Deficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Deficiencies: 0
Jun 17, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Jun 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 8, 2025, standard survey.
Findings
All deficiencies cited in the previous May 8, 2025, standard survey were found to be corrected during the revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 17, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a facility inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Jun 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 8, 2025, standard survey.
Findings
All deficiencies cited in the May 8, 2025, standard survey were found to be corrected during the revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 17, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Twin Fountains Home following a regulatory inspection.
Findings
The report contains initial comments but does not specify detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Jun 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the May 8, 2025, standard survey.
Findings
All deficiencies cited in the previous May 8, 2025, standard survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 6, 2025
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 have been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 6, 2025
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 have been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 6, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 3
May 8, 2025
Visit Reason
A State Licensure survey was conducted at Green Acres Care Center, LLC from May 5, 2025 through May 8, 2025 to assess compliance with state health and safety regulations.
Findings
The survey identified multiple deficiencies including failure to provide written quarterly statements to residents regarding their personal funds accounts, failure to provide written transfer notifications to residents and their representatives, and inadequate food labeling, dating, and storage practices in the kitchen and resident pantries.
Deficiencies (3)
| Description |
|---|
| Failure to provide written quarterly statements within 30 days of the end of the quarter to residents and/or resident representatives regarding personal funds accounts. |
| Failure to provide written notification of transfer to the hospital to the resident and resident representative for one resident. |
| Failure to ensure food items were labeled, dated, and securely wrapped in kitchen storage areas and resident pantries; staff food items were not stored separately from resident food items. |
Report Facts
Residents with personal funds accounts in February: 43
Residents with personal funds accounts in March: 49
Residents at risk of foodborne illness: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R78 | Resident | Interviewed regarding not receiving quarterly statements about personal funds account |
| Business Office Manager | Business Office Manager | Verified resident R78 had an active resident funds account and explained no quarterly statements had been sent since December 2024 |
| R26 | Resident | Resident reviewed for hospital transfer without written notification |
| Director of Nurses | Director of Nurses | Stated facility called family but did not provide written transfer notice |
| Social Services Director | Social Services Director | Was unsure about written transfer notices being sent to family |
| Assistant Director of Nurses | Assistant Director of Nurses | Stated facility called resident's representative and documented transfers in nurse notes |
| Dietary Manager | Dietary Manager | Confirmed concerns about food labeling, dating, and storage practices during kitchen and pantry inspections |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 3
May 8, 2025
Visit Reason
A standard survey was conducted from May 5, 2025 through May 8, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide quarterly statements of residents' personal funds, failure to provide written notification of hospital transfer to a resident and their representative, and failure to ensure proper labeling, dating, and separation of food items in kitchen and resident pantries, posing risks to residents.
Complaint Details
The visit included investigation of complaint intake numbers GA00243776, GA00244194, GA00244999, GA00245619, GA00249945, GA00254086, GA00254149, GA00254581, and GA00254742 in conjunction with the standard survey.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide written quarterly statements within 30 days of the end of the quarter to one resident (R78) and/or their representative regarding personal funds account balance. | D |
| Failure to provide written notification of hospital transfer to one resident (R26) and their representative. | D |
| Failure to ensure food items were labeled, dated, securely wrapped, and that staff food was stored separately from resident food in kitchen and resident pantries. | F |
Report Facts
Residents with active personal funds accounts: 43
Resident census: 93
Resident census: 89
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Business Office Manager | Verified resident R78 had an active personal funds account and explained no quarterly statements had been sent since December 2024. |
| Director of Nurses | Director of Nurses | Stated facility called family and documented transfers but did not provide written transfer notices. |
| Social Services Director | Social Services Director | Was unsure about written transfer notices being sent to families. |
| Assistant Director of Nurses | Assistant Director of Nurses | Confirmed facility called resident's representative and documented transfers in nurse notes. |
| Dietary Manager | Dietary Manager | Confirmed food storage deficiencies including unlabeled, undated food and staff food stored with resident food. |
Inspection Report
Life Safety
Census: 93
Capacity: 116
Deficiencies: 5
May 5, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain door closure for hazardous areas, exit signage under backup power, access to sprinkler riser, smoke doors, and clear access to electrical panels.
Severity Breakdown
D: 4
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain door closure for hazardous areas; a door with a self-closing device was propped open in the laundry area. | D |
| Exit sign near the room labeled 'North Bath' failed to operate under backup power. | D |
| Failed to maintain access to the rear sprinkler riser; numerous items were stored blocking access. | E |
| Smoke doors failed to close completely in two locations: near the Beauty/Barber Shop and near the Dining Room. | D |
| Failed to maintain clear access to electrical panels; multiple items stored blocking access in the rear electrical room. | D |
Report Facts
Census: 93
Total Capacity: 116
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Renewal
Deficiencies: 0
Sep 28, 2023
Visit Reason
A State Licensure survey was conducted at Twin Fountains Home from September 26, 2023 through September 28, 2023 to assess compliance with state health regulations.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection.
Inspection Report
Routine
Census: 86
Deficiencies: 0
Sep 28, 2023
Visit Reason
A standard survey was conducted at Twin Fountains Home from September 26, 2023 through September 28, 2023. Additionally, three complaint intake numbers were investigated in conjunction with this standard survey.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. Two complaints were unsubstantiated, and one complaint was substantiated with no deficiencies identified.
Complaint Details
Complaint Intake numbers GA00230254 and GA00236491 were unsubstantiated. Complaint Intake number GA00232049 was substantiated with no deficiencies.
Report Facts
Complaint Intake Numbers Investigated: 3
Inspection Report
Life Safety
Census: 86
Capacity: 116
Deficiencies: 0
Sep 27, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Deficiencies: 0
Jun 3, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Twin Fountains Home, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2022
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
Mar 17, 2022
Visit Reason
A standard survey was conducted from 03/15/2022 through 03/17/2022, including investigation of three complaint intake numbers (GA0000222168, GA00220861, & GA00219593). The visit aimed to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including improper sanitary storage of resident wash basins in shared bathrooms and failure to ensure food safety practices such as discarding expired foods, proper labeling and dating of opened food items, and cleanliness of kitchen equipment.
Complaint Details
The inspection included investigation of complaint intake numbers GA0000222168, GA00220861, and GA00219593.
Severity Breakdown
Level D: 1
Level F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to store resident personal care items (wash basins) in a sanitary manner; wash basins were unlabeled, unbagged, and nested inside each other in bathrooms shared by eight residents. | Level D |
| Facility failed to ensure expired foods were discarded and opened food items were properly dated and labeled in the walk-in cooler, freezer, and dry food pantry; also failed to keep oven and food carts clean. | Level F |
Report Facts
Resident census: 85
Residents affected: 83
Expired food items found: 3
Open food items without date: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Verified improper storage of wash basins and confirmed wash basins should be labeled and bagged |
| CNA DD | Certified Nursing Assistant | Reported no set time to change wash basins and responsibility for labeling and bagging |
| CNA NN | Certified Nursing Assistant | Described wash basin labeling and bagging procedures and responsibility |
| Administrator KK | Administrator | Confirmed no policy on storage of residents' personal care items |
| Dietary Manager | Identified expired food items and improper labeling in kitchen; confirmed responsibility for labeling and dating food items |
Inspection Report
Life Safety
Census: 89
Capacity: 116
Deficiencies: 1
Mar 17, 2022
Visit Reason
The Life Safety Code Survey was 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 due to failure to document daily inspections of means of egress in areas undergoing construction, alterations, repair, or additions. Specifically, a temporary wall constructed prior to January 2022 isolating rooms #26-30 lacked documented daily inspections.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document a means of egress daily inspection of areas that have undergone construction, alterations, repair or additions to ensure instant usability in case of emergency. | SS= D |
Report Facts
Census: 89
Total Capacity: 116
Smoke Compartments affected: 1
Rooms isolated by temporary wall: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding lack of documented daily inspections | |
| Administrator | Interviewed regarding lack of documented daily inspections | |
| Staff M | Confirmed findings during tour and interview | |
| Staff A | Confirmed findings at time of discovery |
Inspection Report
Renewal
Deficiencies: 2
Mar 17, 2022
Visit Reason
A Licensure Survey was conducted from 3/15/2022 through 3/17/2022 to assess compliance with licensure requirements for the facility.
Findings
The facility was found to have deficiencies related to improper sanitary storage of resident personal care items (wash basins) in shared bathrooms and failure to ensure expired foods were discarded and opened food items properly dated and labeled in the kitchen. Additionally, the oven and food carts were found unclean.
Deficiencies (2)
| Description |
|---|
| The facility failed to store resident personal care items in a sanitary manner in two bathrooms shared by eight residents, with wash basins nested, unlabeled, and unbagged. |
| The facility failed to ensure expired foods were properly discarded and opened food items were properly dated and labeled in the walk-in cooler, freezer, and dry food pantry. The oven and food carts were also unclean. |
Report Facts
Residents affected by food safety deficiency: 83
Residents sharing bathrooms with improper wash basin storage: 8
Residents in facility: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Verified improper storage of resident wash basins and provided information on bathing routines and wash basin handling |
| CNA DD | Certified Nursing Assistant | Provided information on wash basin changing and labeling responsibilities |
| CNA NN | Certified Nursing Assistant | Provided information on wash basin labeling and changing procedures |
| Administrator KK | Administrator | Stated there is no policy on storage of residents' personal care items |
| Dietary Manager | Observed expired and improperly labeled food items and confirmed cleaning deficiencies in kitchen equipment |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted, including investigation of Complaint Intake Numbers GA00211231 and GA00206918.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control. The complaints investigated were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00211231 and GA00206918 were investigated and found to be unsubstantiated.
Report Facts
Total census: 67
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Sep 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the July 15, 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.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 1
Jul 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility failed to ensure housekeeping staff were aware of proper disinfection techniques in accordance with standard and transmission-based precautions to prevent the spread of COVID-19, including improper labeling of disinfectant spray bottles and incorrect use of disinfectant wiping procedures.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure housekeeping staff were aware of proper disinfection techniques and proper use of EPA-registered disinfectants to prevent the spread of COVID-19. | SS=E |
Report Facts
Residents positive for COVID-19: 5
Total census: 86
Contact time for Oxycide disinfectant: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper GG | Housekeeper | Observed cleaning practices and identified mislabeled disinfectant bottles |
| LPN KK | Licensed Practical Nurse | Reported on COVID-19 positive residents and infection control practices on South Wing |
| Housekeeping Supervisor | Housekeeping Supervisor | Responsible for cleaning South Wing and described disinfectant use and labeling issues |
| Housekeeping Director | Housekeeping Director | Provided information on disinfectant use, staff training, and monitoring systems |
| Administrator | Administrator | Oversaw housekeeping services and infection control committee reporting |
Inspection Report
Re-Inspection
Census: 102
Deficiencies: 0
Jan 15, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 11/21/19 Standard Survey.
Findings
All deficiencies cited in the previous 11/21/19 Standard Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 10, 2020
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 at the time of the follow-up survey.
Inspection Report
Life Safety
Census: 96
Capacity: 116
Deficiencies: 2
Nov 19, 2019
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 National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to provide complete automatic sprinkler protection throughout the facility and failure to maintain smoke barriers with a minimum ½ hour fire resistance rating, placing residents at risk in multiple smoke compartments.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide complete automatic sprinkler protection; specifically, no automatic sprinkler head in the IT closet added in the dining room. | SS= D |
| Failure to maintain smoke barriers to have a minimum ½ hour fire resistant rating; penetration in the smoke barrier separating the North Wing above the cross corridor doors where cables penetrate the wall and are not fire stopped. | SS= D |
Report Facts
Census: 96
Total Capacity: 116
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 27, 2019
Visit Reason
A complaint survey was conducted to investigate complaints #GA00196056 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00196056 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint intake #GA00191249.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Complaint Details
Complaint intake #GA00191249 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Routine
Census: 97
Deficiencies: 0
Jul 19, 2018
Visit Reason
A standard survey was conducted at Twin Fountains Home from July 16, 2018 through July 19, 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 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 97
Capacity: 116
Deficiencies: 0
Jul 19, 2018
Visit Reason
The 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 to be in substantial compliance with the Life Safety Code requirements, including emergency preparedness plan compliance as per Appendix Z.
Report Facts
Census: 97
Total Capacity: 116
Inspection Report
Routine
Census: 99
Deficiencies: 0
Sep 7, 2017
Visit Reason
A standard survey was conducted at Twin Fountains Home from September 5, 2017 through September 7, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 99
Capacity: 116
Deficiencies: 0
Sep 6, 2017
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
Twin Fountains Home was found in substantial compliance with the Life Safety Code requirements during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate multiple complaints (#GA00164503, GA00162771, GA00162634, and GA00162516) to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted on April 10-11, 2017.
Complaint Details
The survey was conducted in response to complaints #GA00164503, GA00162771, GA00162634, and GA00162516. No deficiencies were found, indicating the complaints were not substantiated.
Loading inspection reports...
