Hill Haven Nursing Home
HILL HAVEN NURSING HOME in COMMERCE, GA — inspection on February 20, 2025.
Found 11 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
inform him right away specifically abuse to see if it is reportable.
The Administrator emphasized that
contact law enforcement and has since had to do inservice with DON.
Cross Reference F-F610
115710 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
During an interview on 2/20/2025 at 1:58 pm, the DON revealed when reporting an investigation, she would retrieve witness statements, notify family and doctor, and send the resident to the emergency room. DON confirmed she did not complete the skin assessment as indicated in the nurse's notes and could not locate the fax log sent notifying the MD. DON mentioned she thought she called the MD but was not sure what method she used to contact the MD. DON confirmed she did not call local police officials. DON emphasized that she did not observe any injuries and thought the concerns were not true and just rumors.
During an interview on 2/20/2025 at 2:44 pm with the Administrator revealed, he expects his staff to inform him right away specifically abuse to see if it is reportable.
The Administrator emphasized that if it is abuse, neglect, or exploitation and something severe his reporting expectation was one hour and all others two hours.
The administrator shared the previous Administrator was not having staff to contact law enforcement and has since had to do inservice with DON.
Cross Reference F-F609
115710 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
further stated all care areas, including medications, diagnosis, and treatments, should be care
Cross Reference F-F695
115710 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
Review of the facility undated policy titled Water Temperatures, Safety of, under the Policy Interpretation and Implementation revealed, 1.
Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. 2.Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3.
Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log.
Observations on 2/18/2025 from 11:30 am to 11:38 am of water temperature checks on two out of three halls within the facility with Maintenance Director (MD) using the facility's digital thermometer revealed, water temperature measurements in room [ROOM NUMBER] at 108 degrees F, room [ROOM NUMBER] at 132 degrees F, room [ROOM NUMBER] at 136 degrees F and room [ROOM NUMBER] at 135 degrees F, and room [ROOM NUMBER] at 137 degrees F. No other residents' rooms were affected.
Interview on 2/18/2025 at 11:40 am with the MD revealed that he conducted monthly water temperatures in residents' rooms.
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 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
Observation and interview on 2/18/2025 at 3:16 pm in R10's room revealed the nebulizer jar and mouthpiece was lying on the resident's bed, unbagged and exposed to the environment. R10 revealed, it was not used routinely and that she required supervision when used.
Observation on 2/19/2025 at 11:21 am of nebulizer mouthpiece sitting at bedside uncovered.
Interview on 2/19/2025 at 10:18 am with Certified Nursing Assistant (CNA) DD revealed, she was aware that respiratory tubing should be stored in a clear plastic bag if the resident was not using it.
She further stated storing respiratory supplies cuts down on infections and germs and all staff were responsible for ensuring the tubing and mouthpieces were stored while not in use.
Interview on 2/19/2025 at 11:35 am with the Director of Nursing (DON) revealed, staff that worked on Sunday night shift were responsible for ensuring that all respiratory care equipment was properly stored and checked for clean filters, and routine maintenance.
The DON revealed, there was no logging system in place for the maintenance task.
Interview on 2/20/2025 at 3:45 pm with the Director of Nursing (DON) confirmed R10's nebulizer mouthpiece was unbagged and exposed to the environment.
Cross Reference F-F656
Review of the facility's policy entitled, Food Receiving and Storage dated November 2022 under the Policy Statement revealed, Foods shall be received and stored in a manner that complies with safe food handling practices.
Under the section titled Refrigerated/Frozen Storage revealed, 1.
All foods stored in the refrigerator or freezer are covered, labeled and dated, (use by date) 7.
Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded.
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.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
115710 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
Review of the facility policy's titled, Infection Prevention and Control Program revised 10/28/2022 under Policy Explanation and Compliance Guidelines revealed, 16.
Water Management: A water management program has been established as part of the overall infection prevention and control program.
Review of the facility's records revealed the facility did not have an established Water Management Plan.
Interview with the Administrator on 2/20/2025 at 1:40 pm confirmed the facility did not have an established Water Management Plan.
The Administrator revealed, when he started working at the facility two week ago, he identified this issue and added it to the agenda for the next Quality Assurance Performance Improvement (QAPI) meeting in March. He reported that daily hot water temperature checks would be a part of the Water Management Plan.
115710 02/20/2025
Hill Haven Nursing Home 880 Ridgeway Road Commerce, GA 30529
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
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
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
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
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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.