Inspection Report Summary
The most recent inspection on April 5, 2021 found no deficiencies and the complaint investigated was unsubstantiated. Earlier inspections showed a pattern of mostly compliance with occasional deficiencies related primarily to infection control, medication management, resident care, and life safety code issues. Prior reports cited failures in updating COVID-19 policies and ensuring proper PPE use, expired medication disposal, timely reporting of abuse allegations, and multiple life safety code violations including fire sprinkler maintenance and egress concerns. Complaint investigations were generally unsubstantiated, with one substantiated case involving delayed reporting of a physical abuse allegation. The facility appears to have addressed many prior deficiencies over time, with the most recent surveys showing no cited issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
74 residents
Based on a January 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 5, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00213218.
Complaint Details
Complaint #GA00213218 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
Deficiencies: 0
Date: Mar 8, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00212242.
Complaint Details
Complaint GA00212242 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 74
Deficiencies: 0
Date: Jan 27, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was 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 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Date: Jan 19, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Infection Control Survey conducted on 11-12-2020.
Findings
All deficiencies cited in the previous Infection Control Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 68
Deficiencies: 1
Date: Nov 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations, specifically related to COVID-19 preparedness and PPE usage.
Findings
The facility was found not in compliance with infection control regulations due to failure to update COVID-19 policies and failure to ensure staff wore appropriate personal protective equipment, specifically eye protection, when providing care to non-COVID-19 residents, placing residents and staff at risk of COVID-19 transmission.
Deficiencies (1)
Failure to update in-house COVID-19 policies and procedures and failure to ensure staff wore appropriate PPE, including eye protection, when providing direct care to non-COVID-19 residents.
Report Facts
Census: 68
COVID-19 positive residents: 10
County COVID-19 positivity rate: 13.3
County COVID-19 positivity rate: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Observed not wearing eye protection while providing care to a dialysis resident |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 17, 2020
Visit Reason
A Follow-Up desk review survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 8, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00207237.
Complaint Details
Complaint #GA00207237 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
Deficiencies: 0
Date: Jul 29, 2020
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 but does not provide detailed findings or severity levels.
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 1/30/2020 Abbreviated/Partial Extended Survey and to investigate Complaint Intake Number GA#00203678.
Complaint Details
Complaint Intake Number GA#00203678 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited in the previous survey were found to be corrected. The complaint investigation was unsubstantiated and no deficiencies were cited during this revisit.
Report Facts
Census: 90
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
An unannounced abbreviated survey was conducted to investigate Georgia Complaint #00203678.
Complaint Details
Complaint #00203678 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Jul 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were 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 for COVID-19.
Inspection Report
Renewal
Deficiencies: 1
Date: Jan 30, 2020
Visit Reason
A Licensure Survey was conducted from 1/27/2020 through 1/30/2020 to assess compliance with state and federal regulations for facility licensure renewal.
Findings
The facility failed to ensure disposal of expired medications by the appropriate expiration date on one of five medication carts, specifically a bottle of Vitamin D3 expired in December 2019 was found on 1/29/2020.
Deficiencies (1)
Failure to ensure disposal of expired medications by the appropriate expiration date on one of five medication carts.
Report Facts
Medication carts inspected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Nurse | Confirmed expired medications were out of date during observation |
| Director of Nursing | Director of Nursing | Interviewed regarding medication disposal expectations |
Inspection Report
Routine
Census: 92
Deficiencies: 3
Date: Jan 30, 2020
Visit Reason
A standard survey was conducted at Amara Healthcare and Rehab from January 27, 2020 through January 30, 2020 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to report an injury of unknown origin, failure to update a resident's care plan to reflect interventions related to a right hip fracture, and failure to properly dispose of expired medications.
Deficiencies (3)
Failure to report an injury of unknown origin (right hip fracture) to the State Survey Agency within required timeframes.
Failure to update the comprehensive care plan to reflect interventions related to right hip fracture for one resident.
Failure to ensure disposal of expired medications by the appropriate expiration date on one of five medication carts.
Report Facts
Resident census: 92
Sample size: 40
BIMS Assessment score: 9
Medication expiration date: 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Nurse | Confirmed expired medications on medication cart |
| Director of Nursing | Interviewed regarding reporting procedures and care plan updates | |
| Administrator | Interviewed regarding injury reporting and investigation procedures | |
| Care Plan Coordinator | Interviewed regarding care plan updates | |
| Regional Care Plan Coordinator | Interviewed regarding care plan updates |
Inspection Report
Life Safety
Census: 95
Capacity: 193
Deficiencies: 1
Date: Jan 28, 2020
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 maintain the fire sprinkler system, specifically the kitchen sprinkler system tag was out of date since 2017, placing residents and staff at risk in the event of fire.
Deficiencies (1)
Fire sprinkler system in kitchen was tagged in 2017 and tag is currently out of date.
Report Facts
Census: 95
Total licensed beds: 193
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire sprinkler system during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00198119 and GA00199546 from December 10, 2019 to December 12, 2019.
Complaint Details
The survey investigated complaints GA00198119 and GA00199546 which were found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were identified.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 18, 2019
Visit Reason
A follow-up to a complaint survey conducted on April 24, 2019, to verify correction of previously identified deficiencies.
Complaint Details
The visit was a follow-up to a complaint survey from April 24, 2019. All deficiencies identified in the complaint survey were corrected.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of June 8, 2019.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Apr 24, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195938 regarding an allegation of physical abuse reported by Resident #1.
Complaint Details
The complaint involved an allegation by Resident #1 that he was physically abused (hit in the eye) by a staff member. The facility failed to report this allegation to the State Survey Agency within two hours as required. The resident was confused and unable to provide exact dates. Multiple staff interviews confirmed the delay in reporting and notification failures.
Findings
The facility failed to report an allegation of physical abuse within two hours as required by federal and state regulations. Staff did not notify the administrator or state survey agency timely, and the facility's abuse policy did not include the mandated two-hour notification requirement.
Deficiencies (1)
Failure to report an allegation of physical abuse within two hours after Resident #1 reported being hit in the eye.
Report Facts
Resident census: 96
Sample size: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assessed Resident #1, completed incident report, notified RN Weekend Supervisor and left voice messages regarding the abuse allegation. |
| LPN CC | Licensed Practical Nurse | Notified by resident's Power of Attorney about the allegation, assessed Resident #1, and provided care during relevant shifts. |
| LPN Supervisor BB | Licensed Practical Nurse Supervisor | Received voice message late and did not receive incident report until surveyor inquiry. |
| RN DD | Registered Nurse Weekend Supervisor | Was not notified about the allegation and stated she would have notified DON and Administrator immediately if informed. |
| Director of Nursing | Director of Nursing | Was not notified of the allegation until after surveyor inquiry. |
| Administrator | Facility Administrator | Was unaware of the allegation until surveyor inquiry and stated staff should have notified her immediately. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 20, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195275.
Complaint Details
Complaint GA00195275 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 20, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00194637 and GA00194763.
Complaint Details
The survey investigated complaints GA00194637 and GA00194763, which were unsubstantiated with no deficiencies.
Findings
The complaints were found to be unsubstantiated with no deficiencies identified during the survey.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted from July 23, 2018 through July 26, 2018.
Findings
All deficiencies resulting from the annual survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 1, 2018
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 during the follow-up survey.
Inspection Report
Routine
Census: 92
Deficiencies: 3
Date: Aug 10, 2018
Visit Reason
A standard survey was conducted from 7/23/2018 through 7/26/2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to update care plans to reflect residents' self-care deficits, failure to provide adequate ADL care and hygiene for a resident, and failure to maintain acceptable nutritional status for a resident experiencing significant weight loss.
Deficiencies (3)
Failed to update the care plan to reflect resident's self-care deficit after comprehensive assessment.
Failed to provide necessary ADL care to maintain grooming and personal hygiene for a resident unable to carry out ADLs independently.
Failed to maintain acceptable nutritional status as evidenced by significant weight loss for one resident.
Report Facts
Resident census: 92
Sample size: 19
Weight loss percentage: 8.8
Weight loss percentage: 10.5
Resident weight: 92.4
Resident weight: 85
Resident weight: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN GG | Licensed Practical Nurse | Interviewed regarding weight monitoring and at risk meetings |
| CNA BB | Certified Nursing Assistant | Interviewed regarding resident #5's ADL status and care |
| LPN AA | Licensed Practical Nurse | Interviewed regarding medical orders for resident #5 |
| Director of Nursing | Director of Nursing | Interviewed regarding care practices and storage of resident items |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding care plan updates |
| Dietary Manager | Dietary Manager | Interviewed regarding nutritional reviews and weight loss monitoring |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 1
Date: Aug 10, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with medical, dental, and nursing care regulations, focusing on resident care and hygiene.
Findings
The facility failed to provide adequate care for one resident (R#5) who was unable to carry out Activities of Daily Living (ADL), resulting in poor grooming, hygiene, and unsanitary conditions in the resident's room. Observations and interviews revealed neglect in assisting the resident with personal hygiene and improper storage of soiled items.
Deficiencies (1)
Failure to ensure care was provided for one resident unable to carry out ADLs to maintain proper grooming and personal hygiene.
Report Facts
Sample size: 19
BIMS score: 4
MDS assessment date: Jul 24, 2018
MDS assessment ARD: Jul 18, 2018
Shower days per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Certified Nursing Assistant | Interviewed regarding resident #5's usual independence with ADLs |
| AA | Licensed Practical Nurse | Interviewed about medical orders for resident #5 |
| Director of Nursing | Director of Nursing | Interviewed about proper storage of bed pans, wash basins, and urinals |
| Administrator | Administrator | Interviewed about resident #5's preferences and room conditions |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed about updating care plans for resident #5 |
| Occupational Therapist | Occupational Therapist | Interviewed about resident #5's functional status and decline |
Inspection Report
Life Safety
Census: 92
Capacity: 193
Deficiencies: 7
Date: Jul 23, 2018
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 blocked egress paths, lack of handrails on egress ramps, open penetrations in storage rooms, deficiencies in fire alarm and sprinkler systems, unsealed fire and smoke walls, and lack of an emergency power annunciator panel.
Deficiencies (7)
Exit door from G hall laundry area blocked by large laundry carts, impeding path of egress.
Egress ramp leading into western side yard lacked handrails.
Open penetrations existed in the G hall storage room.
No proof of sensitivity testing completed for fire alarm system.
Fire sprinkler system deficiencies including corroded sprinkler head, missing escutcheon ring plate, and painted sprinkler head.
Fire and smoke walls not properly maintained; fire walls above D and H hall fire doors not sealed, and large holes in smoke walls leading to attic space.
No annunciator panel located in a constantly monitored location inside the building for emergency power generator.
Report Facts
Residents at risk: 92
Certified beds: 193
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey found that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2017
Visit Reason
A follow-up to the Recertification survey of July 20, 2017 was conducted from September 22, 2017 through September 27, 2017 to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 15, 2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 1, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00178684 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint investigation #GA00178684 was conducted and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted at Amara Healthcare and Rehab.
Inspection Report
Life Safety
Census: 97
Capacity: 193
Deficiencies: 10
Date: Aug 1, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements including issues with egress doors, emergency lighting, vertical openings, hazardous area enclosures, fire alarm and sprinkler system maintenance, corridor doors, smoke barrier construction, electrical system maintenance, and oxygen cylinder storage.
Deficiencies (10)
Failed to maintain egress doors; doors hard to open/close, missing panic hardware.
Failed to maintain emergency lighting for pathways of egress.
Failed to maintain vertical openings; penetrations and missing ceiling tiles.
Failed to maintain facility clear of storage in hazardous areas, excessive storage creating fire hazard.
Fire alarm panel batteries dated incorrectly.
Failed to maintain fire sprinkler system; missing sprinkler head, dust loaded heads, missing escutcheon plates, missing hydraulic design plates, painted sprinkler heads, storage exceeding height requirements.
Failed to maintain corridor doors; doors not latching secure or missing.
Failed to maintain smoke barrier walls; fire walls not sealed to decking, open penetrations.
Failed to maintain electrical system; multi-outlet power strips, open junction boxes, extension cords in use, open voids in electrical panels.
Failed to properly store oxygen cylinders; cylinders unsecured and unprotected from falling.
Report Facts
Census: 97
Total Capacity: 193
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate multiple complaint numbers GA00173601, GA00173492, GA00170119, GA00166785, and GA00161694.
Complaint Details
The survey was complaint-related, investigating five complaint numbers, and no deficiencies were found.
Findings
No health care deficiencies were cited during the complaint survey conducted from April 7 to April 9, 2017.
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