Complaint Investigation

Hill Haven Nursing Home

February 20, 2025 · Commerce, GA · 880 Ridgeway Road

Citations 4

CMS Rating 3/5

Beds 70

Provider ID 115710

Healthcare Facility

Hill Haven Nursing Home

Commerce, GA · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov) · 11 pages

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

HILL HAVEN NURSING HOME in COMMERCE, GA — inspection on February 20, 2025.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF609

Minimal harm or Few Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, affected

115710

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115710 B.

Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

FF610

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49673 Reporting and Investigating, the facility failed to ensure a thorough investigation was affected

During an interview on 2/19/2025 at 11:09 am with the Human Resource Director (HRD) revealed, when searching for an investigation for a sexual abuse incident for R59, she confirmed that CNA MM was suspended for one day with pay pending investigation. HRD explained that she did not participate in investigations and that she only places reports/findings in employee files.

The HRD confirmed nothing was in employee files at the moment.

115710

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115710 B.

Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

FF656

Minimal harm or Many Based on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, affected

During a tour of the kitchen on 2/18/2025 that began at 9:15 a.m., the following concerns were identified: 1) a sleeve of Waffles was located on shelf in walk in freezer undated, 2) half bag of onion rings was left open in a box unlabeled or dated. 3) a five-pound box of frozen fish sticks, that had been opened and not resealed was present in the freezer and 4) two open containers that contained sausage in one of them and frozen eggs in the other.

During a second observation on 2/19/2025 at 9:30 am of the walk-in freezer and refrigerator it appeared the unlabeled and improperly stored food items were removed, and the box of fish sticks was discarded due to the unknown use by date.

During an interview conducted on 2/20/2025 at 10:45 am with the Dietary Kitchen Manager (DKM) revealed that the kitchen staff were expected to label and date each food item that was received for the facility.

She revealed it was her expectation for each staff member to properly store food items after opening it.

The DKM stated going forward she was going to implement a system to double check behind her staff daily to ensure food safety in the facility.

115710

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115710 B.

Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

FF695

Minimal harm or Few Based on observations, staff interviews, record review and review of the facility's policy titled, Water affected

Review of the facility's water temperature log revealed that water temperature checks were completed on 11/6/2024, 12/19/2024, and 1/16/2025 with temperatures ranges between 94 degrees F and 120 degrees F.

Review of the facility's records revealed, no residents sustained burns injuries related to hot water temperatures.

Follow-up observation on 2/18/2025 from 3:45 pm to 3:54 pm of water temperature checks with the MD revealed, room [ROOM NUMBER] at 106 degrees F, room [ROOM NUMBER] at 109 degrees F, room [ROOM NUMBER] at 101.9 degrees F, room [ROOM NUMBER] at 101.5 degrees F, and room [ROOM NUMBER] at 100.8 degrees F.

115710

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 115710 B.

Wing 02/20/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COMMERCE, GA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HILL HAVEN NURSING HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.