrails, administer medications as ordered, timely meal assistance, proper food storage and kitchen cleanliness, infection control practices, vaccine education, and maintenance of essential equipment such as the walk-in freezer.
Deficiencies (9)
F 0657: The facility failed to revise the care plan to include updated wound care for one resident, potentially affecting needed wound care.
F 0684: The facility failed to ensure physician orders were followed for two residents, including notification of high blood sugars and wound treatment, risking unmet care needs.
F 0700: The facility failed to ensure routine maintenance and inspection of bedrails for three residents, increasing risk of injury.
F 0755: The facility failed to ensure medications were administered as ordered for two residents due to pharmacy supply issues and lack of follow-up.
F 0809: The facility failed to ensure timely meal service and assistance for one resident requiring extensive help with eating.
F 0812: The facility failed to ensure proper food storage and kitchen cleanliness, including ice buildup in the walk-in freezer and food stored on the floor, risking food safety for many residents.
F 0880: The facility failed to ensure staff performed hand hygiene between glove changes during dressing changes for two residents, increasing infection risk.
F 0883: The facility failed to provide education on the risks and benefits of influenza and pneumococcal vaccines to five residents or their representatives.
F 0908: The facility failed to maintain the walk-in freezer properly, resulting in extensive ice buildup that compromised food safety for many residents.
Report Facts
Residents reviewed: 31
Residents affected: 91
Residents affected: 95
Missed medication administrations: 9
Bedrail maintenance: 3
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Confirmed findings related to medication administration and physician notification failures |
| Director of Nursing | Director of Nursing | Provided information on care plan responsibilities, medication administration expectations, and meal assistance |
| Maintenance Director | Maintenance Director | Confirmed lack of routine bedrail inspection and unawareness of walk-in freezer ice buildup |
| Dietary Manager | Dietary Manager | Confirmed kitchen cleanliness issues and walk-in freezer problems |
| Infection Preventionist/Registered Nurse | Infection Preventionist/Registered Nurse | Observed and confirmed failure to perform hand hygiene between glove changes during dressing changes |
| Administrator | Administrator | Confirmed awareness of pharmacy and freezer issues after being informed by Maintenance Director |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Nov 16, 2023
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including timely meal assistance for residents, medication administration failures due to pharmacy supply issues, inadequate hand hygiene practices during dressing changes, lack of routine maintenance and inspection of bedrails and mattresses, and poor physical plant conditions such as extensive ice buildup in the walk-in freezer and improper food storage.
Deficiencies (6)
Facility failed to ensure one resident received meals and assistance with meals in a timely manner.
Facility failed to ensure two residents received medications as ordered due to failure to contact pharmacy to ensure medication availability.
Staff failed to perform hand hygiene between glove changes during dressing changes for two residents, increasing infection risk.
Facility failed to ensure routine maintenance and inspection of bedrails and mattresses for three residents, increasing injury risk.
Facility failed to properly maintain the walk-in freezer, which had extensive ice buildup affecting food safety.
Facility failed to ensure proper food storage, cleanliness of refrigerators and floors, and proper storage of scoops inside bins.
Report Facts
Residents reviewed for medication administration: 5
Residents affected by bedrail maintenance deficiency: 3
Residents affected by walk-in freezer issues: 91
Missed medication administrations for Resident 25: 9
Missed medication administrations for Resident 28: Multiple dates in October and November 2023 with missed medication administrations documented.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed need for better system to ensure timely meal assistance and medication administration. | |
| Certified Nursing Aide (CNA) 6 | Reported normal timing for meal assistance but acknowledged delays. | |
| Licensed Practical Nurse (LPN) 5 | Confirmed medication administration deficiencies and proper follow-up procedures. | |
| Infection Preventionist/Registered Nurse (IP/RN) | Observed failing to perform hand hygiene between glove changes during dressing changes. | |
| Maintenance Director (MD) | Confirmed lack of routine inspection process for bedrails and mattresses and unawareness of walk-in freezer ice buildup. | |
| Dietary Manager (DM) | Reported walk-in freezer issues and food safety concerns. | |
| Dietary Aide (DA) 2 | Reported walk-in freezer ice buildup and food boxes too frozen to use. | |
| Administrator | Acknowledged being uninformed of walk-in freezer issues until recently. |
Inspection Report
Routine
Census: 95
Deficiencies: 9
Date: Nov 16, 2023
Visit Reason
A standard survey was conducted from November 13 through November 16, 2023, including investigation of two complaint intakes (GA00239441 substantiated with no deficiencies cited, GA00240718 unsubstantiated). The survey assessed compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00239441 was substantiated with no deficiencies cited, and intake GA00240718 was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to revise care plans, follow physician orders, maintain bedrails, ensure medication availability and administration, timely meal assistance, sanitary food storage and preparation, infection control practices, vaccine education, and maintenance of essential equipment such as the walk-in freezer.
Deficiencies (9)
Failed to revise care plan to include updated wound care for one resident (R22).
Failed to ensure physician orders were followed for two residents (R22 and R25).
Failed to ensure routine maintenance and inspection of bedrails for three residents (R21, R89, R93).
Failed to ensure medications were available and administered as ordered for two residents (R25 and R28).
Failed to ensure one resident (R22) received meals and assistance with meals in a timely manner.
Failed to ensure food was properly stored, refrigerators and floors were clean, freezers free of ice buildup, food not stored on floor, and scoops stored properly.
Failed to ensure staff performed hand hygiene between glove changes during dressing changes for two residents (R22 and R83).
Failed to provide education regarding risks and benefits of influenza and pneumococcal vaccines to five residents or their representatives.
Failed to maintain walk-in freezer properly; extensive ice buildup encasing food and equipment.
Report Facts
Resident census: 95
Missed medication administrations: 6
Missed medication administrations: 3
Ice buildup height: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding care plan revision, physician orders, meal assistance, and medication administration | |
| MDS Licensed Practical Nurse (MDS LPN) | Responsible for care plans, admitted missing wound care order for R22 | |
| Licensed Practical Nurse (LPN) 5 | Confirmed findings related to medication administration failures | |
| Certified Nursing Aide (CNA) 6 | Interviewed about meal assistance timing | |
| Dietary Aide (DA) 2 | Interviewed about walk-in freezer ice buildup and food handling | |
| Dietary Manager (DM) | Confirmed ice buildup in walk-in freezer and food storage issues | |
| Maintenance Director (MD) | Interviewed about walk-in freezer maintenance and inspection procedures | |
| Infection Preventionist/Registered Nurse (IP/RN) | Observed failing to perform hand hygiene between glove changes during dressing changes | |
| Administrator | Interviewed about walk-in freezer maintenance and medication administration issues |
Inspection Report
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Bell Minor Home, 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: 83
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 10, 2023 Complaint Survey.
Complaint Details
The revisit survey was conducted following a complaint survey on March 10, 2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the March 10, 2023 Complaint Survey were found to be corrected.
Report Facts
Census: 83
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 10, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure to immediately notify physicians after resident falls, inadequate assistance with activities of daily living, failure to provide timely emergency medical treatment after falls, and inaccurate medical record documentation.
Complaint Details
The investigation was complaint-driven, focusing on allegations of delayed physician notification after falls, inadequate assistance with activities of daily living, failure to provide timely emergency treatment after falls, and inaccurate medical record documentation. The complaints were substantiated with findings of delayed notifications, missed scheduled showers, delayed treatment, and inaccurate neurological documentation.
Findings
The facility failed to immediately notify physicians and responsible parties after resident falls for 2 of 3 sampled residents. It also failed to ensure residents received scheduled assistance with activities of daily living, timely emergency medical treatment and follow-up care after falls, and accurate documentation of neurological checks for a resident with a head injury.
Deficiencies (4)
F 0580: The facility failed to immediately notify the physician and responsible party when residents were involved in accidents with injuries for 2 of 3 sampled residents (#2 and #4). Notifications were delayed by several hours after the falls.
F 0677: The facility failed to ensure 3 of 3 residents (#2, #3, and #4) received scheduled showers as required to maintain personal hygiene, with many scheduled bathing opportunities missed.
F 0684: The facility failed to provide timely emergency medical treatment and follow-up care for resident #3 after a fall with injury, including delayed hospital transfer and late initiation of treatment orders for a laceration.
F 0842: The facility failed to ensure accurate documentation of neurological checks for resident #3 after a fall; neurological flow sheet documented checks prior to the actual fall time and included times when the nurse was not on duty.
Report Facts
Scheduled bathing opportunities missed: 6
Scheduled bathing opportunities missed: 6
Scheduled bathing opportunities missed: 6
Scheduled bathing opportunities missed: 7
Scheduled bathing opportunities missed: 5
Scheduled bathing opportunities missed: 8
Scheduled bathing opportunities missed: 2
Scheduled bathing opportunities missed: 2
Neurological checks documented prior to fall: 6
Time delay in physician notification: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in delayed notification of physician and responsible party after Resident #2's fall. |
| LPN #4 | Licensed Practical Nurse | Involved in care and documentation related to Resident #3's fall and treatment. |
| LPN #12 | Licensed Practical Nurse | Mentioned in interviews regarding Resident #4's fall and reporting. |
| LPN #16 | Licensed Practical Nurse | Interviewed regarding Resident #4's fall and documentation. |
| Director of Nursing | Director of Nursing | Provided statements on facility policies and procedures related to falls and treatments. |
| Administrator | Administrator | Provided statements on facility policies and procedures related to falls and treatments. |
| Primary Care Physician | Physician | Provided interview regarding Resident #3's fall and treatment decisions. |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 10, 2023
Visit Reason
A State Licensure survey was conducted at Bell Minor Home from March 7, 2023 through March 10, 2023 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to promptly notify physicians and responsible parties after resident falls, inadequate assistance with activities of daily living such as bathing for several residents, and inaccurate medical record documentation related to neurological checks following a fall.
Deficiencies (3)
Failure to immediately notify the physician when residents were involved in accidents with injuries for 2 of 3 sampled residents (#2 and #4) reviewed for falls.
Failure to ensure 3 of 3 residents (#2, #3, and #4) who required assistance with activities of daily living received the frequency of assistance required to maintain personal hygiene, specifically showers as scheduled.
Failure to ensure medical records were accurately documented for Resident #3, specifically the time and information documented on the Neurological Flow Sheet was inaccurate.
Report Facts
Residents reviewed for falls: 3
Residents with failure to notify physician after falls: 2
Residents with inadequate bathing assistance: 3
Scheduled bathing opportunities missed for Resident #3 in May 2022: 8
Scheduled bathing opportunities missed for Resident #3 in June 2022: 6
Scheduled bathing opportunities missed for Resident #3 in July 2022: 6
Scheduled bathing opportunities missed for Resident #3 in August 2022: 7
Scheduled bathing opportunities missed for Resident #2 in January 2023: 5
Scheduled bathing opportunities missed for Resident #2 in February 2023: 8
Scheduled bathing opportunities missed for Resident #4 in January 2023: 6
Scheduled bathing opportunities missed for Resident #4 in February 2023: 6
Scheduled bathing opportunities missed for Resident #4 in March 2023: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in findings related to delayed notification of physician and responsible party after resident falls. |
| LPN #4 | Licensed Practical Nurse | Named in interview regarding neurological checks and documentation for Resident #3. |
| Director of Nursing | Director of Nursing | Provided statements regarding notification procedures and documentation issues. |
| Administrator | Administrator | Provided statements regarding notification procedures and documentation issues. |
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 4
Date: Mar 10, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted by CertiSurv on behalf of the Georgia Department of Community Health investigating multiple complaint intake numbers from March 7 to March 10, 2023.
Complaint Details
The survey investigated complaint intake numbers GA00227772, GA00226762, GA00226778, and GA00224598. Intake numbers GA226762 and GA226778 were substantiated with deficiencies, GA224598 was substantiated without deficiencies, and GA227772 was unsubstantiated.
Findings
The facility was found noncompliant with deficiencies related to failure to immediately notify physicians of resident falls with injuries, failure to provide scheduled assistance with activities of daily living including showers, failure to provide timely emergency medical treatment and follow-up care for a resident after a fall, and inaccurate documentation of neurological checks after a fall.
Deficiencies (4)
Failure to immediately notify the physician when residents were involved in accidents with injuries for 2 of 3 sampled residents reviewed for falls.
Failure to ensure 3 of 3 residents who required assistance with activities of daily living received the frequency of assistance required to maintain personal hygiene, specifically showers as scheduled.
Failure to ensure treatment and care were provided in accordance with professional standards for 1 of 3 sampled residents reviewed for falls, including failure to provide emergency medical treatment in a timely manner and failure to ensure injury promptly received follow-up treatment as ordered by the physician.
Failure to ensure medical records were accurately documented for 1 of 8 sampled residents, specifically the time and information documented on the neurological flow sheet was inaccurate.
Report Facts
Resident census: 82
Scheduled bathing opportunities: 9
Scheduled bathing opportunities: 9
Scheduled bathing opportunities: 8
Scheduled bathing opportunities: 9
Scheduled bathing opportunities: 9
Scheduled bathing opportunities: 8
Scheduled bathing opportunities: 3
Scheduled bathing opportunities: 8
Scheduled bathing opportunities: 3
Laceration size: 3
Laceration size: 0.5
Laceration size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Reported on Resident #2's fall and notification delays |
| LPN #4 | Licensed Practical Nurse | Documented Resident #3's fall and described emergency response |
| LPN #3 | Licensed Practical Nurse | Former nurse who described treatment order process for Resident #3 |
| Director of Nursing | Director of Nursing | Provided policy and procedural information regarding falls and treatments |
| Administrator | Administrator | Provided facility policy and procedural information regarding falls and treatments |
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 4/12/22 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/14/22 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 91
Deficiencies: 3
Date: Apr 14, 2022
Visit Reason
The inspection was conducted to assess compliance with care planning, respiratory care, and infection prevention standards at the nursing home.
Findings
The facility failed to develop person-centered care plans for two residents regarding Hospice services and indwelling urinary catheter use. Additionally, oxygen therapy was not administered according to physician orders for one resident, and infection control procedures were not followed during medication administration for three residents.
Deficiencies (3)
F 0656: The facility failed to develop a complete care plan with measurable goals for two residents, one for Hospice services and one for indwelling urinary catheter use.
F 0695: The facility failed to ensure oxygen therapy was administered according to physician orders for one resident, with oxygen flow set higher than ordered and no humidification provided.
F 0880: The facility failed to follow infection control procedures during medication administration, as a nurse did not wash or sanitize hands before, during, or after medication passes for three residents.
Report Facts
Residents affected: 2
Sample size: 29
Residents affected: 1
Residents affected: 3
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in infection control deficiency for not washing or sanitizing hands during medication administration |
| Director of Nursing | Confirmed oxygen flow rate set incorrectly for resident R#54 | |
| MDS Director | Interviewed regarding care plan updates and resident discharge | |
| MDS Coordinator | Acknowledged lack of Hospice Care Plan for resident R#44 | |
| Administrator | Interviewed regarding infection control practices and nurse removal |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 3
Date: Apr 14, 2022
Visit Reason
A standard survey was conducted from 4/12/22 through 4/14/22, including investigation of Complaint Intake Number GA00223088, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Complaint Intake Number GA00223088 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop person-centered care plans for two residents, improper oxygen therapy administration for one resident, and failure to follow infection control procedures during medication administration for three residents.
Deficiencies (3)
Failure to develop a person-centered care plan for two residents: one for Hospice services and one for indwelling urinary catheter use.
Failure to ensure oxygen therapy was administered according to physician orders for one resident, including oxygen flow rate and humidification.
Failure to follow infection control procedures during medication administration, including lack of hand hygiene before, during, and after medication passes for three residents.
Report Facts
Resident census: 91
Sample size: 29
Oxygen flow rate: 5
Topical medication dose: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in infection control deficiency for failure to perform hand hygiene during medication administration. |
| MDS Director | Interviewed regarding care plan updates and confirmed lack of care planning for indwelling catheter. | |
| MDS Coordinator | Acknowledged no hospice care plan for resident receiving hospice services. | |
| Director of Nursing (DON) | Confirmed oxygen flow rate discrepancy and lack of humidification for resident R#54. | |
| Administrator | Confirmed LPN BB is an agency nurse and will be removed from the floor due to infection control violations. |
Inspection Report
Renewal
Census: 91
Deficiencies: 2
Date: Apr 12, 2022
Visit Reason
The inspection was a Licensure Survey conducted from April 12, 2022 through April 14, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to develop person-centered care plans for two residents regarding Hospice services and indwelling urinary catheter use. Additionally, infection control procedures were not followed during medication administration, with an agency nurse failing to perform hand hygiene, risking the spread of infection.
Deficiencies (2)
Failure to develop a person-centered care plan for two residents: one for Hospice services and one for indwelling urinary catheter use.
Failure to follow infection control procedures by not practicing hand hygiene during medication administration for three residents.
Report Facts
Sample size: 29
Census: 91
Medication dosage: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in infection control deficiency for failure to perform hand hygiene during medication administration |
Inspection Report
Life Safety
Census: 90
Capacity: 104
Deficiencies: 0
Date: Apr 12, 2022
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 Bell Minor Home was found in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey conducted on 04/12/2022.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00219865.
Complaint Details
Complaint #GA00219865 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations and 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 related to emergency preparedness and infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209104.
Complaint Details
Complaint #GA00209104 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 0
Date: Jul 28, 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.
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 recommended practices to prepare for COVID-19.
Report Facts
Total census: 64
Inspection Report
Routine
Census: 86
Deficiencies: 0
Date: Apr 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) on April 23, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
A complaint survey was conducted to investigate complaints #GA00202429 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00202429 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 11, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00197626, GA00198249, and GA198984 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints #GA00197626, GA00198249, and GA198984; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Jan 28, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 6, 2018 standard survey.
Findings
All deficiencies cited in the prior December 6, 2018 standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 24, 2019
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 during the follow-up survey.
Inspection Report
Routine
Census: 87
Deficiencies: 5
Date: Dec 6, 2018
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to notify physicians of resident condition changes, inaccurate resident assessments, failure to revise care plans to current needs, improper medication administration documentation, and inadequate resident positioning during meals.
Deficiencies (5)
Failure to notify the physician of a change in condition for Resident #72.
Failure to accurately reflect the number of falls on the Minimum Data Set for Resident #35.
Failure to revise care plans to address current care needs for Residents #72 and #55.
Failure to ensure medication administration record was initialed by the nurse administering medications for Resident #83.
Failure to assess and provide proper positioning for Resident #55 during meals.
Report Facts
Resident census: 87
Sampled residents: 34
Medication opportunities: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN DD | Registered Nurse | Interviewed regarding nursing notes and medication administration |
| LPN CC | Licensed Practical Nurse | Interviewed regarding nursing notes and monitoring |
| RN BB | Registered Nurse | Interviewed regarding nursing notes and medication administration |
| Medical Director | Medical Director | Interviewed regarding Resident #72's condition and notification |
| MDS Nurse JJ | Minimum Data Set Nurse | Interviewed regarding care plan updates and MDS assessments |
| LPN KK | Licensed Practical Nurse | Observed administering medications and interviewed about medication documentation |
| RN BB | Registered Nurse | Observed signing medication administration record prior to administration |
| LPN LL | Licensed Practical Nurse | Interviewed about medication administration timing and documentation |
| LPN MM | Licensed Practical Nurse, Charge Nurse | Interviewed about medication administration documentation |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding medication administration and care plan deficiencies |
| CNA FF | Certified Nursing Assistant | Interviewed regarding resident positioning and care plans |
| RN AA | Registered Nurse | Interviewed regarding resident positioning during meals |
| Speech Language Pathologist | Speech Language Pathologist | Interviewed regarding proper positioning for eating |
| Physical Therapy Assistant | Physical Therapy Assistant | Interviewed regarding resident positioning and therapy referrals |
| CNA NN | Certified Nursing Assistant | Interviewed regarding resident positioning during meals |
| CNA EE | Certified Nursing Assistant | Interviewed regarding resident positioning during meals |
| CNA GG | Certified Nursing Assistant | Interviewed regarding resident positioning during meals |
Inspection Report
Routine
Deficiencies: 1
Date: Dec 6, 2018
Visit Reason
The inspection was conducted to assess compliance with professional service requirements, specifically focusing on medication administration practices during a routine survey of the facility.
Findings
The facility failed to ensure that the resident's electronic Medication Administration Record (eMAR) was initialed by the nurse who prepared and administered the medication for eight medication opportunities for one resident. Interviews revealed that medication administration was initialed by a nurse who did not administer the medications, contrary to facility policy.
Deficiencies (1)
Failure to ensure resident's electronic Medication Administration Record (eMAR) was initialed by the nurse preparing and administering the medication for eight medication opportunities for one resident.
Report Facts
Medication opportunities not initialed by administering nurse: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Licensed Practical Nurse (LPN) | Administered medications to resident #83 and initialed by another nurse |
| BB | Registered Nurse (RN) | Newly employed RN who initialed medication administration prior to preparation and administration by LPN KK |
| LL | Licensed Practical Nurse (LPN), Unit Nurse | Interviewed regarding medication administration time window and initialing practices |
| MM | Licensed Practical Nurse (LPN), Charge Nurse | Interviewed regarding proper medication initialing practices |
Inspection Report
Life Safety
Census: 87
Capacity: 104
Deficiencies: 3
Date: Dec 4, 2018
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 missing fire alarm strobes in certain staff restrooms and the front lobby restroom, a trouble signal on the main fire alarm panel, flammable decorations on a patient room door, and improper use of surge protectors in patient care areas.
Deficiencies (3)
Failed to have fire alarm strobes inside MDS office restroom, Therapy office restroom, and front lobby restroom; main fire alarm panel showed a trouble signal.
Patient room 26 door had flammable decorations hanging on it.
Surge protectors found lying on the floor in the beauty shop and Director of Nursing office.
Report Facts
Residents/staff at risk: 10
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 2, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 12/14/17 recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2018
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
Life Safety
Census: 90
Capacity: 104
Deficiencies: 2
Date: Dec 12, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to provide smoke resistance for patient doors, which could place 18 residents at risk in the event of a fire. Several patient room doors did not seal properly to prevent smoke passage and some doors were not latching properly.
Deficiencies (2)
Patient doors upon closing were not sealing to prevent smoke passage, including rooms C1, 24, 12, 5, 21, 1, and the Director of Nursing's door.
Patient room doors in rooms 23 and 6 were not latching properly.
Report Facts
Residents at risk: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding door deficiencies during the tour of the facility |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 15, 2017
Visit Reason
A Follow-Up Survey to the Life Safety Code Revisit of 1/10/17 was conducted to verify correction of previously cited deficiencies.
Findings
It was determined that all previously cited survey tags have been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2017
Visit Reason
A Life Safety Code Follow-Up Survey was conducted to verify correction of previously cited deficiencies from the Federal Life Safety Code Comparative Survey of 12/16/16.
Findings
All previously cited survey tags from the prior Life Safety Code survey were determined to have been corrected.
Inspection Report
Follow-Up
Capacity: 89
Deficiencies: 1
Date: Jan 10, 2017
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at the facility.
Findings
The facility failed to ensure that sprinkler system control valves were supervised properly, specifically the electronic tamper on the exterior Post Indicator Valve had not been repaired, placing 89 residents at risk in the event of a fire.
Deficiencies (1)
Failed to ensure sprinkler system control valves were supervised properly; electronic tamper on exterior Post Indicator Valve not repaired.
Report Facts
Total licensed capacity: 89
Inspection Report
Life Safety
Census: 89
Capacity: 104
Deficiencies: 1
Date: Dec 16, 2016
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted by CMS following a state survey to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and related NFPA codes.
Findings
The facility was found not in substantial compliance due to failure to install automatic sprinklers under two exterior roof overhangs made of combustible wood, which exceeded the allowable length without sprinkler protection.
Deficiencies (1)
Failure to install automatic sprinklers under two exterior roof overhangs made of combustible wood exceeding 4 feet in length.
Report Facts
Census: 89
Total Capacity: 104
Roof overhang length: 5.33
Roof overhang length: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present when deficiencies were identified |
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