Inspection Reports for
Autumn Breeze Healthcare Center
1480 Sandtown Rd SW, Marietta, GA 30008, United States, GA, 30008
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Date: Feb 6, 2025
Visit Reason
The inspection was conducted to assess compliance with providing dental services to residents, specifically addressing whether the facility provided or obtained dental services for each resident.
Findings
The facility failed to provide dental services for one of 38 sampled residents (R25), who had teeth in various stages of decay and had not been offered dental care. Staff interviews revealed a lack of notification and scheduling for dental care for this resident.
Deficiencies (1)
Failed to provide dental services for one of 38 sampled residents (R25), potentially impacting quality of life.
Report Facts
Residents sampled: 38
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding dental care scheduling and notification for resident R25 | |
| DON | Director of Nursing | Interviewed regarding dental complaints and scheduling for residents |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 9
Date: Nov 14, 2022
Visit Reason
The inspection was conducted based on complaints and allegations related to environmental cleanliness, abuse, care planning, tracheostomy care, psychotropic medication monitoring, and facility administration.
Complaint Details
The complaint investigation revealed multiple issues including environmental cleanliness, abuse by a resident and staff physical restraint, inadequate care planning for tracheostomy and dialysis, failure to follow physician orders for wound care and glucose monitoring, lack of staff training and emergency preparedness for tracheostomy care, failure to monitor psychotropic medication effects and behaviors, and inadequate facility-wide assessment and administration. Immediate jeopardy was identified related to abuse and tracheostomy care.
Findings
The facility failed to maintain a clean environment for residents, protect residents from abuse, develop and implement appropriate care plans especially for tracheostomy and dialysis care, ensure staff competency and training for emergency tracheostomy care, monitor psychotropic medication effects and behaviors, and conduct a proper facility-wide assessment to meet resident needs. Immediate jeopardy was identified related to abuse and tracheostomy care.
Deficiencies (9)
Failed to ensure clean, comfortable, and homelike environment for residents with visible debris in rooms.
Failed to protect residents from verbal and physical abuse, including ongoing abuse by a resident and physical restraint by staff.
Failed to develop and implement care plans for emergency tracheostomy care and dialysis treatments.
Failed to provide appropriate treatment and care according to orders, including weekly skin assessments, wound care per physician orders, and obtaining physician orders for fingerstick glucose.
Failed to provide safe and appropriate respiratory care including staff training and emergency tracheostomy kits for residents with tracheostomies.
Failed to administer the facility in a manner that enabled effective and efficient use of resources, including competent staff and supplies for tracheostomy care and abuse prevention.
Failed to implement gradual dose reductions and monitor behaviors for residents on psychotropic medications.
Failed to conduct and document a facility-wide assessment to determine resources necessary to care for residents with tracheostomies.
Failed to develop, implement, and maintain an effective training program for staff on tracheostomy care and emergency management.
Report Facts
Residents sampled: 47
Residents affected by environmental cleanliness deficiency: 3
Residents affected by abuse deficiency: 8
Residents affected by tracheostomy care deficiency: 4
Residents affected by psychotropic medication monitoring deficiency: 6
Dates of survey completion: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper 1 | Housekeeper | Mentioned in relation to cleaning deficiencies in resident rooms |
| Administrator | Facility Administrator | Interviewed regarding environmental cleanliness, abuse incidents, and facility administration |
| Housekeeping Director | Housekeeping Director | Interviewed regarding cleaning expectations and deficiencies |
| Certified Nursing Assistant 2 | CNA | Interviewed regarding abuse training and resident interactions |
| Certified Nursing Assistant 3 | CNA | Interviewed regarding tracheostomy care training |
| Certified Nursing Assistant 4 | CNA | Interviewed regarding observation of resident behaviors and tracheostomy care training |
| Certified Nursing Assistant 5 | CNA | Interviewed regarding physical restraint incident and tracheostomy care training |
| Licensed Practical Nurse 1 | LPN | Interviewed regarding skin assessments and glucose monitoring |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding behavior documentation and tracheostomy care |
| Licensed Practical Nurse 3 | LPN | Observed administering blood sugar tests without physician orders |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding skin assessments, behavior documentation, and blood sugar testing |
| Registered Nurse 2 | RN | Interviewed regarding lack of tracheostomy training and emergency preparedness |
| Unit Manager 1 | Unit Manager | Interviewed regarding tracheostomy care and emergency preparedness |
| Medical Director | Medical Director | Interviewed regarding resident behavior and expectations for tracheostomy care |
| Medical Doctor of Internal Medicine | Physician | Interviewed regarding wound care order adherence |
| Medical Doctor of Dermatology | Physician | Interviewed regarding wound care order adherence |
| Wound Care Nurse-Licensed Practical Nurse | Wound Care Nurse-LPN | Interviewed regarding wound care and emergency hospital transfers |
| Respiratory Therapist | Respiratory Therapist | Interviewed regarding tracheostomy care training and emergency management |
| Assistant Director of Nursing | ADON | Interviewed regarding staff training, behavior monitoring, and tracheostomy care |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 29, 2021
Visit Reason
The inspection was conducted due to concerns about medication error rates exceeding the acceptable threshold of 5 percent or less.
Complaint Details
The visit was complaint-related due to concerns about medication error rates exceeding 5 percent. The complaint was substantiated based on observations, record reviews, and staff interviews confirming medication errors and unavailable medications.
Findings
The facility failed to ensure medication error rates were within acceptable limits, with a total error rate of 16% observed across three residents. Deficiencies included unavailable medications and improper administration techniques, such as failure to instruct residents on inhaler use.
Deficiencies (5)
Medication error rate exceeded 5 percent, with 4 errors in 25 opportunities for three residents.
Memantine 5 mg was not available for Resident #47 during medication pass.
Licensed Practical Nurse did not instruct Resident #47 on proper inhaler use, resulting in medication coming out of nose and mouth.
Aspercreme was not available for Resident #6 during medication pass.
Gabapentin 100 mg was not available for Resident #72 during medication pass.
Report Facts
Medication opportunities observed: 25
Medication errors: 4
Medication error rate: 16
Medication order dates: Feb 11, 2020
Medication order dates: Sep 11, 2020
Medication order dates: Mar 27, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Named in medication error findings for Residents #47 and #6 |
| LPN CC | Licensed Practical Nurse | Named in medication error finding for Resident #72 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration expectations |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed regarding medication refill processes and orders |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 12/8/17 annual inspection and complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
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