Inspection Reports for Waycross Health and Rehabilitation
1910 DOROTHY STREET, GA, 31501
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 5, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The document contains an initial comment section but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Jun 5, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 20, 2025, 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
May 5, 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 5, 2025.
Inspection Report
Life Safety
Census: 69
Capacity: 92
Deficiencies: 1
Mar 21, 2025
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the Emergency Preparedness Program requirements.
Findings
The facility was found not in substantial compliance with fire safety requirements due to failure to ensure fire sprinkler heads were clear from dust accumulation, specifically in the restroom of Room C2. The Emergency Preparedness Program was found to be in substantial compliance.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure fire sprinkler heads were clear from dust accumulation in the restroom of Room C2. | SS= D |
Report Facts
Census: 69
Total Capacity: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of dust accumulation on fire sprinkler head during inspection |
Inspection Report
Routine
Deficiencies: 2
Mar 20, 2025
Visit Reason
A State Licensure survey was conducted at Waycross Health and Rehabilitation from March 25, 2025 through March 27, 2025 to assess compliance with state health regulations.
Findings
The survey identified deficiencies including failure to follow infection control procedures during wound care for one resident, and failure to assess a resident's ability to self-administer medications before leaving medications at the bedside.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staff followed infection control processes during wound care for one of 10 residents reviewed, risking cross-contamination. |
| Failure to assess one of 29 sampled residents for the ability to self-administer medications prior to leaving medications at the bedside, risking unsafe medication use. |
Report Facts
Residents reviewed for wound care: 10
Residents sampled for medication self-administration assessment: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed expectation that nurses sanitize hands when changing gloves during wound care and was unaware of medications at bedside for resident R48. |
| Certified Medication Aide AA | Certified Medication Aide | Unaware that resident R48 had medication at bedside. |
| Wound Care Nurse / Registered Nurse | Wound Care Nurse / Registered Nurse | Observed performing wound care without sanitizing hands between glove changes. |
Inspection Report
Routine
Census: 67
Deficiencies: 2
Mar 20, 2025
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from March 18, 2025, through March 20, 2025, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to assess a resident's ability to self-administer medication and failure to follow infection control procedures during wound care, potentially placing residents at risk.
Complaint Details
Complaint Intake Numbers GA00236828, GA00252825, GA00253989, GA00243569, GA00253938, GA00253774, GA00236399, and GA00234099 were investigated. Five complaints were unsubstantiated, and three were substantiated with no deficiencies cited.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to assess one resident (R48) for ability to self-administer medications prior to bedside medication storage, risking unsafe medication use. | Level D |
| Failed to ensure staff followed infection control processes during wound care for one resident (R38), risking infection due to cross-contamination. | Level D |
Report Facts
Residents sampled for medication self-administration assessment: 29
Residents reviewed for wound care: 10
Brief Interview for Mental Status (BIMS) score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Medication Aide (CMA) | Unaware that resident R48 had medication at bedside |
| Director of Nursing | Director of Nursing (DON) | Unaware that resident R48 had medications at bedside; confirmed hand hygiene expectations during wound care |
| Wound Care Nurse (WCN)/Registered Nurse (RN) | Wound Care Nurse/Registered Nurse | Performed wound care without sanitizing hands between glove changes |
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 22, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies on the provided page.
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 0
Feb 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 12/18/2022 Recertification Survey.
Findings
All deficiencies cited as a result of the 12/18/2022 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 27, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 54
Capacity: 92
Deficiencies: 4
Dec 19, 2022
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 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-functioning emergency lighting at the Therapy Den exit, failure to conduct annual fire alarm testing for 2022, sprinkler pipes obstructed by wires throughout the facility, and power strips not properly mounted off the floor in staff areas.
Severity Breakdown
Level D: 1
Level F: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Emergency lighting of at least 1-1/2-hour duration was not working correctly at the Therapy Den exit. | Level D |
| Annual fire alarm testing was not conducted for the year 2022. | Level F |
| Sprinkler pipes were obstructed by wires throughout the facility. | Level F |
| Power strips were not properly mounted off the floor in staff areas throughout the facility. | Level F |
Report Facts
Census: 54
Total Capacity: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Annual Inspection
Deficiencies: 1
Dec 18, 2022
Visit Reason
A State Licensure survey was conducted from December 16, 2022 through December 18, 2022 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to follow Physician's Orders for one of five residents reviewed for unnecessary medication administration, specifically for resident #44 regarding carvedilol medication given outside prescribed blood pressure parameters.
Deficiencies (1)
| Description |
|---|
| Failure to follow Physician's Orders for resident #44 by administering carvedilol outside of prescribed blood pressure parameters. |
Report Facts
Medication administration dates outside parameters: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Confirmed trainings were provided and reviewed EMAR confirming medication was administered outside order parameters. |
| HH | Director of Nursing (DON) | Reported unawareness of medication being administered outside order parameters until informed by pharmacist. |
Inspection Report
Routine
Census: 54
Deficiencies: 5
Dec 18, 2022
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from December 16, 2022 through December 18, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to obtain a physician's signature on a POLST form, failure to follow medication orders for one resident, serving soup at an unsafe temperature causing second degree burns to a resident, and failure to maintain sanitary conditions related to cross contamination in the laundry and hallways.
Severity Breakdown
D: 3
E: 1
G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to obtain a Physician's signature for a POLST for one resident. | D |
| Failure to follow care plan and medication orders related to antihypertensive medication administration for one resident. | D |
| Failure to follow Physician's Orders related to blood pressure medication resulting in unnecessary medication administration for one resident. | D |
| Failure to ensure soup was served at a safe temperature resulting in second degree burns to one resident. | G |
| Failure to maintain sanitary and clean conditions related to cross contamination in laundry and hallways. | E |
Report Facts
Resident census: 54
Medication administration dates: 25
Temperature of reheated soup: 160
Time to staff response: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in soup burn incident for serving soup and responding to call light |
| CNA DD | Certified Nursing Assistant | Named in soup burn incident for reheating soup |
| LPN FF | Licensed Practical Nurse | Reported resident's code status and lack of physician signature on POLST |
| Director of Nursing | Director of Nursing | Reported unawareness of medication administration outside order parameters and soup incident details |
| Resident Care Coordinator HH | Resident Care Coordinator | Reported on medication administration issue |
| Social Services | Social Services | Responsible for obtaining physician signature on POLST |
| Administrator | Administrator | Reported on POLST signature and expectations for food temperature checks |
| LPN AA | Licensed Practical Nurse | Confirmed medication administration outside order parameters and reheating food procedures |
| Laundry Aide II | Laundry Aide | Observed folding linens without hand sanitization |
| Housekeeper JJ | Housekeeper | Observed cross contamination in cleaning practices |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 10, 2022
Visit Reason
An abbreviated survey was conducted to investigate two complaints, #GA00222000 and #GA00225082.
Findings
Complaint #GA00222000 was found to be unsubstantiated, while complaint #GA00225082 was substantiated. No regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00222000 was unsubstantiated. Complaint #GA00225082 was substantiated.
Inspection Report
Deficiencies: 0
Oct 5, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Waycross Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 5, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey on 2021-08-05.
Findings
All deficiencies cited in the prior Recertification survey were found to be corrected, and the facility was in substantial compliance as of 2021-09-03.
Report Facts
Previous survey date: Aug 5, 2021
Substantial compliance date: Sep 3, 2021
Inspection Report
Renewal
Census: 44
Deficiencies: 0
Aug 5, 2021
Visit Reason
A licensure survey was conducted at Waycross Health and Rehabilitation from 8/3/2021 through 8/5/2021 to assess compliance with licensure requirements.
Findings
The survey revealed that the facility was in substantial compliance with regulatory requirements.
Inspection Report
Routine
Census: 44
Deficiencies: 1
Aug 5, 2021
Visit Reason
A standard survey was conducted at Waycross Health and Rehabilitation from 8/3/2021 through 8/5/2021 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to develop baseline care plans within 48 hours of admission for two residents (R#45 and R#295). The care plans did not address key diagnoses and allergies as required.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a baseline care plan within 48 hours of admission for two residents, with care plans missing key diagnoses and allergy information. | SS= D |
Report Facts
Resident census: 44
Number of residents with deficient baseline care plans: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Minimum Data Set (MDS) Coordinator | Stated that baseline care plans were not completed for R#45 and R#295 on admission and that she was responsible for their completion. | |
| Director of Health Services | Interviewed and revealed unfamiliarity with the baseline care plan process and policy. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 8, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00215543.
Findings
The complaint #GA00215543 was substantiated but no regulatory violations were cited.
Complaint Details
Complaint #GA00215543 was substantiated with no regulatory violations cited.
Inspection Report
Life Safety
Census: 45
Capacity: 92
Deficiencies: 0
Jul 6, 2021
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 substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program met regulatory standards.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 25, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00212299, #GA00212255, and #GA00212275.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were found during the survey.
Complaint Details
Complaints #GA00212299, #GA00212255, and #GA00212275 were investigated and found to be unsubstantiated with no regulatory violations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00211514.
Findings
The complaint investigation was concluded as unsubstantiated with no deficiencies noted in the report.
Complaint Details
Complaint GA00211514 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 13, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00201696, #GA00208267, and #GA00208679.
Findings
The investigation resumed on November 12, 2020 and concluded on November 13, 2020. The complaints were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints #GA00201696, #GA00208267, and #GA00208679 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 46
Deficiencies: 0
Oct 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 0
Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 29, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00206258.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint GA00206258 was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 57
Deficiencies: 0
Jul 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 7, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00201696.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 19, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA#00200815 related to dietary services, environmental services, and quality of care.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
The complaint related to dietary services, environmental services, and quality of care was investigated and found unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 29, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint allegations identified by codes GA00196124, GA00196768, GA00196994, GA00199268, and GA00199325.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaints were unsubstantiated and no deficiencies were cited.
Complaint Details
The complaints investigated during the survey were unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 6, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194488 regarding misappropriation of property.
Findings
The complaint for misappropriation of property was unsubstantiated.
Complaint Details
Complaint for misappropriation of property was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 0
Nov 6, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from September 4, 2018 through September 6, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 68
Capacity: 92
Deficiencies: 0
Sep 5, 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 to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance with Appendix Z requirements.
Report Facts
Certified beds: 92
Census: 68
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 6, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00185978.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00185978 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Dec 27, 2017
Visit Reason
A revisit survey visit was conducted to verify correction of deficiencies cited in the October 19, 2017 Standard Survey.
Findings
All deficiencies cited in the prior October 19, 2017 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 12, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 68
Capacity: 92
Deficiencies: 3
Oct 16, 2017
Visit Reason
The inspection 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) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically related to improper protection of cooking facilities and failure to conduct and document required fire drills. These deficiencies could place 68 residents at risk in the event of a fire.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The hood extinguishing system spray nozzles were not properly aimed at the deep-fat fryer. | SS= D |
| The deep-fat fryer did not maintain a minimum distance of 16 inches from fryer and surface flames from adjacent cooking equipment, nor was a steel or tempered glass baffle plate installed at a minimum of 8 inches in height between the fryer and surface flames of the adjacent appliance. | SS= D |
| Failure to conduct and properly document a fire drill during the 2nd shift of the 4th quarter of 2016. | SS= D |
Report Facts
Census: 68
Certified beds: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observation |
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