Inspection Reports for
Warm Springs Medical Center Nursing Home
5995 SPRING STREET, WARM SPRINGS, GA, 31830
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
68 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 14, 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 of the follow-up survey conducted on May 14, 2025.
Inspection Report
Deficiencies: 0
Date: May 14, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Warm Springs Medical Center Nursing Home following a survey completed on May 14, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 0
Date: May 14, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 27, 2025, recertification survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Mar 27, 2025
Visit Reason
A State Licensure survey was conducted at Warm Springs Medical Center Nursing Home from March 25, 2025, through March 27, 2025.
Findings
The survey revealed there were no State Health deficiencies cited.
Inspection Report
Life Safety
Census: 67
Capacity: 79
Deficiencies: 4
Date: Mar 26, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain emergency lighting backup batteries, improper enclosure of vertical openings, and unsealed penetrations in rated walls in the ground floor elevator area.
Deficiencies (4)
Emergency lighting failed to function on backup battery for two exit signs.
Facility failed to maintain exit signs with back-up batteries affecting residents and staff on the ground level.
Vertical openings such as stairways and elevator shafts were not properly enclosed with required fire resistance rating.
Facility failed to maintain penetrations of the rated wall in the ground floor elevator area; holes drilled through smoke wall were not sealed with fire caulk.
Report Facts
Census: 67
Total Capacity: 79
Number of exit signs failed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting and wall penetrations during facility tour |
Inspection Report
Routine
Census: 67
Deficiencies: 1
Date: Mar 25, 2025
Visit Reason
A standard survey was conducted from March 25, 2025, through March 27, 2025, including investigation of multiple complaint intake numbers which were unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00245145, GA00248073, GA00248466, GA00249447, and GA00250561 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations related to oxygen administration. Specifically, the facility failed to follow physician's orders for oxygen flow rate for one resident, placing the resident at risk of respiratory complications.
Deficiencies (1)
Failed to follow physician's orders for oxygen flow rate for one resident (R18), with oxygen set at 1.25 LPM instead of the ordered 2 LPM.
Report Facts
Resident census: 67
Residents with oxygen orders: 18
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 1.25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Verified and adjusted oxygen flow rate for resident R18 |
| Director of Nursing (DON) | Stated nurses manage oxygen settings and document checks once per shift |
Inspection Report
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Warm Springs Medical Center Nursing Home following a survey completed on January 4, 2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 77
Deficiencies: 0
Date: Jan 4, 2024
Visit Reason
A health revisit survey was conducted from January 2, 2024 through January 4, 2024 to verify correction of deficiencies cited in the November 5, 2023 Recertification Survey.
Findings
All deficiencies cited in the November 5, 2023 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 21, 2023
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted during the Life Safety Code revisit.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 6
Date: Nov 5, 2023
Visit Reason
A State Licensure survey was conducted at Warm Springs Medical Center Nursing Home from November 3, 2023 through November 5, 2023 to assess compliance with state health regulations and identify any deficiencies.
Findings
The survey revealed multiple deficiencies including failure to follow up on resident grievances regarding staff phone use, inadequate RN coverage on multiple days, improper renal diet service, lack of dietitian documentation for weight loss, incomplete wound assessments, unsafe medical equipment electrical connections, and poor dietary sanitation practices.
Deficiencies (6)
Facility failed to follow up on grievances related to CNAs not treating residents with dignity and respect, specifically CNAs HH, JJ, and II being distracted by phone use.
Facility failed to provide RN coverage for at least eight consecutive hours a day, seven days a week on 13 days in 2023.
Facility failed to serve a proper renal diet for one resident and failed to have dietitian document weight loss for another resident.
Facility failed to complete weekly wound assessments for one resident with multiple pressure ulcers.
Medical equipment (oxygen concentrator) was plugged into a power strip instead of a wall outlet in one resident room.
Facility failed to ensure one of three reach-in freezers and the ice machine were clean and free from debris; dietary staff failed to wash hands and change gloves properly to prevent cross contamination.
Report Facts
Days without RN coverage: 13
Census: 76
Residents ordered renal diet: 3
Residents reviewed for pressure ulcers: 3
Residents with oral diet: 74
Weight loss percentage: 9.9
Weight loss percentage: 5
Weight loss percentage: 3.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Certified Nursing Assistant | Named in grievance related to phone use while providing care. |
| JJ | Certified Nursing Assistant | Named in grievance related to phone use while providing care. |
| II | Certified Nursing Assistant | Named in grievance related to phone use while providing care. |
| GG | Human Resources | Confirmed dates with no RN coverage. |
| KK | Licensed Practical Nurse | Acknowledged wound assessments were incomplete. |
| FF | Dietary Aide | Observed not washing hands or changing gloves properly in dish room. |
Inspection Report
Routine
Census: 76
Deficiencies: 8
Date: Nov 5, 2023
Visit Reason
A standard survey was conducted from November 3, 2023 through November 5, 2023, including investigation of a substantiated complaint intake without deficiencies.
Complaint Details
Complaint Intake Number GA00232017 was investigated in conjunction with the standard survey and was substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to provide required Medicare notices, inadequate grievance follow-up, lack of pre-employment reference checks, incomplete wound assessments, unsafe medical equipment use, improper diet service, missing dietitian documentation, insufficient RN coverage, and unsanitary food handling practices.
Deficiencies (8)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents discharged from Medicare Part A services.
Failed to follow up on grievances related to CNAs not treating residents with dignity and respect for three residents.
Failed to ensure pre-employment reference checks were conducted for 10 of 33 employees.
Failed to complete weekly wound assessments for one resident with pressure ulcers.
Failed to have medical equipment plugged into a wall outlet instead of a power strip in one resident room.
Failed to serve proper renal diet for one resident and failed to have dietitian document weight loss for another resident.
Failed to provide RN coverage for at least eight consecutive hours a day, seven days a week for 13 days.
Failed to ensure one of three reach-in freezers and the ice machine were clean and free from debris; failed to ensure dietary staff washed hands and changed gloves to prevent cross contamination.
Report Facts
Residents discharged from Medicare Part A: 3
Residents sampled for grievances: 33
Employees reviewed for reference checks: 33
Employees without reference checks: 10
Residents reviewed for pressure ulcers: 3
Residents receiving oral diet: 74
Days without RN coverage: 13
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding SNFABN form knowledge and grievance follow-up. | |
| Chief Financial Officer | CFO | Interviewed regarding SNFABN form issuance and Medicare guidelines. |
| Director of Human Resources | Director of Human Resources | Interviewed regarding lack of pre-employment reference checks. |
| Licensed Practical Nurse KK | Treatment Nurse | Interviewed regarding wound assessment completion. |
| Director of Nursing | DON | Interviewed regarding RN coverage, weight loss documentation, and medical equipment safety. |
| Director of Dining Services | DDS | Interviewed regarding dietary errors, food handling, and cleaning practices. |
| Dietary aide FF | Dietary Aide | Observed and interviewed regarding improper glove use and hand washing. |
Inspection Report
Life Safety
Census: 74
Capacity: 79
Deficiencies: 3
Date: Nov 4, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with sprinkler system activation due to broken ceiling tiles, penetrations compromising smoke barriers, and uncovered electrical panels posing shock hazards. These deficiencies affect one of three smoke compartments.
Deficiencies (3)
Broken and missing ceiling tiles in the maintenance office prevented proper sprinkler system activation.
Penetrations through smoke barriers in two locations (generator room to corridor and near elevator on main floor) compromised smoke resistance.
Two electrical panels at the generator had open circuits not covered, increasing risk of electrical shock.
Report Facts
Certified beds: 79
Census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a focused infection control survey were conducted at Warm Springs Medical Center Nursing Home on August 15, 2023.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for infection control.
Inspection Report
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory inspection of Warm Springs Medical Center Nursing Home.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
A revisit survey was conducted on 7/22/22 to verify correction of deficiencies cited during the 4/21/22 Recertification Survey.
Findings
The deficiency cited as a result of the 4/21/22 Recertification Survey was found to be corrected.
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous Federal Monitoring Health Comparative and COVID Survey dated 5/19/22.
Findings
All deficiencies cited in the prior survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 74
Deficiencies: 10
Date: May 19, 2022
Visit Reason
A Federal Monitoring Health Comparative and COVID Survey was conducted at Warm Springs Medical Center Nursing Home from 05/16/2022 through 05/19/2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple deficiencies including resident rights violations, failure to accommodate resident needs, inadequate advance directive documentation, unsafe and unsanitary environment conditions, failure to coordinate PASARR assessments, incomplete care plan implementation, medication errors including failure to reduce medication dosage and inadequate monitoring of side effects, improper medication and food storage, and failure to maintain sanitary food service practices.
Deficiencies (10)
Staff stood over a resident while assisting with meals instead of sitting, violating resident dignity.
Facility failed to provide a bed accommodating a resident's height causing discomfort.
Resident's advance directive preference was not updated in the medical record.
Facility environment had damaged walls, missing paint, stained floors, loose sinks, and cracked ceilings posing safety risks.
Facility failed to complete PASARR Level II assessments for residents with qualifying mental health diagnoses.
Facility failed to implement care plan for resident with history of dehydration; incomplete documentation of intake and output.
Facility failed to follow physician's order to reduce medication dosage, resulting in resident receiving double dose for a month.
Facility failed to monitor and report side effects of increased antipsychotic and antianxiety medications leading to resident lethargy.
Medication refrigerators' temperatures were not recorded daily and expired medications were not discarded.
Food items in kitchen and nourishment refrigerators were not labeled or dated, expired food was not discarded, and pans were stacked wet risking cross-contamination.
Report Facts
Census: 74
Deficiency count: 10
Medication dosage: 1000
Medication dosage: 500
Medication administration frequency: 3
Medication administration frequency: 4
Expired medication count: 12
Unlabeled brownies count: 25
Unlabeled plastic trays count: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse Supervisor | Confirmed staff stood over resident during meal assistance and medication refrigerator temperature log issues |
| CNA #3 | Certified Nursing Assistant | Observed standing over resident during meal assistance |
| Administrator | Acknowledged building disrepair and lack of maintenance documentation | |
| Director of Nursing | DON | Confirmed multiple deficiencies including advance directive issue, medication errors, and food storage problems |
| LPN #1 | Licensed Practical Nurse | Confirmed resident lethargy after medication increase and medication administration errors |
| Social Worker | SW | Confirmed PASARR Level II assessments were not completed for qualifying residents |
| Medical Director | Confirmed not notified of resident's lethargy and expected to be informed | |
| Dietary Staff #2 | Confirmed food labeling and sanitation expectations | |
| Registered Dietician | RD | Confirmed food labeling and sanitation expectations |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from April 19, 2022 through April 21, 2022 to assess compliance for license renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from April 19, 2022 through April 21, 2022.
Inspection Report
Routine
Census: 71
Deficiencies: 1
Date: Apr 21, 2022
Visit Reason
A standard survey was conducted from 4/19/2022 through 4/21/2022 to assess compliance with Medicare/Medicaid regulations for the Warm Springs Medical Center Nursing Home.
Findings
The facility was found not in substantial compliance due to failure to ensure that lunch meals remained hot upon delivery to residents, affecting 18 residents on one hall. Observations and interviews confirmed that food was often served cold and was not maintained at a safe temperature.
Deficiencies (1)
Failure to ensure that a lunch meal remained hot upon delivery to residents, affecting 18 residents on the hall.
Report Facts
Resident census: 71
Residents affected: 18
Food temperature: 64
Meal delivery time: 28
Meal cart wait time: 6
Inspection Report
Life Safety
Census: 71
Capacity: 79
Deficiencies: 0
Date: Apr 20, 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 facility was found to be in compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a).
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 29, 2021
Visit Reason
A revisit survey was conducted by desk review on 4/29/2021 to verify correction of deficiencies cited in the 2/24/2021 COVID-19 Focused Infection Control Survey.
Findings
All deficiencies cited as a result of the 2/24/2021 COVID-19 Focused Infection Control Survey were found to be corrected.
Inspection Report
Routine
Census: 48
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to have an effective pneumococcal immunization program in place as per CDC recommendations for residents over 65. One of five sampled residents reviewed lacked documentation of receiving the recommended second pneumococcal vaccine dose.
Deficiencies (1)
Failure to have an effective pneumococcal immunization program ensuring residents were offered pneumococcal vaccinations per CDC recommendations.
Report Facts
Total census: 48
Sampled residents reviewed for immunizations: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding vaccination records and medical record system | |
| Infection Preventionist | Interviewed and confirmed no record of offering second pneumococcal vaccine dose |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 17, 2020
Visit Reason
A Follow-Up desk review survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Warm Springs Medical Center Nursing Home following a survey completed on July 15, 2020.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey. Specific deficiencies and their details are not provided in the available page.
Inspection Report
Re-Inspection
Census: 73
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/6/2020 Recertification Survey.
Findings
All deficiencies cited as a result of the 2/6/2020 Recertification Survey were found to be corrected.
Inspection Report
Routine
Census: 73
Deficiencies: 0
Date: Jul 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Warm Springs Medical Center Nursing Home on 7/15/2020 to assess 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 recommended practices to prepare for COVID-19.
Inspection Report
Renewal
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
A Licensure Survey was conducted from February 3, 2020 through February 6, 2020 to assess compliance with licensure requirements for the nursing home facility.
Findings
The facility failed to ensure post-dialysis assessments were completed for one resident receiving dialysis and failed to ensure open items in dry storage and cooler were labeled and dated, potentially affecting 68 of 72 residents receiving an oral diet.
Deficiencies (2)
Failure to ensure post-dialysis assessments were completed for one resident receiving dialysis, including missing Dialysis Communication Forms for 15 scheduled dialysis days.
Failure to ensure open items in the dry storage and cooler were labeled and dated, affecting 68 of 72 residents receiving an oral diet.
Report Facts
Missing Dialysis Communication Forms: 15
Containers of spices: 30
Containers of milk: 2
Residents affected: 68
Total residents receiving oral diet: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Supervisor | Interviewed regarding post-dialysis nursing responsibilities | |
| Interim Director of Nursing (DON) | Interviewed regarding post-dialysis nursing responsibilities and documentation | |
| Quality Assurance (QA)/Educational Nurse | Interviewed regarding post-dialysis nursing responsibilities and inservices | |
| Food Service Manager (FSM) | Interviewed regarding kitchen observations and food labeling |
Inspection Report
Routine
Census: 72
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
A standard survey was conducted from February 3, 2020 through February 6, 2020 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 complete post-dialysis assessments for one resident receiving dialysis and failure to label and date open food items in storage areas, potentially affecting 68 residents.
Deficiencies (2)
Failure to ensure post-dialysis assessments were completed for one resident receiving dialysis, including vital signs and dialysis site inspection.
Failure to ensure open items in dry storage and cooler were labeled and dated, affecting food safety.
Report Facts
Resident census: 72
Missing Dialysis Communication Forms: 15
Containers of spices: 30
Residents affected: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor | Interviewed regarding post-dialysis nursing responsibilities; stated lack of knowledge due to short tenure | |
| Interim Director of Nursing | Interviewed regarding post-dialysis nursing responsibilities and documentation requirements | |
| Quality Assurance/Educational Nurse | Interviewed regarding post-dialysis nursing responsibilities and lack of inservices | |
| Food Service Manager | Interviewed regarding unlabeled food items in kitchen; employed for two weeks |
Inspection Report
Life Safety
Capacity: 79
Deficiencies: 3
Date: Feb 5, 2020
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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including missing handrails on the front entry stairway, failure to separate combustible storage areas by required fire barriers, and improper storage of flammable liquids in the generator area.
Deficiencies (3)
No handrails provided on either side and within 44 inches of all portions of the front entry stairway at the main entrance.
Failed to ensure that areas storing combustible storage were separated by a one-hour fire barrier as required.
Over 10 gallons of Class II flammable liquids stored in the Nursing Home Generator area without required separation or approved flammable liquids cabinet.
Report Facts
Certified beds: 79
Flammable liquids quantity: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195336.
Complaint Details
Complaint GA00195336 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 18, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00194808.
Complaint Details
Complaint number GA00194808 was investigated and found to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 73
Deficiencies: 0
Date: Oct 11, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 12, 2018 standard survey.
Findings
All deficiencies cited in the prior survey were found to be corrected, and the facility was in compliance as of September 26, 2018.
Inspection Report
Routine
Census: 68
Deficiencies: 11
Date: Aug 12, 2018
Visit Reason
A standard survey was conducted at Warm Springs Medical Center Nursing Home from August 10, 2018 through August 12, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with health regulations, with deficiencies including failure to maintain resident dignity, inadequate resident rights notices, failure to post survey results, incomplete advance directives, unsafe and unclean environment, incomplete care plans, failure to implement restorative services, inadequate nutritional monitoring, failure to post nurse staffing information, failure to maintain proper food temperatures, and infection control issues related to improper storage of personal care items.
Deficiencies (11)
Facility failed to ensure resident dignity by pulling residents backwards in wheelchairs or Geri-chairs.
Facility failed to provide required notices and contact information for reporting abuse or neglect to residents.
Facility failed to post notice of availability of State survey results in a location accessible to residents and visitors.
Facility failed to obtain required physician signatures on POLST forms for Do Not Resuscitate orders for two residents.
Facility failed to maintain a safe, clean, and comfortable environment including leaks, odors, broken ceiling tiles, holes in walls, and dirty wheelchairs.
Facility failed to implement care plans related to pain medication monitoring, psychotropic medication dose reduction, behavior documentation, and restorative services for residents.
Facility failed to revise care plan to address actual weight loss for one resident.
Facility failed to ensure food items on steam table were held at proper temperatures.
Facility failed to store resident personal care items and specimen collection devices in a sanitary manner in multiple bathrooms.
Facility failed to post nurse staffing information in a prominent place accessible to residents and visitors.
Facility's consultant pharmacist failed to recommend gradual dose reduction for antidepressants and failed to ensure documentation of pain medication effectiveness and behavior monitoring.
Report Facts
Resident census: 68
Weight loss percentage: 12.5
Hydrocodone/APAP doses given: 17
Hydrocodone/APAP doses given: 15
Hydrocodone/APAP doses given: 13
Temperature: 133
Temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant CC | CNA | Named in finding for pulling residents backwards in wheelchairs |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including resident dignity, care plans, restorative services, and nurse staffing |
| Activities Director | Observed pulling wheelchair backwards and interviewed about abuse reporting | |
| Certified Nursing Assistant GG | CNA | Observed delivering meals and interviewed about resident meal assistance |
| Licensed Practical Nurse BB | LPN | Interviewed about medication documentation and behavior monitoring |
| Dietary Manager | Interviewed about nutritional monitoring and food temperature | |
| Cook DD | Observed food temperature checks and plating | |
| Licensed Practical Nurse EE | LPN | Interviewed about infection control concerns with urinal storage |
Inspection Report
Routine
Census: 68
Deficiencies: 4
Date: Aug 12, 2018
Visit Reason
The inspection was conducted as a routine regulatory survey of Warm Springs Medical Center Nursing Home to assess compliance with state and federal regulations regarding pharmacy management, medical and nursing care, infection control, restorative services, and environmental sanitation.
Findings
The facility was found deficient in multiple areas including failure of the consultant pharmacist to recommend gradual dose reduction for certain medications, inadequate monitoring and documentation of medication effectiveness and behaviors, failure to implement care plans for restorative services and therapy recommendations, unsanitary storage of resident personal care items, and poor environmental sanitation including dirty wheelchairs and maintenance issues such as leaks, holes, and odors.
Deficiencies (4)
Consultant pharmacist failed to recommend gradual dose reduction for antidepressants and failed to recognize/document irregularities in opioid pain medication use and behavior monitoring for a resident.
Facility failed to store resident personal care items and specimen collection devices in a sanitary manner in multiple bathrooms.
Facility failed to implement care plans related to monitoring pain medication effectiveness, psychotropic medication dosage reduction, and restorative services including walking and therapy recommendations.
Facility failed to maintain a safe, clean, and comfortable environment including issues with leaks, broken ceiling tiles, holes in walls, odors, and dirty wheelchairs.
Report Facts
Facility census: 68
Sample size: 42
Hydrocodone/APAP administrations: 17
Hydrocodone/APAP administrations: 15
Hydrocodone/APAP administrations: 13
Restorative service days: 5
Restorative service days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Verified lack of behavior and side effect monitoring and infection control concerns regarding urinal storage |
| Director of Nursing | Director of Nursing (DON) | Verified multiple deficiencies including lack of behavior monitoring, restorative services, and environmental sanitation issues |
| Certified Nursing Assistant II | CNA II | Reported on restorative walking services and wheelchair cleaning responsibilities |
| Environmental Aide JJ | Environmental Aide | Reported that CNAs are responsible for cleaning wheelchairs |
| Maintenance Worker | Maintenance Worker | Reported on facility maintenance issues including leaks, holes, and ceiling tile damage |
| Housekeeping Supervisor | Housekeeping Supervisor | Reported on cleaning schedules and confirmed environmental sanitation concerns |
Inspection Report
Life Safety
Census: 68
Capacity: 79
Deficiencies: 0
Date: Aug 10, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance.
Report Facts
Stories: 2
Construction Type: 2
Year Constructed: 1966
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 31, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00188548 and #GA00188571.
Complaint Details
Complaints #GA00188548 and #GA00188571 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 69
Deficiencies: 0
Date: Dec 28, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the October 24, 2017 Revisit Survey.
Findings
All deficiencies cited in the October 24, 2017 Revisit Survey were found to be corrected as of December 1, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 25, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 72
Capacity: 79
Deficiencies: 1
Date: Sep 5, 2017
Visit Reason
A 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 standards.
Findings
The facility was found not in substantial compliance due to failure to conduct sensitivity testing on smoke detectors, which could place all residents at risk in the event of fire.
Deficiencies (1)
Failure to conduct sensitivity testing on smoke detectors as required by NFPA 101 and NFPA 72 standards.
Report Facts
Census: 72
Certified beds: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding lack of sensitivity testing on smoke detectors |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 15, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00165784 to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00165784 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
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