Inspection Report Summary
The most recent inspection on April 5, 2024 found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related primarily to fire safety and life safety code compliance, including obstructed means of egress, door latching issues, sprinkler system maintenance, and corridor obstructions. Other recurring issues involved resident care concerns such as medication errors, failure to provide appropriate equipment like wheelchairs, inadequate activity programming, and unsafe hot water temperatures. Complaint investigations during this period were mostly unsubstantiated, with one substantiated complaint in 2017 regarding delayed pain medication and inadequate shower assistance. The facility appears to have made improvements recently, as follow-up surveys confirmed correction of prior deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
17.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
259% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
87 residents
Based on a March 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 26, 2025
Visit Reason
The inspection was conducted following complaints and investigations related to physical and sexual abuse of residents by other residents, and failure to properly monitor and treat a worsening pressure ulcer in residents.
Complaint Details
The complaint investigation revealed that resident R96 was physically abused by resident R64, causing a fractured clavicle and head laceration. Resident R92 was sexually abused by resident R93. Investigations included staff interviews, record reviews, and facility policy reviews. The facility also failed to properly monitor and treat a pressure ulcer for resident R9, which worsened to an unstageable ulcer with infection and osteomyelitis.
Findings
The facility failed to protect residents from physical and sexual abuse by other residents, resulting in actual harm including a fractured clavicle and sexual abuse. Additionally, the facility failed to monitor and intervene appropriately when a resident's pressure ulcer worsened, leading to infection and osteomyelitis.
Deficiencies (2)
Failure to protect residents from physical and sexual abuse by other residents, resulting in actual harm including a fractured clavicle and head laceration, and sexual abuse.
Failure to monitor and intervene when a pressure ulcer worsened, resulting in wound infection and osteomyelitis.
Report Facts
Residents sampled for abuse review: 31
Residents reviewed for pressure ulcers: 6
Residents sampled for pressure ulcers: 33
BIMS score: 3
BIMS score: 5
BIMS score: 12
Pressure ulcer measurement: 4
Pressure ulcer measurement: 8
Pressure ulcer measurement: 0.1
Pressure ulcer measurement: 6
Pressure ulcer measurement: 8.5
Pressure ulcer measurement: 2.5
Braden Scale score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided facility investigation and confirmed staff abuse training; unable to find measures taken to separate residents at time of abuse incidents. | |
| Director of Nurses (DON) | Started December 2024; unable to answer what measures were in place at time of abuse incidents; aware of pressure ulcer case and treatment issues. | |
| Social Service Director (SSD) | Not employed at time of abuse incidents; reported no behaviors from resident R64 since employment. | |
| LPN10 | Licensed Practical Nurse | Reported details of sexual abuse incident involving resident R93 and R92. |
| Wound Nurse Practitioner (WNP) | Provided wound care education and treatment for resident R9's pressure ulcer. | |
| Quality Surgical Management (QSM) nurse practitioner | Provided wound assessments and treatment orders for resident R9. | |
| Primary Care Practitioner (PCP) | Involved in treatment decisions for resident R9's pressure ulcer and osteomyelitis. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - AUGUSTA, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Mar 7, 2024
Visit Reason
A Revisit Survey was conducted on 3/7/2024 to verify correction of deficiencies cited during the January 7, 2024 Recertification/Complaint Survey.
Findings
All deficiencies cited as a result of the January 7, 2024 Recertification/Complaint Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Feb 27, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, with some deficiencies remaining uncorrected.
Findings
The facility failed to maintain compliance with 2012 NFPA 101 Chapter 19 related to means of egress and aisle/corridor width. Specifically, laundry room rated doors were obstructed from closing and the corridor between the kitchen and laundry room was impeded for an extended period.
Deficiencies (2)
Failed to maintain compliance with 2012 NFPA 101 Chapter 19 regarding means of egress; laundry room rated doors were obstructed from closing.
Failed to maintain compliance with 2012 NFPA 101 Chapter 19 regarding aisle, corridor, or ramp width; corridor between kitchen and laundry room was impeded for an extended period.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings related to obstructions and impediments during the survey. |
Inspection Report
Routine
Census: 92
Deficiencies: 8
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, safety, environment, medication administration, infection control, and other care standards at Pruitthealth - Augusta nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide a wheelchair to a resident, unsafe environmental conditions, inaccurate resident assessments, inadequate activity programming, unsafe hot water temperatures, improper oxygen administration, medication errors exceeding 5%, and failure to perform proper hand hygiene during wound care.
Deficiencies (8)
Failed to provide a Geri wheelchair to one resident, limiting mobility and psychosocial wellbeing.
Failed to provide a safe, clean, comfortable, and homelike environment due to missing closet door hinges, missing wood from closet drawer, stained countertops, baseboard disrepair, stained bathtub with missing faucet, and dirty fan.
Failed to document discharge status for three residents in Minimum Data Set assessments.
Failed to ensure an ongoing activities program based on resident preferences, resulting in social isolation for one resident.
Failed to maintain hot water temperatures below 110 degrees Fahrenheit in 12 rooms and one shower room.
Failed to ensure oxygen was administered per physician orders and lacked oxygen in use signage for one resident.
Medication error rate exceeded 5%, including omitted antihypertensive medication, incorrect insulin administration technique, and administration of supplements without physician orders.
Failed to perform hand hygiene appropriately during treatment of a sacral wound.
Report Facts
Facility census: 92
Medication error rate: 11.54
Unsafe hot water temperatures: 12
Residents affected: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Administered insulin using incorrect technique |
| LPN CC | Licensed Practical Nurse | Administered supplements without physician order |
| LPN AA | Licensed Practical Nurse | Failed to perform hand hygiene during wound care |
| Administrator | Acknowledged wheelchair issue and expectations for staff | |
| Activity Director | Acknowledged resident not attending group activities due to lack of wheelchair | |
| Director of Health Services | Verified oxygen administration issues and insulin administration knowledge gaps | |
| Senior Nurse Consultant | Verified oxygen administration issues | |
| Maintenance Director | Confirmed environmental deficiencies and hot water temperature rechecks | |
| Maintenance Supervisor | Stated hot water temperature should be below 110 degrees F | |
| Environmental Services Manager | Observed and cleaned dirty fan | |
| Housekeeper DD | Reported cleaning responsibilities for fans | |
| MDS Coordinator | Confirmed omission of discharge status in assessments |
Inspection Report
Routine
Census: 92
Deficiencies: 8
Date: Jan 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, environment, medication administration, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide a wheelchair to a resident, unsafe environmental conditions such as missing closet door hinges and dirty fans, inaccurate resident assessments, inadequate activity programming, unsafe hot water temperatures, improper oxygen administration, medication errors exceeding 5%, and failure to perform proper hand hygiene during wound care.
Deficiencies (8)
Failed to provide a Geri wheelchair to one resident, limiting mobility and psychosocial wellbeing.
Failed to provide a safe, clean, comfortable, and homelike environment due to missing closet door hinges, missing wood from closet drawers, stained countertops, baseboard disrepair, stained bathtub with missing faucet, and dirty fans.
Failed to document discharge status for three residents in Minimum Data Set assessments.
Failed to ensure ongoing activity program based on resident preferences, resulting in social isolation for one resident.
Failed to maintain hot water temperatures below 110 degrees Fahrenheit in 12 rooms and one shower room.
Failed to ensure oxygen was administered per physician orders and lacked oxygen in use signage for one resident.
Medication error rate exceeded 5% due to omitted antihypertensive medication, incorrect insulin administration technique, and administration of supplements without physician orders.
Failed to perform hand hygiene appropriately during treatment of a sacral wound.
Report Facts
Facility census: 92
Residents affected: 44
Medication error rate: 11.54
Unsafe water temperatures: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Administered insulin using incorrect technique |
| LPN CC | Licensed Practical Nurse | Administered supplements without physician order |
| LPN AA | Licensed Practical Nurse | Failed to perform hand hygiene during wound care |
| Administrator | Acknowledged wheelchair issue and expectations for staff | |
| Activity Director | Acknowledged resident not attending group activities due to lack of wheelchair | |
| Director of Health Services | Verified oxygen administration issues and medication administration knowledge gaps | |
| Senior Nurse Consultant | Verified oxygen administration issues | |
| Maintenance Director | Confirmed environmental deficiencies and water temperature issues | |
| Environmental Services Manager | Observed and cleaned dirty fan | |
| Housekeeper DD | Interviewed about cleaning of personal fans | |
| MDS Coordinator | Confirmed omission of discharge status in assessments |
Inspection Report
Life Safety
Census: 88
Capacity: 100
Deficiencies: 14
Date: Jan 11, 2024
Visit Reason
Life Safety Code Survey 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 multiple Life Safety Code requirements including means of egress obstructions, doors with self-closing devices failing to latch, corridor width impediments, hazardous area enclosures, sprinkler system maintenance, portable fire extinguisher inspections, corridor door latching, smoke barrier penetrations, unsafe electrical wiring and extension cord use, missing light fixture components, prohibited portable space heaters, and improper use of power strips.
Deficiencies (14)
Laundry room rated doors were obstructed from closing.
Fire doors number two and three failed to latch when tested.
Corridor between kitchen and laundry room and Station 3 exit discharge was impeded for an extended period.
Front office storage closet was missing a door closer.
Front office storage closet and nursing supply #2 storage closet storage was within 18 inches of the ceiling.
Fire extinguisher was missing two months of monthly checks.
Resident room door 10 failed to latch when tested.
Above fire door four firewall penetration was not properly sealed.
Admissions office extension cord was used as permanent wiring.
Medical records and kitchen office multi tap power strip was on the floor.
Laundry room had exposed wiring behind the dryers.
Resident room 31 globe was missing from the light fixture.
Front office storage closet and admissions office space heater with no thermostatic documentation.
In the admin office a six-way outlet was installed in the receptacle behind the desk.
Report Facts
Census: 88
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the tour and inspection |
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 5
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to perform proper hand hygiene during wound care, medication administration errors, failure to provide a Geri wheelchair to a resident, lack of ongoing activity programs based on resident preferences, and unsafe hot water temperatures in resident rooms and shower areas.
Deficiencies (5)
Failure to perform hand hygiene during treatment of a sacral wound for one resident.
Medication error rate exceeded five percent; errors included omission of antihypertensive medication, incorrect insulin administration technique, and administration of supplements without physician orders.
Failure to provide a Geri wheelchair to one resident, affecting quality of life and psychosocial wellbeing.
Failure to ensure an ongoing program of activities based on activity preference assessments for one resident.
Failure to maintain hot water temperatures below 110 degrees Fahrenheit in 12 of 40 rooms and one of two shower rooms.
Report Facts
Residents sampled: 44
Facility census: 92
Rooms with unsafe hot water temperatures: 12
Shower rooms with unsafe hot water temperatures: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in hand hygiene deficiency during wound care |
| LPN BB | Licensed Practical Nurse | Named in medication administration errors |
| LPN CC | Licensed Practical Nurse | Named in medication administration errors |
| Director of Health Services | Provided confirmation and interview regarding hand hygiene and medication administration policies | |
| Administrator | Acknowledged wheelchair issue and hot water temperature policy | |
| Activity Director | Acknowledged resident activity and wheelchair issues | |
| Maintenance Director | Verified hot water temperature measurements | |
| Maintenance Supervisor | Provided information on hot water temperature standards |
Inspection Report
Routine
Census: 92
Deficiencies: 8
Date: Jan 11, 2024
Visit Reason
A standard survey was conducted at Pruitthealth-Augusta from January 9, 2024 through January 11, 2024, including investigation of multiple complaint intake numbers which were found unsubstantiated.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey and found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide a wheelchair to a resident, unsafe and unclean environment conditions, inaccurate resident assessments, inadequate activities programming, unsafe water temperatures, improper oxygen administration, medication errors, and failure to perform proper hand hygiene during wound care.
Deficiencies (8)
Failed to provide a Geri wheelchair to one resident (R39), affecting quality of life and psychosocial wellbeing.
Failed to provide a safe, clean, comfortable, homelike environment due to missing closet door hinges, missing wood from closet drawer, stained countertops, baseboard disrepair, stained bathtub with missing faucet, and dirty fan.
Failed to document discharge status for three residents (R101, R104, R106) in assessments.
Failed to ensure ongoing activities based on resident preferences for one resident (R39), limiting socialization and participation.
Failed to maintain hot water temperatures below 110°F in 12 rooms and one shower room.
Failed to ensure oxygen was administered per physician orders and lacked 'oxygen in use' signage for one resident (R73).
Medication error rate exceeded 5% with omitted antihypertensive medication, incorrect insulin administration technique, and administration of supplements without physician order.
Failed to perform hand hygiene during treatment of a sacral wound for one resident (R25).
Report Facts
Facility census: 92
Rooms with unsafe hot water temperature: 12
Residents with undocumented discharge status: 3
Medication error rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Observed administering sliding scale insulin incorrectly |
| LPN CC | Licensed Practical Nurse | Administered supplements without physician order |
| LPN AA | Licensed Practical Nurse | Failed to perform hand hygiene during wound care treatment |
| Administrator | Acknowledged resident R39 did not have a wheelchair and ordered one | |
| Activity Director | Acknowledged resident R39 was not attending group activities due to lack of wheelchair | |
| Maintenance Director | Confirmed environmental deficiencies and water temperature issues | |
| Director of Health Services | Acknowledged oxygen administration and medication errors |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 21, 2022
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
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a healthcare facility inspection conducted at PruittHealth - Augusta.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/12/22 Recertification Survey.
Findings
All deficiencies cited in the previous 8/12/22 Recertification Survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 13, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility had corrected all previously cited deficiencies except for two issues: failure to check resident room doors and failure to label an electrical panel in the old generator room. These deficiencies affect one of four smoke compartments.
Deficiencies (2)
Facility failed to check resident room doors; specifically, resident room door five failed to close and latch.
Facility failed to label electrical panel in the old generator room.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of door failure to close and latch, and missing labeling on electrical panel during facility tour. |
Inspection Report
Routine
Deficiencies: 14
Date: Aug 12, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, rights, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including resident dignity and care, resident choice and self-determination, financial management, abuse reporting and investigation, care planning, restorative nursing services, accident hazard prevention, incontinence care, hydration, respiratory care, pain management, physician visits, and infection control practices.
Deficiencies (14)
Failed to ensure resident dignity during dressing assistance; resident's shirt was put on backwards and inside out.
Failed to provide menus to residents for food choices and failed to provide preferred shower to a resident.
Failed to honor resident's representative request for disbursement of funds from resident trust account.
Failed to timely report injury of unknown origin for a resident with knee swelling and fracture.
Failed to conduct thorough investigation of alleged staff to resident abuse, including failure to interview relevant witnesses and report to law enforcement.
Failed to ensure staff transferred resident correctly using Hoyer lift as per care plan.
Failed to invite residents to participate in care plan meetings.
Failed to provide restorative nursing services as ordered to residents, with missed or undocumented sessions.
Failed to prevent accident hazards by allowing a resident to smoke unsupervised in a smoke-free facility.
Failed to provide timely incontinence care to a resident, leaving brief soiled for hours despite call bell use.
Failed to maintain cleanliness of oxygen concentrator filters, change and label nasal cannula tubing, and store respiratory equipment properly.
Failed to provide timely routine and PRN pain medication to a resident, resulting in unmanaged pain and delayed medication administration.
Failed to ensure residents received required physician face-to-face visits within regulatory timeframes.
Failed to follow infection control measures during wound care and PPE use, including failure to change gloves between cleaning and dressing application.
Report Facts
Residents sampled: 39
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 6
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR | Certified Nursing Assistant | Named in dressing care deficiency for resident R#23 |
| Director of Nursing | Director of Nursing | Interviewed regarding dressing care, menus, hydration, pain management, and other deficiencies |
| Financial Counselor | Financial Counselor | Named in resident funds disbursement deficiency |
| Administrator | Administrator | Interviewed regarding resident funds, abuse investigations, physician visits, and infection control |
| CNA OO | Certified Nursing Assistant | Interviewed regarding food menus and resident choice |
| LPN EE | Licensed Practical Nurse | Interviewed regarding food menus and resident choice |
| LPN FF | Licensed Practical Nurse | Interviewed regarding food menus and resident choice |
| Registered Dietician | Registered Dietician | Interviewed regarding food menus and resident choice |
| CNA TT | Certified Nursing Assistant | Interviewed regarding bathing preference and assistance |
| CNA SS | Certified Nursing Assistant | Interviewed regarding bathing preference and restorative nursing |
| LPN DDD | Licensed Practical Nurse | Interviewed regarding hydration, respiratory care, and oxygen tubing |
| LPN GG | Licensed Practical Nurse | Interviewed regarding pain management and respiratory care |
| CNA EEE | Certified Nursing Assistant | Interviewed regarding hydration and restorative nursing |
| CNA AAA | Certified Nursing Assistant | Interviewed regarding incontinence care |
| LPN JJ | Licensed Practical Nurse | Interviewed regarding pain management |
| RN DD | Registered Nurse | Observed and interviewed regarding wound care infection control |
| LPN II | Licensed Practical Nurse | Observed and interviewed regarding wound care infection control |
Inspection Report
Routine
Census: 92
Deficiencies: 14
Date: Aug 12, 2022
Visit Reason
A standard survey was conducted from August 8, 2022 through August 12, 2022, including complaint investigations, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident rights, self-determination, management of personal funds, reporting of alleged violations, care planning, restorative nursing, accident prevention, nutrition/hydration, respiratory care, pain management, and physician visits.
Deficiencies (14)
Failed to provide dressing care with respect and dignity to one resident (R#23), including putting shirt on properly.
Failed to provide menus for food choices to three residents (R#20, R#40, R#81) and failed to provide shower preference to one resident (R#87).
Failed to provide timely access to resident funds for one resident (R#55) whose representative had legal power of attorney.
Failed to timely report injury of unknown origin for one resident (R#55) with a knee fracture.
Failed to conduct a thorough investigation of abuse allegation for one resident (R#70), including failure to interview relevant witnesses and notify law enforcement.
Failed to ensure staff transferred one resident (R#55) using a Hoyer lift as required by care plan.
Failed to ensure two residents (R#3, R#16) were invited to participate in care plan meetings.
Failed to provide restorative nursing services as ordered to four residents (R#3, R#16, R#53, R#87).
Failed to ensure one resident (R#291) was free of accident hazards related to smoking on facility grounds in violation of smoke free policy.
Failed to provide timely incontinence care to one resident (R#50) resulting in prolonged exposure to soiled brief.
Failed to maintain cleanliness of oxygen concentrator filters, change and label nasal cannula tubing, and store respiratory equipment properly for four residents (R#5, R#31, R#52, R#55).
Failed to provide timely and effective pain management to one resident (R#293) including delayed medication administration and inadequate pain reassessment.
Failed to ensure physician visits were conducted timely as required for six residents (R#2, R#6, R#17, R#34, R#40, R#71).
Failed to follow infection control measures including proper use of PPE and glove changes during wound care for one resident (R#87).
Report Facts
Resident census: 92
Deficiency counts: 14
Pain scale: 9
Pain scale: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nursing Assistant | Named in dressing care deficiency for resident R#23 |
| Director of Nursing | Director of Nursing | Provided expectations and confirmed deficiencies related to resident care and investigations |
| Financial Counselor | Financial Counselor | Named in failure to disperse resident funds to representative |
| CNA SS | Certified Nursing Assistant | Named in restorative nursing and transfer deficiencies |
| LPN EE | Licensed Practical Nurse | Confirmed lack of menu access for residents |
| LPN FF | Licensed Practical Nurse | Confirmed lack of menu access for residents |
| Registered Dietician | Registered Dietician | Confirmed lack of menu access for residents |
| CNA OO | Certified Nursing Assistant | Confirmed lack of menu access for residents |
| CNA BBB | Certified Nursing Assistant | Named in transfer without Hoyer lift deficiency |
| CNA EEE | Certified Nursing Assistant | Named in hydration deficiency for resident R#70 and R#23 |
| LPN DDD | Licensed Practical Nurse | Named in oxygen equipment and hydration deficiencies |
| RN DD | Registered Nurse | Named in wound care infection control deficiency |
| LPN II | Licensed Practical Nurse | Named in wound care infection control deficiency |
| LPN GG | Licensed Practical Nurse | Named in pain management and oxygen equipment deficiencies |
| LPN JJ | Licensed Practical Nurse | Named in pain management deficiency |
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 4
Date: Aug 9, 2022
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 broken door closers, resident room doors failing to close or latch, unlabeled electrical panels, and unsecured oxygen cylinders in multiple smoke compartments.
Deficiencies (4)
Failed to repair door closers on electrical/kitchen supply room and smoke doors missing latching parts affecting 4 of 4 smoke compartments.
Failed to check resident room doors which failed to close or latch affecting 3 of 4 smoke compartments.
Failed to label electrical panel in old generator room affecting 1 of 4 smoke compartments.
Failed to secure oxygen cylinders in hall 2 oxygen storage room affecting 1 of 4 smoke compartments.
Report Facts
Census: 92
Total Capacity: 100
Inspection Report
Routine
Census: 39
Deficiencies: 6
Date: Aug 8, 2022
Visit Reason
The inspection was a licensure survey conducted from August 8, 2022 through August 12, 2022 to assess compliance with state regulations for healthcare facilities.
Findings
The facility was found deficient in multiple areas including failure to provide dignified dressing care for one resident, failure to involve residents in care plan meetings, failure to ensure timely physician visits, failure to provide restorative nursing services as required, failure to provide timely incontinence care, and failure to provide timely pain management for one resident.
Deficiencies (6)
Failure to provide dressing care with respect and dignity to resident #23, including putting the resident's shirt on properly.
Failure to invite two residents (#3 and #16) to participate in care plan meetings.
Failure to ensure residents received physician visits monthly for the first 90 days and every 60 days thereafter for six residents.
Failure to provide restorative nursing services as required for four residents (#3, #16, #53, and #87).
Failure to provide timely incontinence care to resident #50, who was found with a soiled brief for several hours.
Failure to provide timely routine and as needed pain medication to resident #293, resulting in unmanaged severe pain.
Report Facts
Residents reviewed for physician visits: 7
Residents sampled for restorative services: 4
Residents with missed restorative nursing services: 16
Residents with missed restorative nursing services: 16
Residents with missed restorative nursing services: 11
Residents with missed restorative nursing services: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nursing Assistant | Confirmed dressing resident #23 with shirt backwards and inside out. |
| Director of Nursing | Director of Nursing | Confirmed expectations for proper dressing and physician visits. |
| CNA SS | Certified Nursing Assistant | Transferred resident #55 without using Hoyer lift as required. |
| CNA BBB | Certified Nursing Assistant | Transferred resident #55 without using Hoyer lift as required. |
| LPN JJ | Licensed Practical Nurse | Discussed pain medication delays for resident #293. |
| LPN GG | Licensed Practical Nurse | Provided controlled drug record and discussed pain medication authorization for resident #293. |
Inspection Report
Abbreviated Survey
Census: 83
Deficiencies: 0
Date: Feb 11, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00221543.
Complaint Details
Complaint #GA00221543 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 28, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00212717, #GA00213199, #GA00214446, and #GA00214703.
Complaint Details
Complaints #GA00212717, #GA00213199, #GA00214446, and #GA00214703 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 4, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212323.
Complaint Details
Complaint #GA00212323 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint #GA00212323 was found to be unsubstantiated with no regulatory violations identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 15, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00211915.
Complaint Details
Complaint #GA00211915 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: 52
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in a previous Infection Control Survey dated 12-04-2020.
Findings
All deficiencies cited as a result of the 12-04-2020 Infection Control Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 67
Deficiencies: 1
Date: Dec 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and implementation of CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to ensure staff wore appropriate eye protection required for transmission-based precautions, potentially affecting three residents. The facility had a COVID-19 focused emergency preparedness survey and infection control survey on the same date.
Deficiencies (1)
Facility staff failed to wear appropriate eye protection required for transmission-based precautions to prevent the potential spread of COVID-19, affecting three residents.
Report Facts
Total census: 67
Number of residents potentially affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK AA | Housekeeper | Observed not wearing eye protection while cleaning Level 2 unit |
| LPN AA | Licensed Practical Nurse | Nurse for Level 1 and Level 2 units interviewed about PPE requirements |
| IP | Infection Preventionist | Interviewed regarding PPE requirements and training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 17, 2020
Visit Reason
An unannounced visit was made to the facility from September 14, 2020 through September 17, 2020 to investigate multiple complaints.
Complaint Details
Complaints GA00201277, GA00205406, GA00206744, GA00207256, and GA00208131 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were found to be unsubstantiated and no regulatory violations were cited.
Inspection Report
Routine
Census: 69
Deficiencies: 0
Date: Jul 16, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Routine
Census: 63
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant CMS and CDC regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 63
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 20, 2019
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
Re-Inspection
Census: 85
Deficiencies: 0
Date: Apr 29, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/22/19 Recertification Survey.
Findings
All deficiencies cited as a result of the 2/22/19 Recertification Survey were found to be corrected.
Inspection Report
Follow-Up
Capacity: 74
Deficiencies: 2
Date: Apr 17, 2019
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies related to fire safety and sprinkler system maintenance.
Findings
The facility failed to maintain the fire sprinkler system and its components, including out-of-date fire riser gauges and sprinkler heads over 10 years old. Additionally, the facility failed to close open penetrations in hazardous area fire walls, with combustible spray foam used instead of fire-rated caulking. These violations are repeat from the original survey and place residents and staff at risk in the event of fire.
Deficiencies (2)
Failure to maintain fire sprinkler system and components, including out-of-date fire riser gauges and sprinkler heads over 10 years old.
Failure to close open penetrations in hazardous area fire walls, with combustible spray foam used instead of fire-rated caulking.
Report Facts
Total licensed capacity: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the follow-up survey |
Inspection Report
Routine
Census: 77
Deficiencies: 3
Date: Feb 22, 2019
Visit Reason
The inspection was conducted to assess compliance with food procurement, storage, preparation, and serving standards in the facility's kitchen.
Findings
The facility failed to maintain the kitchen dry storage room floor in good repair, had ice buildup in the walk-in freezer causing dripping and freezing on food boxes, and had walls in the dishwashing area that were dirty, buckled, and showed mold growth. These deficiencies potentially affected 73 of the 77 residents receiving an oral diet.
Deficiencies (3)
Kitchen dry storeroom floor had seven broken linoleum tiles with black grime in missing tile areas.
Walk-in freezer had large icicles and ice chunks dripping onto partially open cardboard boxes of food.
Dishwashing area walls had black speckled mold under caulking, buckled walls coming apart, and wet, steamy conditions.
Report Facts
Residents affected: 73
Total residents present: 77
Broken linoleum tiles: 7
Freezer temperature: 0
Ice chunk size: 6
Freezer door repair date: Nov 16, 2018
Repair cost threshold: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Participated in kitchen inspections and reported ice buildup |
| Maintenance Director | Maintenance Director | Provided information on repairs, maintenance requests, and facility conditions |
| Administrator | Administrator | Provided information on approval processes for repairs and capital expenditure requests |
Inspection Report
Routine
Census: 73
Capacity: 77
Deficiencies: 3
Date: Feb 22, 2019
Visit Reason
The inspection was conducted to evaluate compliance with physical plant standards related to the kitchen and food storage areas.
Findings
The facility failed to maintain the kitchen dry storage room floor in good repair, had ice buildup in the walk-in freezer causing dripping and freezing on food boxes, and had black speckled mold under caulking and buckled walls in the dishwashing area. These deficiencies potentially affected 73 of the 77 residents receiving an oral diet.
Deficiencies (3)
Kitchen dry storage room floor was in poor condition with seven broken linoleum tiles and black grime in missing tile areas.
Walk-in freezer had large icicles and ice chunks dripping and freezing on boxes of food due to a door not staying closed properly.
Walls in the dishwashing area had black speckled mold under caulking, buckled walls, and no caulking in some areas.
Report Facts
Residents affected: 73
Total residents: 77
Broken tiles: 7
Freezer temperature: 0
Icicle size: 24
Icicle diameter: 6
Ice chunk size: 6
Freezer door repair date: Nov 16, 2018
Date of CER request: 201809
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Conducted initial kitchen inspection and reported ice buildup and broken tiles |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance issues including freezer door, broken tiles, and mold in dish room walls |
| Administrator | Administrator | Interviewed about building condition, approval process for repairs, and Capital Expenditure Request |
Inspection Report
Life Safety
Census: 74
Capacity: 120
Deficiencies: 11
Date: Feb 21, 2019
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 multiple Life Safety Code requirements including fire door hardware, exit signage and lighting, fire alarm system installation and maintenance, sprinkler system maintenance, smoke barrier penetrations, electrical system safety, suspended unit heaters, smoking regulations, and door maintenance. Several repeat violations were noted.
Deficiencies (11)
Failed to maintain fire door panic hardware on back hall exit door.
Failed to maintain exit lighting; exit lighting missing above back hall exit door.
Failed to maintain door closers on doors from clothes dryer room.
Failed to maintain fire alarm system components; fire alarm breaker missing red lock-out.
Failed to maintain fire alarm system testing and maintenance; fire door releases not releasing during alarm testing, no sensitivity testing documentation.
Failed to maintain fire sprinkler system; yellow tagged with deficiencies, out-of-date gauges, sprinkler heads over 10 years old and corroded, no wrench for sprinkler heads.
Failed to maintain smoke barrier penetrations in boiler room.
Failed to maintain electrical systems; power strip on floor in Director of Nursing office, missing outlet face plate behind oven, open voids in electrical panel.
Failed to maintain suspended unit heaters; missing control knobs possibly eliminating safety features.
Failed to maintain smoking regulations; broken fire safety can, cigarette butts discarded unsupervised, smoking inside boiler room by employees.
Failed to maintain fire door integrity; CMS door testing policy not followed, unapproved hardware devices used to hold fire door open in kitchen.
Report Facts
Census: 74
Total Capacity: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during facility tour |
Inspection Report
Routine
Census: 77
Deficiencies: 3
Date: Feb 19, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility failed to maintain sanitary conditions in the kitchen, including broken linoleum tiles in the dry storage room, ice buildup in the walk-in freezer causing dripping and freezing on food boxes, and black mold and buckling walls in the dishwashing area. These issues had the potential to affect 73 of the 77 residents receiving an oral diet.
Deficiencies (3)
Kitchen dry storage room floor was in poor condition with seven broken linoleum tiles and black grime in missing tile areas.
Walk-in freezer had large icicles and ice chunks dripping and freezing on food boxes due to door not staying closed.
Walls in the dishwashing area had black speckled mold under caulking, buckled walls coming apart in the corner seam, and wet, steamy conditions.
Report Facts
Resident census: 77
Length of icicle: 24
Icicle diameter: 6
Freezer temperature: 0
Number of broken tiles: 7
Ice chunk size: 6
Freezer door open distance: 18
Date of last freezer door repair: Nov 16, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Conducted kitchen inspections and reported ice buildup in freezer |
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance issues including freezer door, broken tiles, and dish room walls |
| Administrator | Administrator | Interviewed about building condition, repair approval process, and capital expenditure requests |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2018
Visit Reason
An unannounced visit was made on 9/4/18 by a State Surveyor for complaint numbers GA189349, GA00190267, GA00190332, and GA00191206.
Complaint Details
Complaint investigation for multiple complaint numbers; findings were unsubstantiated.
Findings
The investigation consisted of a thorough review of the medical records of the complainant residents and sample residents. Findings were unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 14, 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
Abbreviated Survey
Census: 87
Deficiencies: 0
Date: May 2, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00188774 at Pruitthealth Augusta on May 1 and May 2, 2018.
Complaint Details
Investigation of complaint GA00188774; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 30, 2018
Visit Reason
A follow-up to the Recertification survey of 3/1/18 was conducted from 4/30/18 to 5/1/18 to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior Recertification survey were corrected, and the facility was in compliance with the Health portion as of 4/14/18.
Inspection Report
Life Safety
Census: 84
Deficiencies: 4
Date: Apr 19, 2018
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility's Emergency Preparedness Plan was found not in substantial compliance with Appendix Z requirements, placing 84 residents at risk. Multiple fire safety deficiencies were identified, including failure to properly date fire alarm batteries, failure to maintain fire walls, and failure to maintain oxygen cylinder storage separations. All deficiencies were repeat violations.
Deficiencies (4)
Emergency Preparedness Plan was incomplete and not in substantial compliance with Appendix Z requirements.
Fire alarm panel batteries were not marked with the manufactured date of the battery.
Facility failed to maintain fire walls; mixed rated sealers applied in fire walls and uncorrected fire/smoke wall at nurses station.
Facility failed to maintain oxygen cylinder storage separations; mixed empty and full cylinders stored together.
Report Facts
Residents at risk: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Routine
Census: 83
Capacity: 100
Deficiencies: 20
Date: Feb 27, 2018
Visit Reason
Routine Life Safety Code Survey and Emergency Preparedness Plan review conducted to assess compliance with federal and state regulations.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code and emergency preparedness requirements, including blocked egress doors, missing panic hardware, corridor obstructions, dead-end corridor length violations, emergency lighting failures, fire alarm system maintenance deficiencies, sprinkler system maintenance issues, fire extinguisher inspection lapses, door latch failures, fire wall penetrations, electrical system hazards, missing fire drill documentation, smoking policy violations, and oxygen cylinder storage and handling deficiencies.
Deficiencies (20)
Emergency Preparedness Plan not in substantial compliance with Appendix Z requirements.
Fire exit door blocked by cart from laundry room.
Egress door at nurse's station #3 missing panic hardware for exit.
Corridor to exit into smoking yard lined with wheelchairs and medical carts, obstructing corridor width.
Dead-end corridor between kitchen and laundry area measured approximately 105 feet, exceeding 30 feet limit.
Emergency lights in kitchen back door and service hall did not work.
Vertical openings in biohazard room and medical records closet not properly enclosed.
Fire alarm panel batteries not marked with manufacture date.
No annual fire alarm inspection report or smoke detector sensitivity testing report found.
Fire sprinkler system gauges missing manufacture dates; no sprinkler list in cabinet.
Sprinkler system storage height exceeded in kitchen freeze and storage room; loaded sprinkler heads in nursing office and laundry; missing data plate for dry pipe system; no sprinkler wrench for Reliable brand heads.
Fire extinguishers missed on monthly inspections.
Doors in soiled utility room #1, kitchen dining room entry, main dining room, and emergency supply room do not close and latch securely.
Fire rated walls have mixed rated sealers and open penetrations.
Power strips used throughout building except resident rooms; missing faceplate on light switch; open wiring and junction boxes observed in multiple locations.
Incomplete fire drill reports for last quarter.
No fire safety cans for disposing discarded smoking materials; smoking policy not followed with discarded materials at employee entrances/exits.
No remote annunciator installed for emergency power generator.
Oxygen cylinders in storage mixed full and empty together without proper separation.
Oxygen cylinders unsecured and free standing in storage room.
Report Facts
Residents present: 83
Total licensed beds: 100
Dead-end corridor length: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00181566 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00181566 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 3, 2017
Visit Reason
A follow-up to the Recertification survey of June 16, 2017, to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected, and the facility was in substantial compliance as of July 27, 2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 25, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00177598 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00177598 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 2
Date: Jun 16, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00176148 regarding the facility's compliance with resident care and services.
Complaint Details
The investigation was triggered by complaint GA00176148. The complaint was substantiated as the facility was found not in substantial compliance with 42 CFR, Part 483, Subpart B.
Findings
The facility failed to assist one resident with showers as requested and failed to provide physician-ordered pain medications until five days after admission, resulting in noncompliance with federal regulations.
Deficiencies (2)
Facility failed to assist one resident with showers as requested, instead offering bed baths and adhering strictly to a shower schedule.
Facility failed to provide physician-ordered pain medications to one resident until five days after admission.
Report Facts
Facility census: 83
Resident weight: 386
Number of active medications: 23
Pain medication delay: 5
Pain scale rating: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Unit Manager | Interviewed regarding shower schedule and resident care. |
| Director of Nursing | DON | Interviewed regarding bathing assistance policies and pain medication delays. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00174822 at Abercorn Rehabilitation.
Complaint Details
Investigation of complaint GA00174822; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 9, 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 survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 20, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the recertification survey conducted on 2017-02-23.
Findings
All deficiencies cited as a result of the recertification survey conducted on 2017-02-23 were found to be corrected.
Report Facts
Previous survey date: Feb 23, 2017
Inspection Report
Follow-Up
Census: 79
Deficiencies: 2
Date: Apr 10, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies at the facility.
Findings
The facility failed to properly maintain and inspect the sprinkler system and fire-rated walls, placing residents, visitors, and staff at risk in the event of a fire. Specifically, the sprinkler system was not tagged as in service after repair, and fire walls were not maintained or repaired at the administrator's office entrance.
Deficiencies (2)
Sprinkler system inspection was not completed correctly; system was not placed back in service with a green tag indicating proper working order.
Fire walls were not maintained or repaired, specifically at the entrance to the administrator's office door.
Report Facts
Resident count: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Life Safety
Census: 84
Capacity: 100
Deficiencies: 3
Date: Feb 21, 2017
Visit Reason
The 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 provide documentation of sprinkler system maintenance and testing, failure to maintain the integrity of smoke barrier walls with unsealed penetrations, and failure to properly document fire drills, including missing drills on the 3rd shift of the 4th quarter in the past year.
Deficiencies (3)
Failed to provide records documenting inspections, testing, and maintenance of the automatic sprinkler system, including the 5 year internal inspection.
Failed to maintain the integrity of the smoke barrier walls; unsealed penetrations noted above ceiling of double doors adjacent to main entrance.
Failed to properly document fire drills; fire drills were not conducted on the 3rd shift of the 4th quarter during the past 12-month period.
Report Facts
Census: 84
Total Capacity: 100
Date of inspection: Feb 21, 2017
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