Inspection Reports for Westwood Healthcare and Rehabilitation
101 STOCKYARD ROAD, STATESBORO, GA, 30458
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found that all previously cited deficiencies from the May 4, 2025 survey were corrected. Prior inspections showed multiple deficiencies related mainly to environmental safety and sanitation, failure to implement resident care plans including behavioral health and oxygen administration, and life safety code violations such as non-working emergency lighting and blocked electrical panels. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in May 2025 tied to the cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent issues effectively, showing improvement from the May 2025 survey to the latest revisit.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
165% worse than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58 residents
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Westwood Healthcare and Rehabilitation, 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: 58
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/4/2025 Recertification Survey.
Findings
All deficiencies cited as a result of the 5/4/2025 Recertification Survey were found to be corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 20, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westwood Healthcare and Rehabilitation following a survey completed on June 20, 2025.
Findings
The document contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 4, 2025
Visit Reason
A State Licensure survey was conducted at Westwood Healthcare and Rehabilitation from May 2, 2025, through May 4, 2025, to assess compliance with state health regulations and facility policies.
Findings
The survey identified multiple deficiencies including failure to provide written bed hold notices for hospital transfers, failure to implement care plans for residents, failure to maintain a safe environment free of accident hazards, and failure to maintain a safe and sanitary environment in multiple rooms and shared bathrooms.
Deficiencies (4)
Failure to provide a written bed hold notice or reason for transfer to one of 25 sampled residents (R24) at the time of hospital transfer.
Failure to implement care plans for two residents (R306 and R13), including lack of behavioral health services and failure to administer oxygen as prescribed.
Failure to ensure an environment free of accident hazards for three residents (R21, R25, and R18), including water leaks in shared bathroom floors increasing fall risk.
Failure to maintain a safe and sanitary environment in nine rooms on two halls, including presence of dark substances around toilets, holes in walls, broken blinds, ceiling damage, and strong odors.
Report Facts
Sampled residents: 25
Residents with bed hold notice deficiency: 1
Residents with care plan deficiencies: 2
Residents at risk of accident hazards: 3
Rooms with environmental sanitation deficiencies: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Stated nursing staff did not provide written bed hold notices; administration responsible |
| EE | Registered Nurse (RN) | Confirmed Nurse Practitioner recommended behavioral health evaluation for R306 |
| Karen Mc | Mentioned in relation to care plan for R306 | |
| CC | Certified Nursing Assistant (CNA) | Verified residents R21, R25, and R18 were ambulatory and used shared bathroom |
Inspection Report
Routine
Census: 56
Deficiencies: 6
Date: May 4, 2025
Visit Reason
A standard survey was conducted from May 2 through May 4, 2025, including investigation of four complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Westwood Healthcare and Rehabilitation.
Complaint Details
Four complaints were investigated: GA00253181, GA002547314, GA00246648 were unsubstantiated with no deficiencies; complaint GA00254072 was substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to environmental safety and sanitation, failure to provide written bed hold notices, failure to implement care plans for residents, failure to ensure an environment free of accident hazards, failure to follow physician orders for oxygen administration, and failure to provide behavioral health services as recommended.
Deficiencies (6)
Facility failed to maintain a safe and sanitary environment in nine rooms on two halls, including dark substances around toilets, holes in ceilings, rusty door sills, and broken blinds.
Failed to provide written bed hold notice or reason for transfer for one resident (R24) at time of hospital transfer.
Failed to implement care plans for two residents (R306 and R13), including lack of behavioral health services and failure to administer oxygen as ordered.
Failed to ensure an environment free of accident hazards for three residents (R21, R25, R18), including water leaks on bathroom floor causing slip risk.
Failed to ensure oxygen administration per physician's order for one resident (R13), oxygen set at 2 LPM instead of 3 LPM.
Failed to ensure behavioral health services were provided to one resident (R306) as recommended by Nurse Practitioner.
Report Facts
Complaint Intake Numbers Investigated: 4
Residents Sampled: 25
Oxygen Order Rate: 3
Oxygen Observed Rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Stated nurses did not complete or issue bed hold notices; administration responsible |
| EE | Registered Nurse (RN) | Confirmed failure to arrange behavioral health services for R306 |
| AA | Licensed Practical Nurse (LPN) | Responsible for oxygen setting; admitted not checking oxygen rate as ordered |
| CC | Certified Nursing Assistant (CNA) | Verified residents R21, R25, and R18 used shared bathroom with water leak |
| Director of Nursing | Director of Nursing (DON) | Confirmed failures related to behavioral health services and oxygen administration |
| Administrator | Facility Administrator | Confirmed awareness of environmental issues and failures to provide behavioral health services |
| Social Worker | Social Worker | Confirmed no referral for behavioral health services for R306 |
Inspection Report
Life Safety
Census: 56
Capacity: 60
Deficiencies: 8
Date: May 3, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-working emergency lighting and exit signs, missing ceiling sections, improperly stacked storage near sprinklers, unsealed fire walls, open electrical junction boxes, missing light fixture globes, and blocked electrical panels.
Deficiencies (8)
Emergency lights were not working in the Medication Rooms and the Blue Hall.
Exit signs were not operational in the Laundry Room and at the end of Blue Hall.
Ceiling was missing in the Mechanical Room.
Storage was stacked too close to a sprinkler in the Rehab Area storage room.
Fire walls were not properly sealed; wires running through firewall without fire caulking on the Red Hall.
Open electrical junction box found in the front Information Technology (IT) room.
Light fixture missing a globe in the AC room.
Electrical panel was blocked in the laundry room.
Report Facts
Residents affected by emergency lighting deficiency: 20
Residents affected by exit signage deficiency: 15
Residents affected by ceiling deficiency: 25
Residents affected by storage stacking deficiency: 5
Residents affected by fire wall sealing deficiency: 20
Residents affected by open junction box deficiency: 10
Residents affected by missing light fixture globe: 5
Residents affected by blocked electrical panel: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 5/3/2025 |
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00239286, GA00235781, GA00245318, and GA00239280.
Complaint Details
Complaints GA00239286, GA00235781, and GA00245318 were unsubstantiated. Complaint GA00239280 was substantiated.
Findings
Complaints GA00239286, GA00235781, and GA00245318 were unsubstantiated. Complaint GA00239280 was substantiated. No deficiencies were cited related to any of the complaints.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 12, 2023
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
Plan of Correction
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westwood Healthcare and Rehabilitation following a survey completed on June 13, 2023.
Findings
The document does not contain any detailed deficiencies or findings; it appears to be a cover sheet or summary page without specific findings listed.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 2, 2023 recertification survey.
Findings
All deficiencies cited in the prior April 2, 2023 recertification survey were found to be corrected during the June 13, 2023 revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies related to Life Safety Code compliance at Westwood Healthcare and Rehabilitation.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements due to patient room doors in rooms 114 and 117 failing to latch properly when closed, as confirmed by observation and staff interview.
Deficiencies (1)
Patient room doors in rooms 114 and 117 did not latch properly when closed and could be pushed open.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings regarding door latch failures during the survey. |
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 5
Date: Apr 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 NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety code requirements, including overdue sprinkler system inspection, patient room doors not latching properly, lack of fire drill documentation, missing annual door inspection records, and improperly mounted power strips in administrative offices.
Deficiencies (5)
Sprinkler system 5 Year internal inspection overdue, indicated by yellow tag.
Patient room doors not latching properly when closed in two building wings.
Failure to properly document required fire drills for the last 12 months.
Failure to properly document annual inspection and maintenance of fire doors throughout the facility.
Power strips/surge protectors laying on floors in multiple administrative offices instead of being properly mounted.
Report Facts
Census: 53
Total Capacity: 60
Deficiency count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 2, 2023
Visit Reason
A State Licensure survey was conducted from 3/31/2023 through 4/2/2023 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for three of five sampled residents reviewed for immunizations. Documentation and interviews confirmed no evidence of vaccines being offered or given to residents #11, #6, and #50.
Deficiencies (1)
Facility failed to provide evidence that residents were offered the Influenza and/or Pneumococcal vaccine for three residents (R#11, R#6, and R#50) of five sampled residents reviewed for immunizations.
Report Facts
Number of residents sampled for immunizations: 5
Number of residents with vaccine offering deficiencies: 3
BIMS scores: 0
BIMS scores: 3
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant | Interviewed on 4/2/2023 regarding lack of immunization documentation. | |
| Director of Nursing | Interviewed on 4/2/2023 regarding responsibility of Infection Control Preventionist for vaccine consent and administration. |
Inspection Report
Routine
Census: 52
Deficiencies: 3
Date: Apr 2, 2023
Visit Reason
A standard survey was conducted from 3/31/2023 through 4/2/2023 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with infection prevention and control requirements, including failure to maintain effective infection control documentation and procedures to prevent Legionella growth. Additionally, the facility failed to provide evidence that residents were offered influenza, pneumococcal, and COVID-19 vaccines, with missing documentation for three sampled residents.
Deficiencies (3)
Failure to maintain an effective infection prevention and control program including lack of infection control documentation and procedures to reduce Legionella risk.
Failure to provide evidence that three residents were offered influenza and/or pneumococcal vaccines.
Failure to ensure three residents were offered, received, and had documentation related to COVID-19 vaccination.
Report Facts
Resident census: 52
Sampled residents for immunizations: 5
Residents with missing vaccine offer documentation: 3
COVID-19 Staff Vaccination rate: 100
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00229693.
Complaint Details
Complaint #GA00229693 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Westwood Healthcare and Rehabilitation following a survey completed on December 1, 2022.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 51
Deficiencies: 0
Date: Dec 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey conducted from 2022-09-21 through 2022-09-23.
Complaint Details
The revisit survey was conducted following a complaint survey from 2022-09-21 through 2022-09-23. All cited deficiencies were corrected.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Sep 23, 2022
Visit Reason
A Licensure Survey was conducted from 09/21/22 through 09/23/22 to assess compliance with facility policies and regulatory requirements for licensure.
Findings
The facility failed to follow its policy requiring two staff members for mechanical lift transfers, resulting in one resident being transferred with only one staff member present, increasing the risk of injury. Staff were re-educated on the policy following the observation.
Deficiencies (1)
Failure to follow policy for resident safety with mechanical lift transfers, transferring one resident with only one staff member instead of two.
Report Facts
Residents in sample: 10
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | Charge Nurse | Interviewed regarding facility policy on lift transfers |
| Director of Nursing | Director of Nursing | Confirmed policy noncompliance and re-education of staff |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Sep 23, 2022
Visit Reason
A complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health from 9/21/22 through 9/23/22 to assess compliance with 42 CFR subpart B.
Complaint Details
The complaint survey was triggered by multiple complaint intakes (#GA00217902, #GA00219142, #GA00220157, #GA00220509, #GA00221326, #GA00222764). No deficiencies were issued related to these complaint intakes, but deficiencies were found related to discharge summaries and resident safety.
Findings
The facility was found not to be in substantial compliance with discharge summary requirements for two residents who left unexpectedly without formal discharge planning, and failed to follow policy for mechanical lift transfers, resulting in increased risk of injury for one resident.
Deficiencies (2)
Failure to provide a discharge summary recapitulating the residents' stay upon discharge for two residents.
Failure to follow facility policy for resident safety with mechanical lift transfers, transferring one resident with only one staff member present.
Report Facts
Facility census: 54
Sample size: 10
Residents with discharge summary deficiency: 2
Residents affected by lift transfer deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed no discharge summaries for residents R2 and R5 due to unexpected departures and re-educated staff on two-person mechanical lift transfers |
| Corporate Clinical Supervisor | Corporate Clinical Supervisor (CCS) | Confirmed no discharge summaries for residents R2 and R5 due to unexpected departures |
| Licensed Practical Nurse 3 | Charge Nurse Licensed Practical Nurse (LPN) 3 | Stated expectation and facility policy was to always have two staff for mechanical lift transfers |
| Certified Nurse Aid 1 | Certified Nurse Aid (CNA) 1 | Observed transferring resident R1 alone with mechanical lift, violating facility policy |
| Social Services staff | Acting Social Services (SS) staff | Confirmed events related to resident R2's behaviors and discharge circumstances |
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day reporting period from 07/25/2022 to 07/31/2022, 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 seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Jul 25, 2022
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 failed to report complete COVID-19 data to the CDC's NHSN between 07/18/2022 and 07/24/2022 as required, 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 seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 07/11/2022 to 07/17/2022 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
Deficiencies: 0
Date: Nov 1, 2021
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 and a summary statement of deficiencies identified during the inspection.
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 0
Date: Nov 1, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 8/26/21 Recertification Survey.
Findings
All deficiencies cited as a result of the 8/26/21 Recertification Survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Sep 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Westwood Healthcare and Rehabilitation following a survey completed on 09/08/2021.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 0
Date: Sep 8, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 7/13/2021 Complaint Survey.
Findings
All deficiencies cited as a result of the 7/13/2021 Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Aug 26, 2021
Visit Reason
The inspection was a standard survey conducted from 8/24/21 through 8/26/21, which included investigation of two complaint intakes (GA00216664 and GA00216802).
Complaint Details
The visit included investigation of Complaint Intake Numbers GA00216664 and GA00216802.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to honor resident self-determination regarding shower schedules, unsafe and unclean environment conditions in multiple resident rooms, failure to follow a resident's respiratory care plan for oxygen administration, inadequate infection prevention and control practices including lack of PPE for isolation precautions, and lack of a qualified infection preventionist.
Deficiencies (5)
Failed to allow one resident (R#31) the choice of when to take a shower and failed to facilitate that choice in the bathing schedule.
Failed to maintain a safe, clean, comfortable, and homelike environment as evidenced by stained privacy curtains, overbed lighting not properly affixed, large brown stains on floors, holes in closet doors, missing bathroom tiles, cracked trash cans, and protruding metal in bathroom door frames in 12 resident rooms.
Failed to follow the respiratory care plan for one resident (R#27) requiring continuous oxygen; oxygen concentrator was set at 1.5 lpm instead of the ordered 3 lpm.
Failed to ensure infection prevention and control practices were followed, including lack of PPE for staff caring for a resident on observation isolation and improper PPE use during meal service on the COVID isolation unit.
Failed to designate a qualified infection preventionist with specialized training in infection prevention and control; current ADON was not certified and infection control program oversight was unclear.
Report Facts
Resident census: 49
Number of resident rooms with environmental concerns: 12
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 1.5
Number of residents on COVID isolation unit: 4
Total facility census: 49
Inspection Report
Renewal
Census: 49
Deficiencies: 3
Date: Aug 24, 2021
Visit Reason
A Licensure Survey was conducted from 8/24/21 through 8/26/21 to assess compliance with licensure requirements.
Findings
The facility failed to ensure proper infection control practices, including lack of PPE for staff caring for residents on isolation and improper PPE use during meal service on the COVID unit. Additionally, the facility did not follow the respiratory care plan for one resident requiring continuous oxygen and had multiple environmental sanitation deficiencies including stained privacy curtains, damaged fixtures, and unclean areas in 12 resident rooms.
Deficiencies (3)
Failure to provide Personal Protective Equipment (PPE) for staff caring for a resident on observation isolation and failure to ensure infection control practices during meal service on the COVID isolation unit.
Failure to follow the respiratory care plan for one resident requiring continuous oxygen therapy; oxygen concentrator was set below the prescribed level.
Environmental sanitation deficiencies including stained privacy curtains, overbed lighting not properly affixed, large brown stains on floors, holes in closet doors, missing bathroom tiles, cracked trash can, and protruding metal in shared bathroom door frame observed in 12 resident rooms.
Report Facts
Residents on Blue Hall affected by deficient infection control practice: 19
Total census: 49
Residents in COVID isolation rooms: 4
Oxygen flow rate ordered: 3
Oxygen flow rate observed: 1.5
Resident rooms with environmental deficiencies: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed lack of PPE supplies for resident in room 104. |
| DD | Certified Nursing Assistant (CNA) | Reported no PPE training from facility and described PPE use for resident in room 104. |
| FF | Certified Nursing Assistant (CNA) | Expressed concern about lack of full PPE while caring for resident in room 104. |
| GG | Corporate Nurse Consultant | Oversaw infection control after resignation of facility's infection control nurse. |
| EE | Certified Nursing Assistant (CNA) | Described PPE use during meal tray distribution on COVID unit. |
| HH | Licensed Practical Nurse (LPN) | Confirmed full PPE required on COVID unit but was not worn during tray distribution. |
| DON | Director of Nursing | Confirmed expectation for PPE availability and adherence to care plans. |
| ADON | Assistant Director of Nursing | Reported contact with Department of Public Health for new positive COVID cases and staffing changes. |
| Environmental Services Director | Confirmed environmental sanitation issues and described housekeeping cleaning procedures. | |
| Maintenance Director | Described maintenance procedures and work order system. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 10, 2021
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
Renewal
Deficiencies: 2
Date: Jul 13, 2021
Visit Reason
A Licensure Survey was conducted from 7/12/2021 through 7/13/2021 to assess compliance with licensure requirements.
Findings
The facility failed to notify a resident's representative of a fall with injury and failed to document skin assessments, weekly wound measurements, and treatment administration for two residents with pressure ulcers.
Deficiencies (2)
Failure to notify the resident's representative of a fall with injury for one resident.
Failure to document skin assessments, weekly wound measurements, and treatment administration for two residents with pressure ulcers.
Report Facts
Pressure ulcer measurement: 7
Dates with missing wound treatment documentation: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Wound Care Nurse | Provided wound tracking worksheet and interviewed regarding wound assessments and documentation gaps |
| Director of Nursing | Confirmed failure to notify family of resident's fall and lack of treatment administration records | |
| Administrator | Confirmed family was not notified of resident's fall |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Date: Jul 13, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate two complaints, GA00215500 and GA00215015. Complaint GA00215500 was unsubstantiated, while complaint GA00215015 was substantiated with deficiencies.
Complaint Details
Complaint GA00215500 was unsubstantiated. Complaint GA00215015 was substantiated with deficiencies related to notification of falls, neurological assessments, and wound care documentation.
Findings
The facility failed to notify a resident's representative of a fall with injury, failed to complete neurological assessments following two falls for the same resident, and failed to document skin assessments, weekly wound measurements, and treatment administration for two residents with pressure ulcers.
Deficiencies (3)
Failure to notify resident's representative of a fall with injury.
Failure to complete neurological assessments following two falls for one resident.
Failure to document skin assessments, weekly wound measurements, and treatment administration for two residents with pressure ulcers.
Report Facts
Resident census: 52
Pressure ulcer measurement: 7
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Wound Care Nurse | Named in relation to wound care deficiencies and documentation issues |
Inspection Report
Life Safety
Census: 53
Capacity: 60
Deficiencies: 1
Date: Jul 7, 2021
Visit Reason
The visit was a Life Safety Code Survey 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 due to failure to properly seal penetrations in fire/smoke walls with approved products, affecting two smoke compartments.
Deficiencies (1)
Facility failed to properly seal penetrations in fire/smoke walls with approved product, affecting 2 smoke compartments.
Report Facts
Census: 53
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unsealed penetrations in smoke walls during tour |
Inspection Report
Abbreviated Survey
Census: 45
Deficiencies: 0
Date: Jan 27, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211485.
Complaint Details
Complaint #GA00211485 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 34
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 9/24/2020 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 9/24/2020; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 9/24/2020 Complaint Survey were found to be corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
This document is a statement of deficiencies and plan of correction following an inspection survey completed on 12/10/2020 at Westwood Healthcare and Rehabilitation.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Abbreviated Survey
Census: 29
Deficiencies: 10
Date: Oct 15, 2020
Visit Reason
An Abbreviated Survey was conducted to verify the removal of the Immediate Jeopardy identified during a prior survey related to pressure ulcer care and treatment.
Findings
The facility failed to provide timely and adequate treatment and assessments for residents with pressure ulcers, failed to notify physicians timely of wound infections, and failed to maintain proper oversight of wound care and skin assessments. The facility also failed to ensure safe environment related to equipment repair and water temperature monitoring, failed to comply with transfer and discharge requirements, failed to notify legal guardians of hospital transfers, failed to ensure resident return after hospitalization, failed to maintain RN coverage for required hours, and failed to properly reconcile narcotic medications.
Deficiencies (10)
Failure to provide adequate wound care and skin assessments for residents with pressure ulcers, including failure to perform treatments as ordered and notify physicians timely.
Failure to ensure safe environment related to broken shower bed rail and lack of water temperature monitoring.
Failure to comply with transfer and discharge requirements, including failure to provide 30-day notice and failure to allow resident to return after hospitalization.
Failure to notify legal guardian of resident hospital transfer.
Failure to provide RN coverage for 8 hours per day on multiple dates.
Failure to properly reconcile narcotic medications on medication carts.
Failure of facility administration to provide adequate oversight and monitoring of wound care program and skin integrity.
Failure to ensure licensed nurse maintained active license while employed.
Failure to maintain effective quality assurance program to identify and correct deficiencies in skin integrity and wound care.
Failure to assess and provide supervision to prevent elopement for a resident with high risk for wandering.
Report Facts
Resident census: 29
Dates without RN coverage: 6
Nurses educated on skin integrity: 11
Nursing assistants educated on skin integrity: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | Employed with expired license from 3/31/2019 until termination on 6/11/2019 |
| RN GG | Wound Nurse | Observed wound care and participated in audits and education |
| Executive Director | Responsible for oversight of wound care program and QAPI process | |
| Regional Nurse Consultant | Interim Director of Nursing | Responsible for DON duties and wound care audits |
| Administrator | Responsible for facility operations and maintenance oversight | |
| CNA NN | Certified Nursing Assistant | Reported shower bed rail issue and elopement observations |
| LPN BB | Licensed Practical Nurse | Reported resident elopements and medication count procedures |
Inspection Report
Licensure Survey
Census: 29
Deficiencies: 7
Date: Oct 15, 2020
Visit Reason
Licensure Survey initiated from 2/26/2020 through 3/16/2020, continued on 8/3/2020 and concluded on 9/24/2020 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to comply with transfer and discharge regulations, failure to maintain active nursing licenses, inadequate narcotic medication reconciliation, ineffective pressure ulcer management and wound care, safety hazards with equipment, failure to monitor water temperatures, and incomplete employee health screenings.
Deficiencies (7)
Failure to comply with requirements for involuntary discharge and refusal to allow resident to return after hospital transfer.
Failure to ensure licensed nurse maintained an active license while employed.
Failure to ensure narcotic medications were reconciled and properly signed off each shift.
Failure to have an effective pressure ulcer recognition and management program including consistent weekly skin assessments, wound treatment as ordered, timely physician notification, and infection control.
Failure to ensure resident equipment was in good repair; shower bed rail did not lock.
Failure to ensure hot water temperatures were monitored and documented.
Failure to provide evidence of annual tuberculosis screening for employees.
Report Facts
Facility census: 29
Number of licensed nurse files reviewed: 7
Number of medication carts reviewed: 2
Number of residents reviewed for pressure ulcers: 10
Number of staff files reviewed for TB screening: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | Named in license expiration deficiency |
| Administrator | Named in refusal to allow resident return after hospital transfer | |
| LPN UU | Licensed Practical Nurse | Named in wound care treatment observation and infection control deficiency |
| Interim Director of Nursing (DON) EE | Interim Director of Nursing | Named in narcotic reconciliation and wound care deficiencies |
| Regional Nurse Consultant (RNC) | Regional Nurse Consultant/Interim DON | Named in wound care deficiencies |
| LPN AA | Licensed Practical Nurse | Named in wound care and wound physician communication deficiencies |
| LPN BB | Licensed Practical Nurse | Named in wound care and wound physician communication deficiencies |
| CNA NN | Certified Nursing Assistant | Named in equipment safety deficiency |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 6
Date: Sep 24, 2020
Visit Reason
An Abbreviated/Partial Extended Survey investigating multiple complaints was conducted from 2/26/20 through 9/24/20, including allegations of pressure ulcer care deficiencies, wound infections, and elopement.
Complaint Details
The survey was initiated due to multiple complaints alleging inadequate pressure ulcer care, wound infections, and resident elopement. Some complaints were substantiated with deficiencies, others were unsubstantiated or partially substantiated.
Findings
The facility was found to have Immediate Jeopardy level noncompliance related to failure to provide adequate pressure ulcer care, including lack of timely wound assessments, treatments, and infection management, failure to notify physicians timely, failure to prevent resident elopement, and failure to maintain adequate RN coverage and medication security. The facility also failed to maintain an effective QAPI program to address these issues.
Deficiencies (6)
Failure to provide timely and adequate wound care and assessments for residents with pressure ulcers, including failure to administer treatments as ordered, failure to obtain wound cultures, and failure to notify physicians of wound infections.
Failure to prevent elopement of a cognitively impaired resident who exited the facility unsupervised multiple times, including one incident requiring police involvement.
Failure to ensure RN coverage for at least 8 hours per day on multiple days in July and August 2020.
Failure to reconcile narcotic medications properly on two medication carts, with missing counts and signatures.
Failure to ensure licensed nursing staff maintained active licensure.
Failure of facility administration to provide effective oversight and monitoring of the skin integrity program and QAPI activities related to pressure ulcers.
Report Facts
Facility census: 29
Days without RN coverage: 6
Pressure ulcer measurements: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to Immediate Jeopardy notification and oversight failures | |
| Minimum Data Set (MDS) Coordinator | Named in relation to Immediate Jeopardy notification and care plan development | |
| Licensed Practical Nurse (LPN) AA | Named in relation to wound care failures and communication | |
| Licensed Practical Nurse (LPN) UU | Named in relation to wound care and treatment cart issues | |
| Regional Nurse Consultant / Interim Director of Nursing | Named in relation to wound care oversight and RN coverage | |
| Medical Director | Named in relation to wound care oversight and facility issues | |
| Human Resources | Named in relation to license monitoring |
Inspection Report
Licensure Survey
Census: 29
Deficiencies: 6
Date: Sep 24, 2020
Visit Reason
Licensure Survey initiated on 2/26/2020 through 3/16/2020, continued on 8/3/2020 and concluded on 9/24/2020 to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to comply with transfer and discharge regulations, failure to maintain active nursing licenses, inadequate narcotic medication reconciliation, ineffective pressure ulcer management, safety hazards with resident equipment, and incomplete employee health screenings.
Deficiencies (6)
Failure to comply with requirements for involuntary discharge and refusal to allow resident to return after hospital visit.
Failure to ensure a licensed nurse maintained an active license while employed.
Failure to ensure narcotic medications were reconciled and properly signed off each shift.
Failure to provide effective pressure ulcer recognition and management including consistent weekly skin assessments, wound treatments, infection control, and timely physician notification.
Failure to ensure resident equipment was in good repair; shower bed rail did not lock and hot water temperatures were not monitored.
Failure to provide evidence of annual tuberculosis screening for multiple staff members.
Report Facts
Facility census: 29
Number of licensed nurse files reviewed: 7
Number of staff files missing TB screening: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | License expired on 3/31/2019 but employed until 6/11/2019 |
| Administrator | Involved in refusal to allow resident R#26 to return to facility after hospital visit | |
| LPN UU | Licensed Practical Nurse | Provided wound treatment observed with infection control failures |
| LPN AA | Licensed Practical Nurse | Interviewed regarding wound care and narcotic medication reconciliation |
| LPN CC | Licensed Practical Nurse | Interviewed regarding maintenance issues and wound care |
| CNA NN | Certified Nursing Assistant | Reported shower bed rail not locking and maintenance issues |
| Interim Director of Nursing | Director of Nursing | Interviewed regarding narcotic medication reconciliation and TB screening |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 7/1/2020 COVID-19 Infection Control Survey.
Findings
All deficiencies cited as a result of the 7/1/2020 COVID-19 Infection Control Survey were found to be corrected during the revisit survey.
Inspection Report
Routine
Census: 34
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on July 30-31, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and infection control. No deficiencies were cited during this survey.
Inspection Report
Routine
Census: 39
Deficiencies: 1
Date: Jul 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility failed to consistently follow its policy for daily monitoring of resident temperatures and completing respiratory assessments for residents with temperatures between 99 and 99.9 degrees Fahrenheit. This failure affected four of five sampled residents and increased the risk of unidentified COVID-19 infections and virus spread within the facility.
Deficiencies (1)
Failure to follow policy for daily monitoring of temperatures and completing respiratory assessments for residents with temperatures between 99 and 99.9 degrees Fahrenheit.
Report Facts
Census: 39
Residents affected: 4
Temperature range: 99
Temperature range: 99.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding expectations for temperature monitoring and respiratory assessments | |
| Licensed Practical Nurse (LPN) AA | Interviewed regarding resident monitoring and documentation practices | |
| Licensed Practical Nurse (LPN) BB | Interviewed regarding resident monitoring and documentation practices | |
| Administrator | Interviewed regarding policy adherence and review of monitoring documentation |
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