Nurse Care of Buckhead: Infection Control Failures - GA
The July inspection at Nurse Care of Buckhead revealed staff repeatedly failed to follow enhanced barrier precautions during high-contact care, leaving residents vulnerable to infection. The facility's own policy required gowns and gloves when caring for residents with chronic wounds or medical devices during activities like bathing, dressing changes, and wound care.
Certified Nursing Assistant YYY removed a soiled brief containing feces from a resident with a stage four pressure ulcer and feeding tube, then used the same contaminated gloves to clean the resident's buttocks and remove bed linens. She never changed her gloves or performed hand hygiene between tasks. When inspectors asked about enhanced barrier precaution requirements, she shrugged and said she didn't know.
The resident, identified as R53 in inspection records, had been admitted with diagnoses including a stage four pressure ulcer with exposed bone, tendon, or muscle, a gastrostomy feeding tube, and dementia. Assessment records showed she was severely cognitively impaired and dependent on staff for all daily care activities.
Licensed Practical Nurse EE entered the same room minutes later to perform wound care. She applied double gloves but wore no gown during the high-contact procedure, placing her supplies next to the plastic container being used for the resident's bath. When inspectors questioned her about barrier precaution requirements, she acknowledged the policy but admitted she hadn't followed it.
"Barrier precautions are resident-to-resident, and you are supposed to wear a gown when providing high-touch care," LPN EE told inspectors. Asked if she wore a gown during wound care, she replied, "No, I didn't."
The nurse claimed there was no gown available on the cart outside the resident's room, though she confirmed the facility had adequate personal protective equipment readily available for staff use. Inspectors found no gowns on the linen cart outside the room and no PPE cart available.
The facility's Infection Preventionist expressed confusion about the enhanced barrier precaution policy during the inspection. "I think there has been confusion related to EBP. We might need to reevaluate EBP," she told inspectors. When asked what she meant by reevaluate, she stated, "To get rid of EBP."
The infection control violations were part of broader systemic failures at the 189-bed facility. Inspectors found staff had failed to offer required vaccinations to residents, left essential equipment broken for months, and allowed a persistent pest infestation to spread throughout the building.
Two residents lacked documentation showing they had been offered influenza, pneumococcal, or COVID-19 vaccines as required by federal regulations. R28, who was severely cognitively impaired, had no record of being offered any vaccines or of family members being educated about the risks and benefits of vaccination. Her electronic medical record showed "consent refused" for influenza and pneumococcal vaccines, but contained no documentation of the refusal process.
R55, a resident with multiple sclerosis, had refused pneumococcal vaccines in 2018 when she was moderately cognitively impaired. By 2024, her cognitive function had improved significantly, but staff never reassessed her vaccination status or re-educated her about the vaccines. "No, we haven't" readdressed the vaccines since 2018, the Administrator admitted to inspectors.
Equipment failures left residents without basic necessities for months. R49 told inspectors her wheelchair brakes hadn't worked for months despite repeated notifications to maintenance. R48's electric wheelchair malfunctioned in June when a registered nurse attempted to operate it, leaving the paralyzed resident unable to use her primary means of mobility. The facility offered her a manual wheelchair, which she couldn't operate due to her paralysis.
"She declined to use a regular wheelchair when the maintenance department offered her one and explained she was paralyzed on one side and was unable to utilize a manual wheelchair," inspection records noted.
Multiple ice machines throughout the facility had been broken for weeks or months. Staff on the fourth floor told inspectors their ice machine had been inoperable for over a month, forcing them to rely on the first-floor machine, which had also broken. Dietary staff confirmed the kitchen ice machine had been non-functional for over two weeks.
The walk-in freezer in the kitchen consistently failed to maintain proper temperatures, registering 23 to 25 degrees Fahrenheit during multiple inspections over several days. Federal food safety standards require freezers to maintain temperatures of 0 degrees Fahrenheit or below.
A persistent pest infestation plagued the facility throughout 2024. Pest control records showed ongoing treatments for roaches, rodents, ants, and fruit flies from January through June. Despite monthly treatments, the problems worsened over time.
In April, pest control documented that "roaches were reported to have been seen at all nurses' stations and residents' rooms." By May, maintenance reported fruit flies had spread to resident rooms. Pest control noted the treatment required was "over and above standard contract treatment" and identified problems with food being left around kitchenettes and nurses' stations.
R25 was unable to eat her breakfast in July because multiple fruit flies swarmed around her bacon, bread, and oatmeal. "She was unable to enjoy her meal because of the excessive amounts of fruit flies in her room," inspectors noted. The resident said the infestation had persisted for over a month despite her complaints to staff.
Kitchen staff confirmed mouse droppings in the pantry and on kitchen floors. "The small dark droppings in the kitchen pantry showed mouse infestation was a concern," the Assistant Maintenance Director acknowledged.
The facility's kitchen door leading to the parking lot was repeatedly observed propped open with a rock, allowing pests easy access to food preparation areas.
Safety hazards extended throughout the building's five floors. Handrails were loose, missing end caps, or completely absent in hallways where residents with mobility impairments relied on them for support. On the third floor, one handrail was missing entirely and covered with duct tape.
The Maintenance Director attributed many problems to understaffing. "We know there are lots of things that need to be done however, we had not been told about the handrails," he told inspectors, though facility policy required maintaining the building "in good repair and free from hazards."
The Administrator acknowledged the facility was still working to establish basic systems. When asked about vaccination protocols, she stated, "Since we started in May of this year, we are still getting immunizations up and running and getting the documentation together."
R25 remained in her bed, surrounded by fruit flies, unable to eat the breakfast that had been delivered hours earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nurse Care of Buckhead from 2024-08-01 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
NURSE CARE OF BUCKHEAD in ATLANTA, GA was cited for violations during a health inspection on August 1, 2024.
She never changed her gloves or performed hand hygiene between tasks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.