Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236760 regarding an elopement incident involving Resident #1.
Findings
The facility failed to implement policies and procedures to support memory-impaired residents in a safe environment, resulting in Resident #1 eloping from the memory care unit. The investigation revealed lapses in protective care and oversight, with staff unable to determine how the resident exited the secured area despite all exit doors reportedly secured.
Complaint Details
The investigation was initiated following a complaint intake #GA00236760 about Resident #1 eloping from the memory care unit on 7/1/2023. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement policies, procedures, and practices to support memory impaired residents in a safe environment. | SS= D |
| Failure to provide protective care and watchful oversight meeting the needs of residents admitted and retained. | SS= D |
Report Facts
Incident date: Jul 1, 2023
Incident report submission date: Jul 3, 2023
Resident admission date: Jun 30, 2023
In-service training date: Jul 5, 2023
Staff work shift: 12
Staff work shift: 12
Elopement duration: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported the elopement incident and was interviewed regarding the investigation | |
| Staff B | Worked 7:00 a.m. to 7:00 p.m. on 7/1/2023, contacted Staff E to return Resident #1 safely | |
| Staff C | Observed Resident #1 wandering and was interviewed about the incident | |
| Staff D | Worked 7:00 p.m. to 7:00 a.m. on 7/1/2023, spoke with Resident #1 after elopement | |
| Staff E | Escorted Resident #1 back to memory care and completed incident report | |
| Staff F | Worked 7:00 p.m. to 7:00 a.m. on 7/1/2023, counted medications and observed Resident #1's exit | |
| GG | Interviewed and advised by Staff A of the incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 16, 2022
Visit Reason
The purpose of this visit was to complete the compliance inspection and to investigate intake #GA00226649.
Findings
No rule violations were cited during the investigation completed on 09/16/2022.
Complaint Details
Investigation was related to intake #GA00226649; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 27, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212412 and GA00213990.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes #GA00212412 and GA00213990 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 22, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00206157, which was started on 2020-07-13 and completed on 2020-07-22.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00206157 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00203406.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
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
Complaint Investigation
Deficiencies: 1
Oct 30, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint #GA00199802. The investigation was started on 2019-10-08 and completed on 2019-10-30.
Findings
The facility failed to provide protective care and watchful oversight for one resident who was left alone in a wheelchair, resulting in the resident sliding out and breaking their left tibia. Staff responsible were identified and terminated following the incident.
Complaint Details
Complaint #GA00199802 was investigated and substantiated based on the incident where Resident #1 was left alone for over 10 minutes, leading to injury.
Deficiencies (1)
| Description |
|---|
| Failed to provide protective care and watchful oversight for 1 of 10 sampled residents, resulting in a resident sliding out of a wheelchair and breaking a left tibia. |
Report Facts
Number of sampled residents: 10
Duration resident left alone: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding the incident and investigation | |
| Staff B | On duty during incident; terminated after incident | |
| Staff C | On duty during incident; terminated after incident |
Inspection Report
Original Licensing
Deficiencies: 0
Apr 24, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection, converting the facility from a personal care home to an assisted living community.
Findings
No rule violations were cited as a result of this inspection.
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