Deficiency Records for Douglasville Nursing and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Douglasville Nursing and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-08 | 2024-03-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-02-08 | 2024-03-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-03-24 | N |
| Meet other general requirements. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-06 | 2024-03-24 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-03 | 2023-11-17 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-10-03 | 2023-11-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-03 | 2023-11-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-03 | 2023-11-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-03 | 2023-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-11-17 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-03 | 2023-11-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-03 | 2023-11-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-03 | 2023-11-17 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-03 | 2023-11-17 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-03 | 2023-11-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-03 | 2023-11-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-03 | 2023-11-17 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-03 | 2023-11-17 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-25 | 2022-09-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-25 | 2022-09-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-28 | 2022-09-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-28 | 2022-09-07 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-28 | 2022-09-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-28 | 2022-09-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-28 | 2022-09-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-28 | 2022-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2022-01-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-25 | 2021-07-07 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-01-11 | 2019-02-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-11 | 2019-02-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-11 | 2019-02-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-11 | 2019-02-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-01-11 | 2019-02-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-11 | 2019-02-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-11 | 2019-02-25 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-12-18 | 2019-02-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-18 | 2019-02-01 | N |
