Inspection Reports for
The Landings of Douglas
1360 WEST GORDON STREET, DOUGLAS, GA, 31533
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Inspection Report — Nov 12, 2024
Complaint Investigation State
Date: Nov 12, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00251957, triggered by a complaint regarding infection control and resident care practices.
Complaint Details
The investigation was initiated due to a complaint (intake #GA00251957) about improper infection control and resident care. Staff B was found to have inserted a hand inside Resident #1's adult brief without proper hygiene and smelled the hand to check for UTI. Resident #1 experienced worsening symptoms and was hospitalized. Staff B admitted the actions and was terminated.
Findings
The facility failed to ensure proper infection control and respect for resident dignity for 1 of 3 sampled residents (Resident #1). Staff B inappropriately inserted a hand inside Resident #1's adult brief without proper hygiene and smelled the hand to check for UTI, violating infection control protocols and resident rights. Resident #1 suffered from untreated UTI symptoms leading to hospitalization. Staff B was suspended and later terminated.
Deficiencies (3)
Failure to ensure staff demonstrate understanding and use of proper infection control practices in delivery of care to residents.
Failure to operate in a manner that respects the personal dignity and human rights of residents.
Failure to ensure residents receive adequate, appropriate care and services in compliance with laws and regulations.
Report Facts
Residents in facility: 25
Residents in MCU: 4
Residents sampled: 3
Incident date: Oct 17, 2024
Hospital admission date: Oct 23, 2024
Staff B hire date: Apr 7, 2024
Staff B termination date: Oct 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Admitted to improper infection control practice by inserting hand inside Resident #1's brief and smelling it; employment terminated | |
| Staff A | Interviewed regarding Staff B's actions and facility response; stated Staff B's actions were inappropriate and unsanitary | |
| AB | Witnessed incident and reported it; involved in care and reporting Resident #1's symptoms | |
| BC | Witnessed incident and provided statements about Staff B's inappropriate behavior |
Inspection Report — Jan 5, 2023
Routine State
Date: Jan 5, 2023
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report — Aug 26, 2021
Routine State
Date: Aug 26, 2021
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report — Sep 16, 2020
Complaint Investigation State
Date: Sep 16, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00207003, #GA00207498, and #GA00207527, focusing on an incident involving Resident #1 who eloped from the facility.
Complaint Details
The investigation was initiated due to complaint intakes #GA00207003, #GA00207498, and #GA00207527 regarding Resident #1's elopement and injury. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to provide adequate supervision for Resident #1, who eloped from the facility on 7/25/2020 and sustained a closed head trauma. Staff did not hear the pager alerts when the resident's exit door was opened, and staff were not required to carry pagers or walkie-talkies while on break. Resident #1 had no prior history of elopement or cognitive decline.
Deficiencies (2)
Facility failed to provide supervision consistent with residents' needs for Resident #1 who eloped from the facility.
Facility failed to ensure each resident received adequate and appropriate care and services in compliance with applicable laws for Resident #1.
Report Facts
Resident count: 31
Incident time range: 105
Resident admit date: Feb 7, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Facility Administrator | Provided interviews and information about the incident and pager system |
| Staff B | On duty during incident, no longer employed, could not be contacted | |
| Staff C | On duty in Memory Care Unit, on break during incident, did not hear pager | |
| Staff D | Assigned to Resident #1, on break during incident, did not carry pager | |
| Staff E | Assisted with virtual tour demonstrating pager system |
Inspection Report — Apr 6, 2020
Monitoring State
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report — Sep 30, 2019
Complaint Investigation State
Date: Sep 30, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00199529 and conduct the compliance inspection.
Complaint Details
Investigation of intake #GA00199529; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report — Feb 22, 2019
Follow-Up State
Date: Feb 22, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/20/18 initial inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report — Sep 20, 2018
Original Licensing State
Date: Sep 20, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, specifically for 3 of 31 residents with Alzheimer's Disease. Additionally, the facility did not meet conditions of waivers for these residents following a change in ownership.
Deficiencies (2)
The home admitted and retained residents who were not ambulatory and incapable of self-preservation, contrary to admission requirements.
The facility failed to ensure that conditions of a waiver were met for 3 residents after a change in ownership.
Report Facts
Residents present: 31
Residents not ambulatory: 3
Waivers granted date: May 7, 2018
Ownership change date: Apr 7, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding residents' capability of self-preservation and waiver applications |
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