Inspection Reports for Ashton Senior Living, Gainesville
1012 ENOTA AVENUE, GAINESVILLE, GA, 30501.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 23, 2025, was a complaint investigation that found no rule violations. Earlier inspections showed a pattern of deficiencies primarily related to medication administration, including failure to employ certified medication aides, inaccurate medication records, and improper medication storage, as well as issues with staff qualifications and background checks. Several complaint investigations substantiated concerns about community leadership, staff oversight, and resident care, but enforcement actions such as fines or license suspensions were not listed in the available reports. Complaint investigations were mostly unsubstantiated in recent visits, with the exception of some substantiated issues involving medication management and staff qualifications. The facility’s inspection history shows ongoing challenges with medication administration and staff oversight, with no clear improvement trend evident through the latest reports.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
182% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
54 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005591 through an unannounced onsite visit conducted on 9/23/2025.
Complaint Details
Investigation of intake #GA50005591 found no rule violations.
Findings
The investigation was completed on 9/25/2025 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 8, 2025
Visit Reason
The purpose of this visit was to conduct a complaint intake #GA50003235 with an on-site visit starting on 2025-07-18 and completed on 2025-08-08.
Complaint Details
Complaint intake #GA50003235 triggered the inspection. The complaint was substantiated by findings related to community leadership and evaluation of applicants for admission.
Findings
The inspection found that the assisted living community failed to designate qualified staff to act on behalf of the administrator or on-site manager, and failed to provide a physical examination for Resident #3 conducted within 30 days prior to admission, reflecting the resident does not require continuous medical or nursing care and is free of active tuberculosis.
Deficiencies (2)
Failed to designate qualified staff as responsible to act on behalf of the administrator or on-site manager.
Failed to provide a physical examination conducted by a licensed physician, nurse practitioner, or physician's assistant dated within 30 days prior to admission for Resident #3.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to lack of access to documentation and inability to locate physical examination for Resident #3. | |
| Staff E | Named in findings related to lack of access to documentation and identified as owner and in charge. | |
| Staff F | Named in findings as having access to documentation and identified as owner and in charge. | |
| Staff C | Acknowledged receipt of email requesting documentation but did not forward requested physical examination. |
Inspection Report
Follow-Up
Census: 54
Deficiencies: 4
Date: Jun 17, 2025
Visit Reason
The purpose of this visit was to conduct a compliance follow-up inspection to verify correction of previous deficiencies.
Findings
The facility failed to ensure proper oversight by the governing body, resulting in repeated violations including failure to conduct criminal background checks for direct access employees, lack of a registered nurse or licensed practical nurse on-site for required hours, and failure to employ certified medication aides to administer medications. These deficiencies were consistent with prior inspections.
Deficiencies (4)
Failure to obtain satisfactory fingerprint records check determination for direct access employees.
Failure to have a registered professional nurse or licensed practical nurse on-site to support care and oversight for communities with 31 to 60 residents, minimum 16 hours per week.
Failure to employ certified medication aides to administer medications.
Failure of governing body to provide oversight to ensure compliance with state rules and regulations.
Report Facts
Census: 54
Staff without fingerprint background check: 2
Staff without CMA certification: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Direct access employee without fingerprint background check and no CMA certification; administered medications | |
| Staff C | Direct access employee without fingerprint background check and no CMA certification; administered medications; resigned April 2025 | |
| Staff D | No CMA certification; administered medications | |
| Staff A | Interviewed regarding staff employment and certification status |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
The purpose of this visit was to investigate complaint #GA50001173.
Complaint Details
Investigation of complaint #GA50001173 resulted in no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 6
Date: Mar 24, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to verify correction of previous deficiencies.
Findings
The facility was found to have ongoing violations including falsification of medication administration records, failure to designate qualified staff to act in the administrator's absence, failure to obtain criminal background checks for direct access employees, failure to employ certified medication aides to administer medications, and failure to securely store and properly document controlled substances. No rule violations were cited as a result of the follow-up investigation conducted on 3/17/2025.
Deficiencies (6)
Facility continues to submit falsified medication administration records indicating Staff B administered medications on a day Staff B was not scheduled to work.
Administrator failed to designate qualified staff to act on his/her behalf and carry out duties in absence of administrator.
Facility failed to obtain satisfactory fingerprint background checks for 3 of 7 direct access staff (Staff B, Staff C, Staff F).
Facility failed to employ certified medication aides to administer medications for 3 of 7 staff (Staff B, Staff C, Staff J).
Facility failed to maintain daily medication assistance records properly updated for residents receiving medication assistance.
Facility failed to ensure medications, including controlled substances, were stored securely and inventoried appropriately to prevent loss and unauthorized use.
Report Facts
Staff without CMA certification: 3
Staff without fingerprint background check: 3
Residents with medication administration records reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in falsification of medication records and lack of CMA certification. | |
| Staff C | Administered medications without CMA certification and lacked fingerprint background check. | |
| Staff F | Lacked fingerprint background check. | |
| Staff J | Lacked CMA certification. | |
| Staff A | Interviewed regarding staffing and medication administration practices. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 7
Date: Mar 4, 2025
Visit Reason
The purpose of this visit was to investigate complaints #GA50000294 and GA00247594 with an onsite visit made on 3/4/25 and investigation completed on 3/5/25.
Complaint Details
The visit was complaint-related to investigate allegations including unqualified personnel administering medications, lack of criminal background checks, missed medications, and improper medication handling.
Findings
The facility failed to ensure proper oversight by the governing body, resulting in unqualified staff administering medications, lack of criminal background checks for staff, absence of licensed nurses on-site, failure to administer medications as ordered, failure to employ certified medication aides, failure to maintain accurate medication administration records, and improper medication storage and inventory control.
Deficiencies (7)
Failure to ensure governing body oversight resulting in unqualified staff administering medication.
Failure to obtain satisfactory fingerprint background checks for direct access employees (Staff B and Staff C).
Failure to have a registered professional nurse or licensed practical nurse on-site for required hours.
Failure to administer medications according to physician's orders for Resident #4.
Failure to employ certified medication aides to administer medications (Staff B, Staff C, Staff D).
Failure to update Medication Administration Record (MAR) each time medication was offered or taken for Residents #1 and #5.
Failure to properly inventory medications and maintain controlled substances log for Resident #1.
Report Facts
Census: 56
Medication doses missed: 3
Staff without fingerprint background checks: 2
Staff failing to be certified medication aides: 3
Unaccounted medication pills: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and aware of lack of CMAs, missing medications, and background check issues. | |
| Staff B | Administered medications without CMA certification; initials on MARs; unaware of missing medications and unaccounted pills. | |
| Staff C | Administered medications without CMA certification; lacked fingerprint background check. | |
| Staff D | Administered medications without CMA certification. |
Inspection Report
Follow-Up
Deficiencies: 6
Date: Jan 15, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to verify correction of previously cited deficiencies, with an on-site visit made on 12/18/2024.
Findings
The facility was found to have multiple ongoing deficiencies including submission of falsified medication administration records, failure to designate qualified staff to act on behalf of the administrator, failure to obtain required criminal background checks for staff, failure to employ certified medication aides to administer medications, failure to maintain accurate medication administration records, and failure to securely store and inventory medications, especially controlled substances.
Deficiencies (6)
Facility continues to submit falsified medication administration records indicating Staff B administered medications on a day Staff B was not scheduled to work.
Administrator failed to designate qualified staff to act on his/her behalf and carry out duties in absence.
Facility failed to obtain satisfactory fingerprint background checks for 3 of 7 direct access staff (Staff B, Staff C, Staff F).
Facility failed to employ certified medication aides to administer medications for 3 of 7 staff (Staff B, Staff C, Staff J).
Medication administration records (MAR) for multiple residents were not accurately maintained or updated.
Medications, including controlled substances, were not stored securely or inventoried properly; discrepancies found in controlled drug logs and administration documentation.
Report Facts
Staff without background checks: 3
Staff without CMA certification: 3
Residents with medication record issues: 4
Controlled substances prescribed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in falsified medication administration records and lack of CMA certification. | |
| Staff C | Administered medications without CMA certification and lacked background check. | |
| Staff F | Lacked background check and resigned effective 11/25/24. | |
| Staff J | Lacked CMA certification. | |
| Staff A | Interviewed regarding staffing and medication administration practices. |
Inspection Report
Follow-Up
Deficiencies: 8
Date: Nov 1, 2024
Visit Reason
The purpose of this visit was to conduct a follow-up to the 5/30/24 complaint investigation with onsite visits on 10/10/24 and 10/23/24, completed on 11/1/24.
Complaint Details
This visit was a follow-up to the complaint investigation initiated on 5/30/24, with onsite visits on 10/10/24 and 10/23/24, completed on 11/1/24.
Findings
The facility was found to have multiple deficiencies including falsification of medication administration records, failure to designate qualified staff to act in the administrator's absence, failure to employ certified medication aides, failure to administer medications according to physician orders, failure to maintain accurate medication administration records, and failure to securely store and inventory medications, particularly controlled substances.
Deficiencies (8)
Facility submitted falsified medication administration records showing Staff B administered medications on a date when Staff B was not present.
Administrator failed to designate qualified staff to act on his/her behalf in absence; no certified medication aide or nurse was onsite with access to narcotics.
Facility failed to obtain satisfactory fingerprint background checks for direct access employees Staff B, Staff C, and Staff F.
Staff assisting with medication administration did not follow proper procedures including handling medications in properly labeled containers and documenting administration.
Facility failed to administer medications according to physician orders for Resident #1, including continued administration of discontinued Fentanyl patches and discrepancies with Percocet administration.
Facility failed to employ certified medication aides to administer medications; Staff B, Staff C, and Staff J were not certified.
Facility failed to maintain accurate Medication Administration Records (MAR) for Residents #9, #10, and #13; medications were administered but not documented properly.
Medications, including controlled substances for Resident #1, were not stored securely or inventoried properly; missing doses of Percocet were unaccounted for.
Report Facts
Medication doses missing: 27
Medication delivery: 45
Staff without fingerprint check: 3
Residents with MAR documentation issues: 3
Residents sampled for medication administration issues: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in falsification of medication records, unauthorized medication administration, lack of certification, and absence during medication administration. | |
| Staff C | Administered medications without certification or access to MARs; involved in medication administration documentation deficiencies. | |
| Staff J | Administered medications without certification; involved in medication administration documentation deficiencies. | |
| Staff A | Facility staff who acknowledged lack of certified medication aides and explained medication administration practices. | |
| Resident #13 | Provided interview regarding medication administration via G-tube on 10/23/24. | |
| BB | Interviewed regarding medication discontinuation and orders for Resident #1. | |
| JJ | Interviewed about medication delivery and availability for Resident #1. | |
| FF | Interviewed regarding physician discontinuation order for Resident #1. | |
| Staff G | Interviewed about staff presence and medication administration on 10/23/24. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 30, 2024
Visit Reason
The purpose of this visit was to investigate complaints #GA00245921, #GA00245622, and #GA00245465, with the investigation beginning on 5/29/24 and an onsite visit on 5/30/24.
Complaint Details
The investigation was complaint-driven based on complaints #GA00245921, #GA00245622, and #GA00245465. The investigation included review of records, interviews, and observations related to medication administration, staffing, and background checks.
Findings
The facility was found to have multiple deficiencies including failure to obtain satisfactory fingerprint background checks for direct access employees, failure to administer medications according to physician orders for 3 of 8 sampled residents, lack of certified medication aides to administer medications, failure to update medication administration records properly, and failure to securely store and inventory medications, especially controlled substances.
Deficiencies (5)
Failed to obtain a satisfactory fingerprint records check determination for 1 of 9 direct access staff (Staff B).
Failed to administer medications according to physician's orders for 3 of 8 sampled residents (Resident #1, Resident #3, Resident #6).
Failed to employ certified medication aides to administer medications for 2 of 9 staff (Staff B and Staff C).
Failed to ensure staff updated the Medication Administration Record (MAR) each time medication was offered or taken for 2 of 8 sampled residents (Resident #3 and Resident #6).
Failed to ensure medications were stored securely and inventoried appropriately to prevent loss and unauthorized use, including lack of proper narcotic logs for controlled substances for Resident #1.
Report Facts
Staff with missing fingerprint check: 1
Residents with medication administration issues: 3
Staff without CMA certification: 2
Medication patches delivered: 5
Medication patches unaccounted: 1
Pills observed: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiencies for missing fingerprint check, not certified medication aide, and medication administration issues | |
| Staff C | Named as not certified medication aide and involved in medication administration | |
| Staff G | Interviewed regarding fingerprint check and staffing issues | |
| Staff A | Received medication deliveries and mentioned in narcotic storage and access issues | |
| Staff H | Previously employed CMA who was no longer on staff | |
| DD | Department representative interviewed regarding medication storage and narcotic access |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 11, 2024
Visit Reason
The purpose of the survey was to investigate complaint #GA00244535 with an onsite visit conducted on 4/11/24.
Complaint Details
Investigation of complaint #GA00244535. The complaint was substantiated by observations and interviews confirming pest presence.
Findings
The facility failed to maintain an effective insect, rodent, or pest control program as evidenced by the observation of bugs on the walls in Resident #3's room and staff reports of bugs in closets and bathrooms despite recent pest control treatments.
Deficiencies (1)
Failure to maintain an insect, rodent or pest control program that continually protects the health of residents, evidenced by bugs observed on walls in Resident #3's room.
Report Facts
Pest control treatment dates: 7
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 2, 2024
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00240835, #GA00240833, #GA00240788, #GA00240755, and #GA00240995) concerning medication administration and related issues at Ashton Senior Living, Gainesville.
Complaint Details
The visit was complaint-driven, investigating multiple intake numbers related to medication errors, improper medication administration, and narcotic discrepancies. Substantiation details include confirmed medication errors, altered fentanyl patches, missing narcotics, and unauthorized staff access to medications.
Findings
The investigation found multiple deficiencies including medication administration errors, failure to employ certified medication aides, improper medication record keeping, and inadequate secure storage and inventory of medications, especially controlled substances. Specific incidents involved residents receiving incorrect medications, altered fentanyl patches, missing narcotics, and staff unauthorized to administer medications.
Deficiencies (4)
Failed to ensure residents were provided medication administration services according to physicians' orders and needs, resulting in a resident receiving the wrong medication.
Failed to employ certified medication aides to administer medications for 2 of 6 staff members.
Failed to ensure staff updated the Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 7 residents.
Failed to store medications securely and maintain an updated inventory log for controlled substances for 5 of 7 residents.
Report Facts
Residents involved: 7
Medication doses administered: 10
Fentanyl patches administered: 5
Hydrocodone quantity delivered: 90
Hydrocodone quantity delivered: 14
Hydrocodone quantity delivered: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in medication error finding, medication administration without certification, and narcotic log discrepancies | |
| Staff B | CNA | Named in medication administration without certification and narcotic log discrepancies |
| BB | Interviewed regarding medication errors and narcotic discrepancies | |
| EE | Observed medication handling and reported narcotic access issues | |
| FF | Notified about altered fentanyl patches and investigated medication issues | |
| CC | Provided pharmacy information regarding medication imprints | |
| DD | Provided pharmacy information and resident medication refill reports |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00238309. The onsite visit was conducted on 10/26/2023 and the survey was completed on 11/3/2023.
Complaint Details
The visit was complaint-related, investigating complaint #GA00238309. The complaint was substantiated by findings of uncertified medication administration and missing resident files.
Findings
The facility failed to employ a certified medication aide to administer medications for one of three sampled staff, and failed to maintain a resident file for three years after discharge for one of four sampled residents.
Deficiencies (2)
Facility failed to employ certified medication aide (CMA) to administer medications for 1 of 3 sampled staff (Staff B).
Facility failed to maintain a resident file for three years after discharge for 1 of 4 sampled residents (Resident #1).
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to have active certification for medication administration but administered medications. | |
| Staff C | Interviewed and made aware of findings regarding uncertified medication aide and missing resident file. | |
| Staff A | Interviewed regarding missing resident file for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 3, 2023
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00230838, GA00231121, GA00232070, GA00232684, GA00232719, GA00232963). The investigation began on 2023-03-13, an onsite visit was made on 2023-03-21, and the investigation was completed on 2023-04-03.
Complaint Details
The visit was complaint-related, investigating multiple intake numbers. The investigation included review of records and interviews conducted on 3/21/23. The complaint was substantiated with multiple deficiencies found.
Findings
The facility was found to have multiple deficiencies including failure to have a valid administrator license, failure to obtain satisfactory fingerprint records checks for staff, failure to maintain required physical exams for residents, and failure to maintain individual resident files. Additionally, the facility lacked a memory care unit despite residents requiring specialized memory care placement.
Deficiencies (5)
Facility failed to have an administrator with a valid license from the State Board of Long-Term Care Facility Administrators for 1 of 8 staff (Staff A).
Facility failed to ensure a satisfactory fingerprint records check determination prior to serving as administrator for 1 of 8 staff (Staff A).
Facility failed to ensure a satisfactory fingerprint records check determination prior to serving as a direct access employee for 1 of 8 staff (Staff F).
Facility failed to ensure administrator considered and maintained documentation of a physical exam within 30 days prior to admission for 2 of 9 residents (Resident #2 and Resident #4) who required placement in a specialized memory care unit.
Facility failed to maintain an individual resident file by the administrator for 1 of 9 residents (Resident #6).
Report Facts
Staff involved: 8
Residents reviewed: 9
Incident date: Sep 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator without valid license and fingerprint check; interviewed multiple times regarding deficiencies | |
| Staff B | Interviewed regarding administrator license status | |
| Staff F | Direct access employee without fingerprint check; quit on day of interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 12, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00230487 and #GA00230485, with the investigation beginning on 2023-01-10, an onsite visit on 2023-01-11, and completion on 2023-01-12.
Complaint Details
Investigation was initiated based on complaint intakes #GA00230487 and #GA00230485. The investigation was substantiated by findings of missing required physical examinations for residents.
Findings
The facility failed to obtain physical examinations conducted by a licensed physician, nurse practitioner, or physician's assistant dated within 30 days prior to admission for 2 of 3 sampled residents (Resident #1 and Resident #3). The required documentation was not received by the close of business on 2023-01-12.
Deficiencies (1)
Failed to obtain a physical examination conducted by a licensed physician, nurse practitioner or physician's assistant dated within 30 days prior to admission for Resident #1 and Resident #3.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 31, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00228571, GA00228572, GA00228576, and GA00228650.
Complaint Details
Investigation of four intakes (GA00228571, GA00228572, GA00228576, GA00228650) with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 18, 2022
Visit Reason
The purpose of this survey was to investigate complaints #GA00227938, GA00228246, and GA00228419. The onsite visit was conducted on 10/18/2022 to address concerns related to staffing, medication administration, and facility conditions.
Complaint Details
The investigation was complaint-driven based on complaints #GA00227938, GA00228246, and GA00228419. Findings included substantiated issues with staffing, medication administration, furniture condition, and nutrition.
Findings
The facility failed to provide sufficient staff time for residents to receive services and medications, employed uncertified medication aides, failed to update medication administration records properly, did not maintain furniture in good condition, and failed to offer at least one nutritious snack. Multiple residents and staff interviews confirmed these deficiencies.
Deficiencies (5)
Failed to have sufficient staff time so that each resident received services and medications for 2 of 5 sampled residents.
Failed to maintain furniture that was in good condition; observed worn and stained chairs.
Failed to employ certified medication aides to administer medications for 1 of 4 sampled staff.
Failed to ensure staff updated the Medication Administration Record each time medication was offered or taken for 1 of 4 sampled residents.
Failed to offer at least one nutritious snack; facility menu did not show snacks and residents reported no snacks served at night.
Report Facts
Sampled residents: 5
Sampled staff: 4
Dates with missing medication administration: 5
Dates with missing medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiency for not being a certified medication aide and unaware medication was not given | |
| Staff E | Made aware of multiple findings during the investigation | |
| AA | Interviewed regarding staffing and medication administration issues |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 17, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00225701, #GA00225737, #GA00225738, #GA00225810, and #GA00225791. The investigation began on 2022-08-01, an onsite visit was made on 2022-08-17, and the investigation was completed on 2022-08-18.
Complaint Details
The investigation was initiated based on multiple complaint intakes (#GA00225701, #GA00225737, #GA00225738, #GA00225810, and #GA00225791). The investigation included interviews and record reviews related to medication administration errors and employment of staff with unsatisfactory background checks.
Findings
The facility failed to ensure that an individual with an unsatisfactory criminal background check was not employed, and failed to provide medication administration services in accordance with physicians' orders for multiple residents. Additionally, certified medication aides were not used to administer medications for all residents, and medication errors occurred including wrong medication given to Resident #1.
Deficiencies (3)
Failed to ensure that an individual with an unsatisfactory criminal background check was not employed (Staff C).
Failed to provide medication administration services in accordance with physicians' orders for 3 of 6 residents (Resident #01, Resident #03, Resident #1, and Resident #5).
Failed to ensure that certified medication aides were used to administer medications for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5).
Report Facts
Number of residents with medication administration issues: 3
Number of residents without certified medication aides administering medications: 5
Date of fingerprint results showing unsatisfactory background check: Aug 6, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Employed despite unsatisfactory criminal background check; involved in medication administration | |
| Staff B | One of the only staff members passing medications; not certified medication aide | |
| Staff A | Med tech listed on work schedule; involved in fingerprint result communication | |
| Staff E | Gave medication without knowledge; no medication tech certification | |
| BB | Interviewed regarding medication errors and incidents | |
| DD | Interviewed regarding medication administration practices for Resident #03 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 12, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00225673. The onsite visit was conducted on 7/12/2022 to assess the facility's compliance related to elevator accessibility for residents dependent on wheelchairs.
Complaint Details
Investigation of complaint #GA00225673 regarding elevator accessibility. The elevator had been non-operational since 6/13/2022, impacting residents' ability to exit the facility. Staff confirmed the elevator was broken and parts were ordered. Facility staff and local authorities were coordinating to assist residents.
Findings
The facility failed to provide at least two wheelchair-accessible exits for residents dependent on wheelchairs due to an elevator that had been out of service since 6/13/2022. Staff reported the elevator was broken for two weeks, and the facility relied on local sheriff deputies and fire department assistance to move residents between floors.
Deficiencies (1)
Facility failed to provide at least two exits that were wheelchair accessible for residents dependent upon wheelchairs due to a non-functioning elevator.
Report Facts
Residents observed in wheelchairs on second floor: 5
Staff observed interacting with residents on second floor: 3
Date elevator non-operational since: Jun 13, 2022
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 11, 2022
Visit Reason
The purpose of the survey was to conduct a compliance inspection and investigate complaint #GA00223043. The survey started on 2022-05-10, with the onsite visit on 2022-05-11, and was completed on 2022-06-14.
Complaint Details
The inspection was conducted in response to complaint #GA00223043. The complaint involved concerns about facility administration licensure, staff certifications, resident care including ingestion of cleaning solution by a resident, and medication management.
Findings
The facility failed to have an administrator with a valid license, failed to ensure staff had current CPR certification and required continuing education, failed to ensure satisfactory criminal background checks, failed to provide protective care for a resident who ingested cleaning solution, and failed to properly update medication administration records and obtain timely medication refills for residents.
Deficiencies (7)
Facility failed to have an administrator with a valid license from the State Board.
Facility failed to ensure staff hired to provide hands-on personal services received current CPR certification with return demonstration of competency for 1 of 13 sampled staff.
Facility failed to ensure staff providing hands-on personal services had a minimum of sixteen hours of job-related continuing education annually for 4 of 13 sampled staff.
Facility failed to ensure each staff file included evidence of a satisfactory fingerprint record check or criminal history background check for 1 of 13 staff sampled.
Facility failed to provide protective care and watchful oversight for 1 of 5 sampled residents who ingested cleaning solution.
Facility failed to update the medication administration record (MAR) each time medication was offered or taken for 1 of 5 sampled residents.
Facility failed to ensure timely refills of prescribed medications to avoid interruption in routine dosing for 2 of 5 sampled residents.
Report Facts
Staff sampled: 13
Residents sampled: 5
Hours of continuing education required: 16
Medication doses missed: 2
Date of hospital visit: Apr 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding administrator licensure, CPR certification awareness, and made aware of findings | |
| Staff B | Interviewed regarding continuing education, resident ingestion incident, medication administration, and medication refills | |
| Staff E | Staff with online CPR certification but no return demonstration | |
| Staff L | Staff lacking required continuing education | |
| Staff M | Staff lacking required continuing education |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 21, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00210418 and #GA00210400. An on-site visit was made on 2021-01-21 and the investigation was completed on 2021-04-22.
Complaint Details
Investigation was complaint-related based on intake numbers #GA00210418 and #GA00210400. Multiple interviews and record reviews substantiated neglect in resident care, including failure to change or clean residents timely, resulting in discomfort and unsanitary conditions.
Findings
The facility failed to provide sufficient staff time to ensure that four of eight residents were kept comfortable and clean, with multiple instances of residents being found soaked, soiled, or left uncleaned for extended periods. Interviews and record reviews confirmed neglect in timely changing and cleaning of residents, contributing to discomfort and unsanitary conditions.
Deficiencies (1)
Facility failed to provide sufficient staff time to ensure residents were kept comfortable and clean, resulting in soaked sheets, dried feces on beds and wheelchairs, and residents left uncleaned for extended periods.
Report Facts
Residents affected: 4
Dates of observations: 6
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 23, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00205236 and GA00205779. The investigation began on 2020-06-09 and was completed on 2020-06-23.
Complaint Details
The inspection was complaint-driven based on intake numbers #GA00205236 and GA00205779. The complaint involved failure to conduct required background checks and inappropriate staff behavior involving residents in social media videos.
Findings
The facility failed to obtain required fingerprint background checks for certain staff members and failed to ensure residents were treated with dignity and respect, as evidenced by staff posting inappropriate TikTok videos involving residents. Specific deficiencies included missing fingerprint checks for three staff members and inappropriate social media behavior involving two residents with dementia.
Deficiencies (3)
Failed to obtain a records check application for the administrator upon application for employment and prior to placement in the position for 1 of 4 staff (Staff A).
Failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 2 of 4 sampled staff (Staff B and Staff C).
Failed to ensure each resident was treated with dignity, kindness, consideration and respect for 2 of 6 residents sampled (Resident #1 and Resident #2), including inappropriate TikTok videos posted by staff.
Report Facts
Staff sampled: 4
Residents sampled: 6
Residents involved: 2
Staff without fingerprint checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator and staff member lacking fingerprint check; interviewed regarding background checks and TikTok videos | |
| Staff B | Direct care staff lacking fingerprint check; involved in inappropriate TikTok videos and interviewed about the videos and background checks | |
| Staff C | Direct care staff lacking fingerprint check; involved in inappropriate TikTok videos |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Date: Jun 17, 2020
Visit Reason
The investigation was conducted to investigate complaint #GA00203938, starting on 2020-05-20 and completed on 2020-06-17.
Complaint Details
Investigation was complaint-driven (#GA00203938). Multiple interviews with residents and staff confirmed substantiated issues of insufficient staffing, poor hygiene care, delayed medication administration, and uncertified staff administering medications.
Findings
The facility failed to provide sufficient staff time to assist residents with daily hygiene and medication administration. Several residents and staff reported inadequate staffing, poor hygiene care, delayed medication administration, and uncertified staff administering medications.
Deficiencies (2)
Facility failed to provide sufficient staff time to assist residents with daily hygiene, including baths and oral care.
Facility failed to ensure that only certified medication aides performed medication administration services for 5 of 9 sampled staff.
Report Facts
Resident census: 58
Sampled staff uncertified for medication administration: 5
Sampled staff total: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Acknowledged facility was short staffed and certified med techs administered medications | |
| Staff F | Uncertified staff who administered medications | |
| Staff I | Uncertified staff who administered medications | |
| Staff J | Uncertified staff who administered medications | |
| Staff K | Uncertified staff who administered medications | |
| Staff L | Uncertified staff who administered medications | |
| AA | Reported insufficient staffing and no certified staff for medication administration | |
| BB | Reported insufficient staffing | |
| DD | Reported poor resident hygiene and uncertified medication administration by Staff J | |
| FF | Reported night shift did not check on him/her and left him/her in urine/feces | |
| Staff G | Reported staff shortages and absenteeism | |
| Staff I | Reported staff leaving during nights and absenteeism |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 22, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00202797, #GA00202894, #GA00203705, and #GA00203074 with on-site visits on 2/13/20 and 2/26/20, and survey completion on 4/22/20.
Complaint Details
The investigation was triggered by allegations of neglect and failure to provide protective care and watchful oversight. Specific complaints included a resident found on the floor after falling and not being checked on overnight, lack of staff documentation for resident checks, presence of children running in halls at night, and failure to notice or report a resident's deteriorating foot condition leading to possible amputation.
Findings
The facility failed to maintain personnel files for one staff member, failed to provide adequate protective care and watchful oversight for three residents, and failed to immediately address changes in a resident's condition including notifying representatives. Multiple incidents of neglect and inadequate staff oversight were documented.
Deficiencies (3)
Failed to maintain personnel files for each employee and ensure availability for inspection for 1 of 10 sampled staff (Staff C).
Failed to provide protective care and watchful oversight meeting residents' needs for 3 of 3 residents (Resident #1, Resident #01, Resident #02).
Failed to immediately take appropriate actions in case of accident or sudden adverse change in resident's condition, including notifying representative for 1 of 1 resident (Resident #2).
Report Facts
Intakes investigated: 4
Residents affected: 3
Staff sample size: 10
Inspection Report
Monitoring
Deficiencies: 0
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
Follow-Up
Deficiencies: 3
Date: Mar 27, 2020
Visit Reason
The visit was conducted to complete a follow-up to the 5/21/19 inspection and to investigate complaint intakes #GA00202797 and GA00202894, with on-site visits on 2/13/20 and 2/26/20 and survey completion on 3/27/20.
Complaint Details
The visit included investigation of complaint intakes #GA00202797 and GA00202894. The complaint investigation found substantiated issues including uncertified staff administering medications and failure to respond appropriately to a resident's adverse health condition.
Findings
The facility was found deficient in maintaining personnel files for employees, employing certified medication aides for medication administration, and failing to take immediate appropriate actions for a resident's adverse condition change, including notifying legal representatives. Specific deficiencies included missing personnel files, uncertified staff administering medications, and inadequate response to a resident's foot gangrene leading to hospitalization and surgery.
Deficiencies (3)
Failed to maintain personnel files for each employee and ensure availability for inspection (Staff T).
Failed to employ certified medication aides to administer medications; uncertified staff (Staff L and Staff O) passed medications.
Failed to immediately take appropriate actions and notify representative/legal surrogate for Resident #24 after adverse condition change.
Report Facts
Staff sampled: 10
Residents reviewed for medication records: 5
Incident report date: Feb 6, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Mentioned in relation to missing personnel file and passing medications without certification | |
| Staff O | Mentioned in relation to passing medications without certification | |
| Staff T | Personnel file missing | |
| Staff B | Reported staffing issues and uncertified medication administration | |
| Staff M | Reported medication tech absence and communication with Staff L | |
| Staff R | Completed incident report regarding Resident #24 | |
| Staff S | Involved in incident report and care of Resident #24 | |
| AA | Interviewed regarding Resident #24's condition and events |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00201710. The investigation started on 2020-01-08 and was completed on 2020-01-10.
Complaint Details
Investigation of complaint #GA00201710 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 16, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00197890.
Complaint Details
Complaint GA00197890 was investigated and substantiated by findings of failure to obtain criminal background checks and failure to provide medications as ordered.
Findings
The facility failed to obtain criminal background checks prior to employment for 2 of 6 sampled staff and failed to provide medications as ordered by the physician to 9 sampled residents due to lack of Certified Medication Aide on the morning of 06/12/19.
Deficiencies (2)
Failed to obtain criminal records check determination in compliance with O.C.G.A 31-7-250-et seq. for 2 of 6 sampled staff (Staff C, Staff D).
Failed to provide medications as ordered by the physician to 9 sampled residents due to no Certified Medication Aide available on 06/12/19 morning shift.
Report Facts
Number of sampled staff with missing criminal background checks: 2
Number of sampled residents not provided medications: 9
Date of inspection: Jul 16, 2019
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 9, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195875 and #GA00195686. An on-site visit was made to the facility on 4/9/19 and the investigation was completed on 4/15/19.
Complaint Details
The visit was complaint-related, investigating intake #GA00195875 and #GA00195686.
Findings
The facility was found to have multiple deficiencies including failure to ensure staff received tuberculosis screening and physical examinations within twelve months, failure to obtain criminal background checks for staff, failure to ensure staff wore visible employee identification badges, and failure to employ certified medication aides for medication administration.
Deficiencies (4)
Failed to ensure staff received tuberculosis screening and physical examination within twelve months for one of six staff sampled (Staff C).
Failed to obtain a criminal records check determination for one of six sampled staff (Staff C).
Failed to ensure staff wore employee identification badges which are readily visible with abbreviations for professional/special credentials for one of six sampled staff (Staff F).
Failed to have specialized staff for medication administration; Staff D and Staff E were not certified medication aides or certified nurse aides.
Report Facts
Staff sampled: 6
Staff D hire date: Feb 28, 2017
Staff E hire date: Jan 15, 2019
Staff C hire date: Mar 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiencies for missing tuberculosis screening, physical examination, and criminal background check | |
| Staff D | Named in deficiency for medication administration without certification | |
| Staff E | Named in deficiency for medication administration without certification | |
| Staff F | Named in deficiency for not wearing visible employee identification badge | |
| Staff B | Interviewed staff providing information about deficiencies |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Apr 9, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 2/11/2019 inspection.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time the medication was offered or taken for multiple residents, as evidenced by missing MAR updates on specific dates and times for residents #4, #5, #12, #19, and #24. The facility was working to correct the issue, including termination of staff.
Deficiencies (1)
Facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for multiple residents.
Report Facts
Dates MAR not updated: 11
Residents with MAR issues: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Interviewed and stated Staff K was aware of missing MAR signatures and facility was working to correct issue including termination of staff | |
| Staff K | Named by Staff I as aware of missing MAR signatures |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 15, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate multiple intakes (#GA00190470, #GA00190762, #GA00190846, #GA00190940, and #GA00192867).
Complaint Details
The inspection was conducted to investigate multiple complaint intakes (#GA00190470, #GA00190762, #GA00190846, #GA00190940, and #GA00192867).
Findings
The facility was found deficient in multiple areas including failure to provide infection control training to staff, failure to provide protective care and watchful oversight for a resident resulting in injury, failure to maintain accurate medication assistance records, failure to obtain timely medication refills, improper storage and disposal of medications, and failure to ensure residents received adequate and appropriate care in compliance with state regulations.
Deficiencies (7)
Failed to ensure staff received infection control training within first 60 days of employment for 3 of 6 sampled staff.
Failed to provide protective care and watchful oversight for 1 of 27 sampled residents resulting in injury from mechanical lift device.
Failed to update Medication Assistance Record (MAR) each time medication was offered or taken for 4 of 27 sampled residents.
Failed to obtain timely refills of prescribed medications for 1 of 27 sampled residents.
Failed to securely store and inventory medications to prevent loss for 4 of 27 sampled residents.
Failed to properly dispose of unused medications for 1 of 27 sampled residents.
Failed to provide care and services adequate, appropriate, and in compliance with state law for 1 of 27 sampled residents.
Report Facts
Staff not trained on infection control: 3
Residents sampled: 27
Medication discrepancies: 54
Medication missing: 11
Medication missing: 11
Medication not available: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding infection control training and witnessed replacement of Hydrocodone tablets with Tylenol tablets. | |
| Staff B | Sampled staff lacking infection control training. | |
| Staff C | Sampled staff lacking infection control training. | |
| Staff D | Interviewed regarding missing staff initials on MAR and CSL, unaware of discrepancies. | |
| Staff E | Sampled staff lacking infection control training. | |
| Staff G | Involved in incident where Resident #23 was injured using mechanical lift device. | |
| AA | Witnessed replacement of Hydrocodone tablets and provided interview about Resident #23 incident. | |
| BB | Interviewed about Staff G being alone with residents during incident. |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Mar 7, 2019
Visit Reason
The purpose of the visit was to investigate intake #GA00195175 involving allegations of drug diversion and medication mismanagement at Ashton Senior Living, Gainesville.
Complaint Details
The visit was complaint-related to investigate allegations of drug diversion and medication mismanagement at the facility. The complaint was substantiated with findings of drug diversion by staff, medication errors, and failure to follow regulatory requirements.
Findings
The investigation found multiple deficiencies including failure to investigate drug diversion, staff not wearing identification badges, medication administration errors, uncertified staff administering medications, lack of quarterly medication observations and drug regimen reviews, improper medication storage and disposal, missing resident files, failure to update medication records, and confirmed drug diversion resulting in arrests.
Deficiencies (12)
Facility's governing body failed to ensure compliance with rules including investigation of drug diversion allegations.
Staff failed to wear employee identification badges as required.
Medication administration errors including giving medications at incorrect times and failure to administer as ordered for multiple residents.
Non-certified staff administered medications.
No quarterly medication administration observations conducted by licensed nurse or pharmacist.
No quarterly drug regimen reviews conducted by licensed pharmacist for multiple residents.
Medications not stored securely; narcotics found in staff vehicle and in unauthorized locations.
Resident file missing for a discharged resident.
Failure to provide adequate and appropriate care; residents in pain due to medication diversion and mismanagement.
Failure to update medication assistance records accurately for residents.
Failure to report serious incidents involving residents to the Department in a timely and acceptable format.
Failure to ensure residents were free from neglect and exploitation related to medication diversion and pain management.
Report Facts
Medication tablets unaccounted for: 21
Medication tablets unaccounted for: 6
Medication tablets unaccounted for: 21
Medication tablets unaccounted for: 53
Medication tablets unaccounted for: 83
Medication tablets unaccounted for: 32
Fentanyl patches unaccounted for: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in multiple findings including drug diversion, medication administration errors, and improper medication storage. | |
| Staff B | Owner | Responsible for facility oversight; failed to ensure compliance and follow-up on reports of drug diversion. |
| Staff C | Involved in drug diversion; arrested during investigation; failed to maintain resident files. | |
| Staff D | Interviewed regarding medication administration and missing medications. | |
| Staff H | Administered medications without certification. | |
| Staff I | Interviewed regarding staff badge compliance. | |
| FF | Reported drug diversion concerns to management. | |
| HH | Reported resident pain complaints and medication issues. | |
| JJ | Reported medication access issues for Resident #3. | |
| AA | Found narcotics in staff vehicle during investigation. | |
| EE | Observed medication patch misuse. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 29, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 7/19/18 inspection.
Findings
The facility failed to ensure that one of seven sampled staff had the required 16 hours of continuing education units (CEUs) and failed to obtain a fingerprint check for the onsite manager.
Deficiencies (2)
Facility failed to ensure staff had 16 hours of continuing education units (CEUs) for 1 of 7 sampled staff (Staff A).
Facility failed to obtain a fingerprint check for the onsite manager (Staff A).
Report Facts
Sampled staff: 7
Continuing education hours required: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to continuing education and fingerprint check deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 13, 2018
Visit Reason
The purpose of this visit was to investigate complaint # GA00189070 and to conduct a second follow up inspection to the 6/8/17 annual inspection.
Complaint Details
Complaint # GA00189070 was investigated and rule violations related to the complaint are listed in the report.
Findings
The facility failed to ensure that each resident was given the right to be free from physical restraints for 1 of 11 sampled residents. Specifically, Resident #1 was observed with a raised half bed rail, which was not allowed for residents with dementia.
Deficiencies (1)
Facility failed to ensure residents were free from physical restraints; Resident #1 observed with raised half bed rail despite dementia diagnosis.
Report Facts
Sampled residents: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding use of half bed rails |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 13, 2018
Visit Reason
The visit was conducted as a second follow-up to the 6/8/17 annual inspection and to investigate complaint # GA00189070.
Complaint Details
Complaint # GA00189070 was investigated during this visit.
Findings
No rule violations were cited as a result of the follow-up inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 24, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00188651. An on-site visit was made on 5/24/18 and the investigation was completed on 7/19/18.
Complaint Details
The complaint investigation was triggered by complaint #GA00188651. The facility was found noncompliant for failing to obtain required criminal background checks for staff and failing to report a serious injury to the Department involving Resident #1, who suffered multiple injuries from falls and hospitalization.
Findings
The facility failed to obtain satisfactory fingerprint records checks for the Director and one employee, and failed to report a serious injury requiring medical care for one resident to the Department. The investigation revealed deficiencies in criminal background checks and reporting serious incidents.
Deficiencies (3)
Facility failed to obtain a satisfactory fingerprint records check determination for the Director who served as the administrator or onsite manager.
Facility failed to obtain a criminal records check determination for one employee as required.
Facility failed to report a serious injury to the Department that required medical care for one resident.
Report Facts
Sampled staff: 4
Sampled residents: 5
Incident report date: May 8, 2018
Hospital admission dates: May 11, 2018
Hospital discharge date: May 17, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Director | Named in deficiency for lack of fingerprint records check and interview regarding criminal background checks and incident reporting |
| Staff B | Employee | Named in deficiency for lack of criminal records check |
| Staff C | Interviewed regarding review of Staff A's file |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187293. An on-site visit was made on 4/18/18 and the investigation was completed on 6/14/18.
Complaint Details
Complaint #GA00187293 was investigated. The complaint involved the facility providing prohibited proxy caregiver services by administering morphine to Resident #3 based on hospice nurse instructions.
Findings
The facility failed to ensure that medical and nursing health services required on a periodic basis, or for short-term illness, were not provided as services of the assisted living community, specifically for 1 of 4 sampled residents (Resident #3). Staff administered morphine to Resident #3 based on hospice nurse instructions, which is prohibited.
Deficiencies (1)
Facility failed to ensure that medical and nursing health services required on a periodic basis, or for short-term illness, were not provided as services of the assisted living community for Resident #3.
Report Facts
Medication dose: 5
Date of visit: Apr 18, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Administered morphine to Resident #3 and interviewed regarding the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 13, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184887 with an on-site visit made on 2/13/18 and the investigation completed on 2/16/18.
Complaint Details
Complaint #GA00184887 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Nov 15, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 6/8/17 annual inspection.
Findings
The community failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 3 of 6 sampled residents, and failed to ensure adequate and appropriate care for 2 of 6 sampled residents. The violations were previously cited on 6/8/17 and involved medication documentation errors and missed medication administration.
Deficiencies (2)
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 3 of 6 residents sampled (Resident #5, Resident #6, and Resident #8).
Failed to ensure that each resident received care and services which were adequate, appropriate, and in compliance with state law and regulations for 2 of 6 sampled residents (Resident #8).
Report Facts
Residents sampled: 6
Residents with MAR deficiencies: 3
Residents with care deficiencies: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 17, 2017
Visit Reason
The purpose of the survey was to conduct a paperwork follow-up to the 5/8/17 inspection.
Findings
Based on a review of documentation submitted by the facility, the violations cited on the inspection have been corrected.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 8
Date: Jun 7, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of Ashton Senior Living, Gainesville. An on-site visit was made to the facility on 6/7/17 and the inspection was completed on 6/8/17.
Findings
The inspection identified multiple deficiencies including failure to ensure staff received timely tuberculosis screenings and physical exams, incomplete documentation of residents' physical exams prior to admission, medication aides not listed in good standing on the Georgia Certified Medication Aide Registry, failure to update Medication Assistance Records accurately, lack of a three-day emergency water supply, improper infection control practices by staff, and failure to provide adequate and appropriate care and services to residents as per state regulations.
Deficiencies (8)
Failure to ensure that each employee received a tuberculosis screening and physical examination within twelve months prior to providing care to residents.
Failure to maintain documentation of physical examination conducted within 30 days prior to admission reflecting resident does not require continuous medical or nursing care and is free of active tuberculosis for 2 of 6 sampled residents.
Medication aides employed were not listed in good standing on the Georgia Certified Medication Aide Registry for 2 of 5 sampled staff.
Failed to provide documentation to the Georgia Certified Medication Aide Registry necessary to complete application for placement of aide's name for 2 of 5 sampled staff.
Failed to ensure staff updated Medication Assistance Records each time medication was offered or taken for 5 of 6 sampled residents.
Failed to maintain a three-day supply of water for emergency use based on usual resident census.
Failed to ensure staff demonstrated understanding and use of proper infection control practices in delivery of care for 1 of 5 sampled staff.
Failed to provide care and services which were adequate, appropriate, and in compliance with state law and regulations for 5 of 6 sampled residents.
Report Facts
Residents present: 54
Medication errors: 5
Staff sampled: 5
Residents sampled: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to have tuberculosis screening and physical exam within twelve months; reported residents sometimes refused medications | |
| Staff C | Not listed on Georgia Certified Medication Aide Registry; observed improper infection control practice when handling medication | |
| Staff E | Not listed on Georgia Certified Medication Aide Registry; failed to demonstrate proper infection control practices | |
| Staff D | Not listed on Georgia Certified Medication Aide Registry | |
| Staff A | Administrator or on-site manager interviewed regarding deficiencies and registry issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 26, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00173772 and #GA00174182, with an on-site visit conducted on 4/26/17 and the investigation closed on 5/8/17.
Complaint Details
The visit was complaint-related, investigating complaints #GA00173772 and #GA00174182. The investigation was closed on 5/8/17.
Findings
The facility failed to obtain criminal background checks prior to employment for 2 of 2 sampled staff and failed to ensure that all Certified Medication Aides were listed in good standing on the Georgia CMA registry before permitting medication administration for 1 of 2 CMAs.
Deficiencies (2)
Failed to obtain a criminal records check determination prior to serving as an employee for 2 of 2 sampled staff (Staff D and Staff E).
Failed to ensure that all Certified Medication Aides were listed in good standing on the CMA registry before permitting the aide to administer medications for 1 of 2 CMAs (Staff D).
Report Facts
Number of sampled staff without criminal record check: 2
Number of Certified Medication Aides not listed in good standing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in findings for lack of criminal record check and not listed in good standing on CMA registry | |
| Staff E | Named in findings for lack of criminal record check | |
| Staff A | Interviewed staff who provided information about criminal record checks and CMA registry status |
Viewing
Loading inspection reports...
