Inspection Reports for
Woodstock Nursing & Rehab Ctr
105 ARNOLD MILL ROAD, WOODSTOCK, GA, 30188
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
3.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
131 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
A Federal Health Complaint Comparative Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 11, 2025, to investigate Complaint Intake Number GA00254855.
Complaint Details
Complaint Intake Number GA00254855 was investigated and found not substantiated, with no deficient practice identified.
Findings
The facility was found in compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities. The complaint investigation did not result in any deficient practice.
Inspection Report
Abbreviated Survey
Census: 133
Deficiencies: 0
Date: May 6, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00254855.
Complaint Details
Complaint GA00254855 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 146
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaints GA00254003, GA00251382, GA00252649, GA00253305, GA00253335, GA00253336, GA00253607, GA00253842, GA00253895, GA00253928, and GA00253955 were investigated and found to be unsubstantiated.
Findings
All complaints investigated during the survey were found to be unsubstantiated, and no deficiencies were cited related to the complaints.
Inspection Report
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Woodstock Nursing & Rehab Center following a survey completed on July 16, 2024.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the May 16, 2024, recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 16, 2024
Visit Reason
A State Licensure survey was conducted at Woodstock Nursing & Rehabilitation Center from May 15, 2024, through May 17, 2024, to assess compliance with state health regulations.
Findings
The survey identified deficiencies including unsecured medication carts left unattended, improper infection control practices during medication administration, and failure to provide adequate activities of daily living such as showers for one resident.
Deficiencies (3)
Facility failed to safely secure resident medications; two of six medication carts were left unlocked and unattended.
Failure to properly perform infection control practices during medication administration, including not disinfecting blood pressure cuff between uses and handling medication with ungloved hands.
Failure to provide activities of daily living (showers/baths) for one resident dependent on staff assistance.
Report Facts
Medication carts observed unlocked: 2
Residents sampled: 50
Dates showers given to resident R35: Showers documented on 3/7/2024, 3/20/2024, 3/24/2024, 4/10/2024, and 4/29/2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN QQ | Registered Nurse | Left medication cart unlocked and explained key access |
| LPN NN | Licensed Practical Nurse | Confirmed medication cart was not supposed to be left unlocked |
| LPN FF | Licensed Practical Nurse | Observed failing to disinfect blood pressure cuff and handling medication with bare hands |
| LPN PP | Licensed Practical Nurse | Observed handling medication with bare hands during administration |
| Director of Nursing | Director of Nursing | Provided statements on medication cart security and infection control expectations |
Inspection Report
Routine
Census: 120
Deficiencies: 6
Date: May 16, 2024
Visit Reason
A standard survey was conducted from 5/13/2024 through 5/16/2024, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Multiple complaint intake numbers were investigated; some were unsubstantiated, some substantiated without deficiencies, and others substantiated with deficiencies related to abuse and care.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies related to resident abuse, ADL care, respiratory care, medication administration errors, medication storage, and infection control practices.
Deficiencies (6)
Failed to protect residents from sexual abuse by other residents.
Failed to provide adequate activities of daily living care related to showers/baths for one resident.
Failed to follow physician orders related to oxygen liter flow for one resident.
Medication administration error rate exceeded 5 percent, with errors observed in medication preparation and administration.
Failed to safely secure resident medications; medication carts were left unlocked and unattended.
Failed to properly perform infection control practices during medication administration, including failure to disinfect blood pressure cuff between uses and handling medication with ungloved hands.
Report Facts
Resident census: 120
Medication administration error rate: 6.45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Interviewed regarding abuse reporting and education |
| RN BB | Registered Nurse / Unit Manager | Interviewed regarding abuse reporting and oxygen therapy |
| LPN AA | Licensed Practical Nurse | Interviewed regarding oxygen therapy |
| LPN PP | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors |
| RN QQ | Registered Nurse | Observed leaving medication cart unlocked |
| LPN NN | Licensed Practical Nurse | Observed leaving medication cart unlocked |
| LPN FF | Licensed Practical Nurse | Observed failing to disinfect blood pressure cuff and handling medication with bare hands |
| Director of Nursing | Director of Nursing | Interviewed regarding medication errors, abuse reporting, medication cart security, and infection control |
Inspection Report
Life Safety
Census: 118
Capacity: 171
Deficiencies: 1
Date: May 14, 2024
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 due to failure to properly secure empty oxygen cylinders in an approved outside enclosure, posing a risk to staff and surrounding personnel.
Deficiencies (1)
Failed to properly secure empty oxygen cylinders in an outside approved enclosure.
Report Facts
Census: 118
Total Capacity: 171
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of improper oxygen cylinder storage during tour |
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Date: Jan 27, 2023
Visit Reason
A Focused Infection Control Survey in conjunction with an Abbreviated Survey was conducted to investigate multiple complaints at Woodstock Nursing and Rehab Center from January 24, 2023 through January 27, 2023.
Complaint Details
The complaints #GA002230870, #GA00230202, #GA00226124, #GA00224976, and #GA00224664 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior licensure survey.
Findings
All deficiencies cited as a result of the licensure survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the extended recertification survey on 2022-05-04.
Findings
All deficiencies cited in the previous extended recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 28, 2022
Visit Reason
A desk review was conducted by the Life Safety Surveyor to verify correction of previous citations.
Findings
Documentation showed all previous citations had been corrected; no new deficiencies were noted.
Inspection Report
Renewal
Deficiencies: 2
Date: May 4, 2022
Visit Reason
The inspection was a Licensure Survey conducted from April 27, 2022 through May 4, 2022, to assess compliance with professional standards and regulatory requirements for Woodstock Nursing & Rehab Center.
Findings
The facility was found noncompliant due to failure to conduct an Interdisciplinary Team meeting regarding resident safety and failure to initiate neurological checks after an unwitnessed fall, resulting in an Immediate Jeopardy situation that was removed on May 3, 2022. Additionally, the facility failed to maintain an effective infection prevention and control program with missing surveillance data for several months.
Deficiencies (2)
Failure to conduct an Interdisciplinary Team meeting including Psychiatrist and Medical Director related to resident safety and failure to initiate neurological checks after an unwitnessed fall resulting in resident harm and death.
Failure to maintain an effective infection prevention and control program with missing surveillance data for November 2021, December 2021, and March 2022.
Report Facts
Sample size: 37
Licensed nurses educated: 28
Licensed nurses not educated: 2
Contract licensed nurses educated: 12
Unwitnessed fall incidents reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in failure to initiate neuro checks after resident fall and noted as terminated by previous employer |
| Administrator BB | Previous Administrator | Involved in decision to move resident out of Memory Unit without full interdisciplinary input |
| Administrator KK | Current Administrator | Reported lack of policy for Memory Care Unit moves and involvement in IDT meetings |
| Psychiatrist | Consulted on resident #68 but not always notified of moves or behaviors; favored IDT involvement | |
| Director of Nursing | DON | Acting Infection Prevention and Control Nurse; involved in neuro-checks education and infection control oversight |
| Social Worker EE | Social Worker | Responsible for appointments and bed changes; involved in discussions about resident moves |
| Social Worker FF | Social Worker | Expressed concerns about moving resident out of Memory Unit; involved in IDT meetings |
| Nurse Practitioner DD | Nurse Practitioner | Not consulted about resident move out of Memory Unit; stated moves should be discussed |
| Medical Director | Not aware of resident move out of Memory Unit; stated decision should be left to Psychiatrist |
Inspection Report
Routine
Census: 117
Capacity: 171
Deficiencies: 1
Date: Apr 27, 2022
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Program for compliance with federal regulations, specifically 42 CFR 483.73.
Findings
The facility's Emergency Preparedness Program was found not to be in substantial compliance because there was no documentation that the emergency preparedness plan had been updated within the last twelve months. However, the facility was found in compliance with Life Safety Code requirements.
Deficiencies (1)
No documentation available that the emergency preparedness plan includes an annual update within the last twelve months.
Report Facts
Census: 117
Total Capacity: 171
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Date: Oct 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints.
Complaint Details
Multiple complaints were investigated; all but one complaint (#GA00212134) were unsubstantiated. Complaint #GA00212134 was substantiated but no regulatory violations were cited.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. Most complaints were unsubstantiated, and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Census: 129
Deficiencies: 0
Date: Jun 2, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00214218 from May 5, 2021 to June 2, 2021.
Complaint Details
Complaint #GA00214218 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Report Facts
Resident census: 129
Inspection Report
Routine
Deficiencies: 0
Date: Dec 22, 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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Date: Dec 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from December 1 through December 4, 2020, including investigation of multiple complaint intake numbers related to infection control and COVID-19 preparedness.
Complaint Details
Multiple complaints (GA00201952, GA00207837, GA00205354, GA00203181, GA00207655, GA00209305, GA00205509) were investigated and found unsubstantiated. Complaint GA00206113 was substantiated with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations, with most complaints unsubstantiated and one complaint substantiated with no deficiencies. The facility implemented CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Re-Inspection
Census: 140
Deficiencies: 0
Date: Nov 30, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 28, 2020 Complaint Survey.
Findings
All deficiencies cited as a result of the September 28, 2020 Complaint Survey were found to be corrected.
Inspection Report
Deficiencies: 1
Date: Sep 28, 2020
Visit Reason
The inspection was conducted to evaluate compliance with nursing care requirements, specifically regarding the revision of care plans related to smoking privileges for residents.
Findings
The facility failed to revise the care plans for two residents who were grandfathered in to smoke, resulting in care plans that did not reflect new smoking limits or allowances. Care plan interventions remained outdated despite updated goals.
Deficiencies (1)
Failure to revise care plans related to smoking to reflect new limits or allowances for two residents permitted to smoke during their stay.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Work Assistant | Interviewed regarding smoking care plans and screening for residents #7 and #8. |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Sep 28, 2020
Visit Reason
An Abbreviated Survey was conducted to investigate multiple complaints against Woodstock Nursing & Rehab Center, initiated on 2020-03-30 and concluded on 2020-09-28 after an onsite visit between 2020-09-21 and 2020-09-28.
Complaint Details
The survey investigated complaints GA00200900, GA00201777, GA00203256, GA00204004, GA00204037, and GA00206219. All complaints except GA00204037 were unsubstantiated. For GA00204037, allegations related to Infection Control and Nursing Services were unsubstantiated, but the allegation related to Physical Environment was substantiated with deficiencies.
Findings
The survey found that most complaints were unsubstantiated except for one related to the Physical Environment. Deficiencies were identified related to failure to revise care plans for smoking residents and failure to assess safety risks for residents permitted to smoke under a 'grandfathered in' policy.
Deficiencies (2)
Failure to revise care plans related to smoking to reflect new limits or allowances for two residents permitted to smoke during their stay.
Failure to assess abilities, needs, and safety risks for two residents permitted to smoke under the 'grandfathered in' policy.
Report Facts
Complaint numbers investigated: 6
Dates of complaint investigation: Investigation initiated on 2020-03-30 and concluded on 2020-09-28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding resident smoking status and supervision |
| Assistant Director of Social Services | Assistant Director of Social Services | Interviewed regarding smoking policy and resident assessments |
| Administrator | Administrator | Interviewed regarding facility smoking policy and resident grandfathering |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Interviewed regarding resident smoking on premises |
| Director of Nursing | Director of Nursing | Interviewed regarding smoking policy and assessments |
| Social Work Assistant | Social Work Assistant | Interviewed regarding care plan updates and smoker screening |
Inspection Report
Routine
Census: 131
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 147
Deficiencies: 0
Date: Nov 18, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 9/18/19 Recertification Survey.
Findings
All deficiencies cited in the previous 9/18/19 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 4, 2019
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
Re-Inspection
Census: 136
Deficiencies: 0
Date: Sep 18, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/2/19 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 8/2/19; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 8/2/19 Complaint Survey were found to be corrected.
Inspection Report
Life Safety
Census: 137
Capacity: 171
Deficiencies: 4
Date: Sep 17, 2019
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, with deficiencies related to means of egress, exit door locking devices, emergency lighting, and fire alarm notification systems, potentially placing residents at risk in the event of a fire emergency.
Deficiencies (4)
Release devices for exit doors from the main dining area and physical therapy suite were installed approximately 66 inches above the floor, exceeding the required 34 to 48 inches.
Exit door locking devices were improperly installed and maintained; specifically, a pad lock was used on the exterior door from the memory care patio that could not be readily unlocked.
Emergency lighting was not provided in the large interior courtyard area and an emergency lighting unit failed to operate properly at the MSU exit discharge area; required annual 90-minute tests of emergency lighting units were not conducted.
Fire alarm system failed to provide proper audible and visual notification in the large interior courtyard and memory care patio areas.
Report Facts
Residents at risk: 82
Residents at risk: 38
Residents at risk: 137
Residents at risk: 95
Certified beds: 171
Census: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews. |
Inspection Report
Re-Inspection
Census: 137
Deficiencies: 0
Date: May 23, 2019
Visit Reason
An unannounced visit was made to the facility from 2019-05-20 through 2019-05-23 in conjunction with a revisit to investigate Complaint GA00196033 by a Registered Nurse.
Complaint Details
Visit was a revisit to investigate Complaint GA00196033.
Findings
No deficiencies were cited during this inspection.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 22, 2019
Visit Reason
A revisit survey was conducted from 5/20/19 through 5/23/19 to investigate complaint intake numbers GA00196033, GA00196396, and GA00196468 in conjunction with this revisit survey.
Complaint Details
Complaint Intake Numbers GA00196033 was substantiated with no deficiencies, GA00196468 was unsubstantiated, and GA00196396 was unsubstantiated.
Findings
All deficiencies cited as a result of the 3/28/19 complaint survey were found to be corrected. The complaint investigation found GA00196033 substantiated with no deficiencies, GA00196468 unsubstantiated, and GA00196396 unsubstantiated.
Report Facts
Complaint Intake Numbers investigated: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2018
Visit Reason
A complaint survey was conducted from 10/22/18 to 10/24/18 to investigate complaints GA00191253, GA00191813, GA00192014, and GA00192099 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to multiple complaints; no deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 14, 2018
Visit Reason
A revisit survey was conducted on 8/14/18 to verify correction of deficiencies cited in the 6/14/18 Standard Survey. Additionally, a complaint investigation (GA00190385) was conducted in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00190385 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 6/14/18 Standard Survey were found to be corrected. The complaint investigation GA00190385 was unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 14, 2018
Visit Reason
A revisit survey was conducted on 8/13/18 and 8/14/18 to verify correction of deficiencies cited in the 6/14/18 Standard Survey and to investigate Complaint Intake Number GA00190385.
Complaint Details
Complaint Intake Number GA00190385 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 6/14/18 Standard Survey were found to be corrected. The complaint investigation GA00190385 was unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 7, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 124
Capacity: 171
Deficiencies: 2
Date: Jun 13, 2018
Visit Reason
The visit was a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically regarding fire rated doors that failed to close and latch properly, and improper storage of oxygen cylinders without required signage and stored too close to combustible materials.
Deficiencies (2)
Fire rated doors in an exit passageway failed to close and latch in the closed position.
Oxygen cylinders were not stored properly: missing required precautionary signage and stored within five feet of combustible construction.
Report Facts
Census: 124
Total Capacity: 171
Residents at risk: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire doors and oxygen cylinder storage during facility tour |
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Date: May 31, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 4/30/18 complaint survey.
Findings
All deficiencies cited as a result of the 4/30/18 complaint survey were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 16, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186444 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186444 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 2, 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
Follow-Up
Deficiencies: 0
Date: Nov 2, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 118
Capacity: 171
Deficiencies: 4
Date: Oct 2, 2017
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted following a state survey to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and related NFPA codes.
Findings
The facility failed to maintain the smoke and ½ hour fire resistance of smoke barriers as required by NFPA codes. Specifically, unsealed or improperly sealed penetrations were found in three of four smoke barriers near rooms 303, 206, and 103, and the facility lacked a written policy for maintaining and monitoring outside contractors working on smoke barrier walls.
Deficiencies (4)
Smoke barrier near room 303 penetrated by two ¾" metal sleeves with unsealed wires not firestopped.
Smoke barrier near room 206 penetrated by a ¾" metal sleeve with unsealed wires not firestopped.
Smoke barrier near room 103 had a 2" hole with unsealed grey wires not firestopped.
Facility lacked a written policy for maintaining and monitoring outside contractors working at smoke barrier walls.
Report Facts
Census: 118
Total Capacity: 171
Number of smoke barriers affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Identified smoke barriers and was present when deficiencies were identified |
Inspection Report
Routine
Census: 124
Deficiencies: 0
Date: Aug 24, 2017
Visit Reason
A standard survey was conducted at Woodstock Nursing and Rehabilitation Center from August 21, 2017 through August 24, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 124
Capacity: 171
Deficiencies: 6
Date: Aug 21, 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 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including deficiencies in hazardous area enclosures, fire alarm system installation, sprinkler system maintenance, utilities (gas and electric), electrical systems, emergency lighting in medication preparation rooms, and use of power strips in resident treatment areas.
Deficiencies (6)
Hazardous areas not properly sealed to prevent smoke passage; laundry door does not properly latch; memory care storage room lacks self-closer; electrical room ceiling penetrations not sealed.
Fire alarm system not properly installed; fire alarm breaker not marked, red, or locked out to prevent power shutoff.
Sprinkler system not properly maintained; sprinkler heads in kitchen loaded with dust and grease; sprinkler drain not properly marked.
Utilities (gas and electric) not properly maintained; openings in panel box in laundry area; missing cover in linen closet switch.
Electrical systems deficiencies; medication preparation rooms lack emergency lighting.
Power strips in resident treatment areas not code compliant; unapproved power strips used with non-medical devices in resident rooms on multiple halls.
Report Facts
Census: 124
Total Capacity: 171
Number of residents at risk due to hazardous area sealing deficiency: 75
Number of residents at risk due to electrical system deficiencies: 50
Number of residents at risk due to power strip deficiencies: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and staff interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 14, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00161591 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00161591 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted by a Registered Nurse at Woodstock Nursing & Rehab Center.
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