Inspection Reports for Avery Place
124 AVERY STREET, WINTERVILLE, GA, 30683.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 8, 2022, identified deficiencies related to medication orders, specifically that some medications were administered without physician orders. Earlier inspections showed a pattern of deficiencies involving resident care, medication management, staffing, and documentation, including issues with supervision, delayed responses to call alerts, and failure to maintain required staff training and certifications. Several investigations substantiated complaints of inadequate care, neglect, and abuse, with some staff terminations and a police involvement following substantiated abuse cases, but no fines or license suspensions were listed in the available reports. Most complaints were substantiated, particularly those involving medication errors and resident treatment concerns. The facility’s inspection history shows ongoing challenges with medication administration and resident supervision, with some corrective actions taken such as staff terminations, but no clear trend of overall improvement or worsening.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
41 residents
Based on a September 2021 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2022
Visit Reason
The purpose of this visit was to investigate intake complaints GA00226493, GA00226887, and GA00226924.
Complaint Details
The investigation was triggered by intake complaints GA00226493, GA00226887, and GA00226924. Staff D administered over-the-counter medications (Melatonin and Tylenol PM) to residents without physician orders. Staff D was terminated on 8/17/22 for medication/documentation error. Staff B was also terminated for giving medications without a physician's order.
Findings
The facility failed to ensure that orders were required for all medications, including over-the-counter medications, for 2 of 3 residents (Resident #2 and Resident #3). Staff administered medications without physician orders, leading to termination of involved staff.
Deficiencies (1)
Facility failed to ensure that orders were required for all medications, including over-the-counter medications for 2 of 3 residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in medication error finding and termination for administering medications without orders. | |
| Staff B | Terminated for giving medications without a physician's order. | |
| Staff C | Interviewed regarding observations of Staff D's medication administration. | |
| Staff F | Paired with Staff D for medication training and observed medication administration. | |
| Staff G | Witnessed Staff D taking medication from bag and inquired about it. | |
| Staff H | Saw bottles of Melatonin and Tylenol PM in Staff D's bag. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 5, 2022
Visit Reason
The purpose of the survey was to conduct a compliance inspection and investigate complaint #GA00221884. The survey started on 2022-03-18 and was completed on 2022-04-05.
Complaint Details
The complaint investigation involved an incident with Resident #1 on 2/21/2022 where Staff D repeatedly responded to the resident's paging, removed the resident's pendant without proper respect, and failed to replace it. Staff D was terminated due to this incident. Resident #1 reported the pendant was taken away and staff did not treat him/her with respect.
Findings
The facility failed to ensure staff providing hands-on personal services had the required continuing education, failed to display the memory care certification, failed to comply with fire and safety rules including lack of fire drills for 2021, failed to maintain the ceiling in good repair, and failed to ensure residents were treated with dignity and respect as evidenced by an incident involving Resident #1 and Staff D.
Deficiencies (5)
Facility failed to ensure staff providing hands-on personal services had a minimum of sixteen (16) hours of job-related continuing education annually for 2 of 6 sampled staff (Staff B and Staff E).
Facility failed to display the memory care certification.
Facility failed to comply with applicable fire and safety rules; no fire drills were conducted in 2021.
Facility failed to ensure the ceiling was in good repair; ceiling trim was unattached in the non-memory care unit hallway.
Facility failed to ensure that each resident was treated with dignity, kindness, consideration and respect; incident involving Resident #1 where Staff D removed the resident's pendant and did not treat the resident respectfully.
Report Facts
Sampled staff: 6
Staff lacking continuing education: 2
Fire drills: 0
Sampled residents: 4
Resident involved: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in continuing education deficiency | |
| Staff E | Named in continuing education deficiency | |
| Staff A | Interviewed regarding multiple findings and aware of deficiencies | |
| Staff D | Involved in dignity and respect deficiency; terminated due to incident with Resident #1 | |
| Staff C | Interviewed regarding dignity and respect deficiency involving Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 14, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00219280. An onsite visit was made on 2021-12-06 and the investigation was completed on 2022-01-14.
Complaint Details
Investigation of intake #GA00219280 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 22, 2021
Visit Reason
The purpose of this survey was to investigate complaint #GA00218023. The investigation started on 2021-10-20 and was completed on 2021-10-22.
Complaint Details
The investigation was initiated due to complaint #GA00218023 regarding neglect and inadequate care of Resident #1, who was in pain and denied transfer to recliner despite requests. Staff interviews confirmed the resident's pain and denial of requested care. Resident did not recall events. Staff B did not offer pain medication when resident reported pain.
Findings
Based on record review and interviews, the facility failed to provide adequate and appropriate care to Resident #1, who was in pain and wanted to move from a wheelchair to a recliner but was denied by staff. The facility also failed to ensure the resident's right to be free from neglect, including not offering pain medication when requested.
Deficiencies (2)
Failed to provide adequate care and services to Resident #1, who was in pain and denied transfer to recliner.
Failed to ensure each resident's right to be free from neglect.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to denying resident transfer to recliner and not offering pain medication. | |
| Staff C | Involved in assisting resident and lifting resident; involved in denial of transfer to recliner. | |
| Staff D | Reported resident crying in pain and denied transfer to recliner. | |
| Staff E | Reported conversation with Staff B about resident wanting to lie down. | |
| Staff A | Reported Staff B did not honor resident's choice or offer pain medication. | |
| AA | Reported resident crying in pain and wanting recliner but was denied. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 13, 2021
Visit Reason
The purpose of this visit was to investigate complaint #GA00216848, with the investigation starting on 2021-09-16 and completing on 2021-10-13.
Complaint Details
Investigation of complaint #GA00216848 regarding failure to respond appropriately to a resident's fall on 8/5/2021, including failure to notify family and failure to document the incident properly.
Findings
The facility failed to ensure immediate appropriate action was taken in response to a resident's fall and adverse change in condition, including failure to notify the resident's representative or legal surrogate and failure to retain proper records of the incident and response.
Deficiencies (1)
Failure to ensure immediate action and notification to representative/legal surrogate after a resident's fall and adverse change in condition.
Report Facts
Date of resident fall incident: Aug 5, 2021
Number of staff involved in response: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in failure to assist resident after fall and failure to notify family | |
| Staff C | Reported finding resident on floor and called for help | |
| Staff A | Stated staff could not find notification to family |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 3
Date: Sep 7, 2021
Visit Reason
The purpose of this visit was to investigate complaint #GA00216637. The investigation started on 2021-08-25 and was completed on 2021-09-07.
Complaint Details
Investigation of complaint #GA00216637 regarding inadequate supervision and delayed staff response to resident call alerts, as well as concerns about staffing levels and resident care.
Findings
The facility failed to supervise residents consistent with their needs, as evidenced by delayed responses to resident call alerts ranging from 15 to 80 minutes. Multiple unwitnessed resident falls were reported. The facility also failed to maintain the interior ceiling in good repair and did not provide evidence of family involvement in resident care plans when appropriate.
Deficiencies (3)
Failure to supervise residents consistent with their needs, with delayed staff responses to call alerts.
Facility failed to ensure the ceiling was in good repair, with unattached ceiling trim and holes in hallways.
Resident care plans lacked evidence of family involvement in their development when appropriate.
Report Facts
Resident census: 41
Staff worked alone duration: 29
Number of residents sampled: 5
Number of unwitnessed falls: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Worked alone for 29 minutes on 2021-08-04 and acknowledged staffing issues | |
| Staff B | Provided staff timesheets and acknowledged ceiling repair findings | |
| Staff O | Acknowledged ceiling repair findings and lack of family signatures on care plans | |
| AA | Reported staffing shortages and delays in resident care | |
| BB | Reported staffing shortages and challenges in memory care unit | |
| CC | Reported staff no-shows and staffing shortages in July and August 2021 |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Jun 18, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00213680, #GA00213691, #GA00213699, and #GA00213702, with the investigation starting on 2021-05-11, an onsite visit on 2021-05-13, and completion on 2021-06-18.
Complaint Details
Investigation was complaint-related based on multiple intakes. The investigation included review of staffing schedules, incident reports, pendant call response times, and interviews with staff and a former resident. Staffing shortages, no call/no show agency staff, delayed medication administration, and inadequate supervision were substantiated.
Findings
The facility failed to ensure adequate supervision for 12 of 13 residents, with staffing shortages and frequent no call/no show incidents by agency staff. Multiple residents in memory care required two to three person assists, and there were multiple falls and incidents of aggression. Pendant call response times were excessively long, and medication administration was delayed due to staffing issues.
Deficiencies (1)
Failed to ensure residents were supervised consistent with their needs for 12 of 13 residents.
Report Facts
Residents present: 34
Diabetic residents: 4
Incontinent residents: 15
Wheelchair dependent residents: 12
Residents requiring two person assist: 4
Incidents of falls in memory care: 9
Residents requiring two to three person assist: 3
Pendant call response times: 99
Fire department calls for one resident: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 21, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00212501 and to conduct the compliance inspection with on-site visits made on 3/31/21 and 5/13/21, and the survey completed on 5/21/21.
Complaint Details
Investigation of intake #GA00212501 with substantiated findings related to medication administration and timely medication refills.
Findings
The facility failed to update the Medication Administration Record (MAR) each time medication was offered or taken for 3 of 4 sampled residents, and failed to ensure timely refills of prescribed medications for 2 of 4 sampled residents, resulting in missed doses due to medications not being on the cart.
Deficiencies (2)
Facility failed to update the Medication Administration Record (MAR) each time medication was offered or taken for 3 of 4 sampled residents.
Facility failed to ensure refills of prescribed medications were obtained timely, causing interruptions in routine dosing for 2 of 4 sampled residents.
Report Facts
Dates of missed medication doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding documentation of circled initials on MAR and issues with medication delivery. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 20, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210492. An on-site visit was made on 1/20/2021 and the investigation was completed on 3/11/2021.
Complaint Details
The investigation was triggered by intake #GA00210492. The complaint involved failure to develop and use an appropriate care plan for Resident #1, failure to address specific behaviors and interventions, and failure to notify the responsible party after an incident where Resident #1 was scratched during an altercation with staff.
Findings
The facility failed to develop an individual written care plan within 14 days of admission and failed to require staff to use the care plan as a guide for care for Resident #1. The care plan did not address specific behaviors or interventions. Additionally, the facility failed to take immediate appropriate action after an incident involving Resident #1, including failure to notify the responsible party of the incident.
Deficiencies (3)
Failed to develop the resident's individual written care plan within 14 days of admission and require staff to use the care plan as a guide for care and services.
Failed to ensure the care plan addressed specific behaviors with interventions for the resident.
Failed to ensure immediate appropriate action was taken after an accident or sudden adverse change, including notifying the representative or legal surrogate.
Report Facts
Dates of staff notes: 37
Care plan completion date: Dec 24, 2020
Incident date and time: Dec 13, 2020
Incident report date: Dec 14, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Completed staff notes and incident report related to Resident #1 | |
| Staff D | Involved in incident with Resident #1 and interviewed about the event | |
| Staff A | Interviewed and acknowledged care plan deficiencies and communication practices | |
| Staff C | Completed first responder worksheet and involved in incident with Resident #1 | |
| BB | Responsible party for Resident #1, unaware of incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2020
Visit Reason
The investigation was conducted to investigate complaint #GA00206871, starting on 2020-08-15 and completed on 2020-09-08.
Complaint Details
Investigation of complaint #GA00206871 found substantiated physical abuse by Staff D against Resident #1, who was injured and given medication for pain. Staff D was placed on administrative leave.
Findings
The facility failed to ensure a resident was free from physical abuse. Staff D grabbed Resident #1's left arm to retrieve bags of food, causing pain and bruising. Staff D was placed on administrative leave as a result of the abuse.
Deficiencies (1)
Facility failed to ensure each resident was free of physical abuse for 1 of 7 residents sampled (Resident #1). Staff D grabbed Resident #1's left arm causing pain and bruising.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in physical abuse finding involving grabbing Resident #1's left arm. | |
| Staff C | Witnessed Resident #1 holding arm in pain and reported incident. | |
| Staff A | Acknowledged that Staff D grabbed Resident #1's left arm. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Aug 25, 2020
Visit Reason
The purpose of this investigation was to investigate complaints #GA00206100 and #GA00206240, with the investigation starting on 2020-07-13 and ending on 2020-08-25.
Complaint Details
Investigation was complaint-driven based on complaints #GA00206100 and #GA00206240. Multiple interviews with residents and staff confirmed substantiation of staffing shortages and delays in resident care.
Findings
The facility failed to maintain the required minimum on-site staff to resident ratio during waking and non-waking hours, resulting in insufficient staffing to meet resident needs. Multiple residents and staff reported delays in assistance and concerns about short staffing, especially at night.
Deficiencies (1)
Facility failed to maintain a minimum on-site staff to resident ratio of one awake direct care staff person per 15 residents during waking hours and one awake direct care staff person per 25 residents during non-waking hours where residents have minimal care needs.
Report Facts
Resident census: 35
Assisted Living residents: 19
Memory Care residents: 15
Staff on night shift: 1
Residents in Assisted Living during night shift: 18
Residents in Memory Care during night shift: 15
Frequency of short staffing at night: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Medication Tech | Named in relation to night shift staffing and workload |
| Staff M | Acknowledged the findings on 8/25/20 | |
| AA | Staff who stated the facility census was 35 residents | |
| BB | Staff who expressed concerns about staffing and scheduling | |
| CC | Staff who described night shift staffing and resident risks | |
| EE | Staff who stated the facility needed more staff and described resident health decline |
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
Complaint Investigation
Deficiencies: 1
Date: Nov 14, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00200537. The onsite visit was made to the facility on 11/14/19 and the survey was completed on 11/15/19.
Complaint Details
The investigation was triggered by complaint #GA00200537 regarding alleged abuse by Staff E towards Resident #1. The complaint was substantiated based on incident reports and staff interviews.
Findings
The facility failed to ensure that each resident received adequate and appropriate care in compliance with state law for 1 of 4 sampled residents (Resident #1). Resident #1 alleged that Staff E struck him/her, and Staff E was separated due to substantiated verbal abuse. Interviews and incident reports confirmed the allegations.
Deficiencies (1)
Failure to provide adequate, appropriate care and services in compliance with state law for Resident #1, including substantiated verbal abuse by Staff E.
Report Facts
Date of incident: Oct 24, 2019
Date of staff separation: Nov 4, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Employee alleged to have struck Resident #1 and separated due to substantiated verbal abuse | |
| Staff A | Witnessed Resident #1's agitation and reported verbal abuse by Staff E | |
| Staff B | Nurse, Care Plan Director | Accompanied Staff A to Resident #1's room during incident |
| Staff D | Heard Staff E say 'stop hitting me' and helped get supervisor and nurse | |
| AA | Reported observations of Resident #1's agitation and Staff E's strong tone | |
| Staff C | Encouraged Resident #1 to calm down during incident |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 9, 2019
Visit Reason
The purpose of this visit was to conduct a compliance visit and investigate complaint intakes #GA00199698 and #GA00199659 with onsite visits made on 10/2/19, 10/8/19, and 10/9/19.
Complaint Details
The visit was triggered by complaint intakes #GA00199698 and #GA00199659. The investigation found substantiated deficiencies including failure to provide timely emergency response and failure to maintain required staff training and documentation.
Findings
The facility failed to ensure staff had current CPR certification with return demonstration for 3 of 6 sampled staff, failed to ensure 16 hours of continuing education for 6 of 8 sampled staff, failed to maintain the facility in good repair with cracks and stains observed, failed to maintain documentation of quarterly medication administration observations for 4 CMAs, failed to update Medication Assistance Records for 2 of 14 sampled residents, and failed to immediately contact emergency medical services for a resident with a sudden change in condition.
Deficiencies (6)
Staff hired to provide hands-on personal services did not have current CPR certification with return demonstration for 3 of 6 sampled staff.
Staff failed to have 16 hours of continuing education annually for 6 of 8 sampled staff.
Facility failed to maintain walls and floors in good repair; cracks and stains observed.
Facility failed to maintain documentation of quarterly observations of random medication administration for 4 CMAs.
Medication Assistance Records were not updated each time medication was offered or taken for 2 of 14 sampled residents.
Facility failed to immediately contact emergency medical services to arrange for emergency transport for a resident with a sudden change in condition.
Report Facts
Staff without current CPR certification: 3
Staff without required continuing education hours: 6
Certified Medication Aides without quarterly observations: 4
Residents with incomplete Medication Assistance Records: 2
Incident report date: Oct 2, 2019
Time delay in treatment: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in CPR certification and medication observation deficiencies | |
| Staff E | Named in CPR certification and medication observation deficiencies | |
| Staff F | Named in CPR certification and medication observation deficiencies | |
| Staff A | Interviewed regarding staff training and facility conditions | |
| AA | Interviewed regarding resident condition and MAR deficiencies | |
| Resident #1 | Resident involved in delayed emergency response incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00193513. An onsite visit was made to the facility on 2019-01-03 and the investigation was completed on 2019-01-15.
Complaint Details
Complaint #GA00193513 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/4/18 investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Sep 19, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00191284, with on-site visits made on 9/18/18 and 9/19/18.
Complaint Details
The inspection was conducted to investigate intake #GA00191284.
Findings
The facility was found deficient in multiple areas including failure to ensure staff had required continuing education hours, incomplete emergency preparedness drills, lack of posted keypad instructions for memory care unit exits, missing physician physical examinations for memory care residents, failure to complete annual competency reviews for certified medication aides, untimely medication refills causing interruptions in dosing, and failure to conduct required National Sex Offender Registry searches for most sampled residents.
Deficiencies (7)
Facility failed to ensure staff had a minimum of 16 hours of job-related continuing education for 3 of 4 sampled staff.
Facility failed to ensure fire and disaster drills were conducted in compliance with fire safety regulations.
Facility failed to post directions for the keypad used to lock and unlock exits to the memory care unit.
Facility failed to obtain physician's report of physical examination within 30 days prior to admission for 2 of 6 sampled memory care residents.
Facility failed to complete annual competency reviews for certified medication aides for 3 of 6 sampled staff.
Facility failed to obtain timely refills of prescribed medications causing interruption in routine dosing for 1 of 6 sampled residents.
Facility failed to conduct a search of the National Sex Offender Registry for 5 of 6 sampled residents.
Report Facts
Fire drills conducted: 6
Fire drills conducted: 3
Fire drills conducted: 0
Staff missing continuing education: 3
Staff missing annual competency reviews: 3
Residents missing NSOR search: 5
Residents missing PE within 30 days: 2
Days medication not administered: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding missing training records, fire and disaster drills, physical exams, and NSOR search requirement | |
| Staff B | Interviewed regarding continuing education, disaster drills, keypad instructions, and competency reviews | |
| Staff C | Interviewed regarding medication refill delays and competency reviews | |
| Staff D | Named in deficiencies related to continuing education and competency reviews |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 8, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00190241. An onsite visit was made on 8/8/18 and the investigation was completed on 9/4/18.
Complaint Details
The investigation was initiated due to complaint #GA00190241. The complaint involved concerns about fingerprint background checks for the Executive Director and proper care planning and admission requirements for residents in the memory care unit.
Findings
The facility failed to obtain a satisfactory fingerprint records check for the Executive Director prior to employment, failed to update the care plan for a resident assigned to the memory care unit, and failed to obtain a physician's report supporting the need for placement in the specialized memory care unit for one sampled resident.
Deficiencies (3)
Failed to obtain a satisfactory fingerprint records check determination for the Executive Director prior to serving.
Failed to update the care plan where the needs of the resident changed substantially or the resident was assigned to a specialized memory care unit for 1 of 1 sampled resident.
Failed to obtain a physician's report of physical examination completed within 30 days prior to admission to the memory care unit that clearly reflects the resident's diagnosis and need for placement in the specialized memory care unit for 1 of 1 sampled resident.
Report Facts
Deficiencies cited: 3
Date of Executive Director hire: Jul 10, 2017
Resident #2 admission date: Jun 30, 2018
Resident #2 memory care unit admission date: Jul 2, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director (temporary) | Named in deficiency for lack of fingerprint background check |
| Staff C | Interviewed regarding care plan updates | |
| AA | Interviewed regarding resident assessment and memory care placement |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 28, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 12/18/17 follow-up inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 6, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00185177, which began on 2018-02-21 with an on-site visit on 2018-02-26 and completed on 2018-03-06.
Complaint Details
The investigation was complaint-driven based on allegation #GA00185177 regarding neglect of Resident #1 related to medication administration and care. The complaint was substantiated as the facility failed to provide adequate medication administration and care, leading to Resident #1's hospitalization and death.
Findings
The facility failed to provide medication administration services in accordance with physicians' orders for Resident #1, who had multiple missed insulin doses leading to diabetic ketoacidosis and subsequent death. The community also failed to ensure adequate care and services, failed to immediately respond to a sudden adverse change in Resident #1's condition, and failed to notify the representative or retain proper documentation of adverse changes and refusals of medication.
Deficiencies (3)
Failure to provide medication administration services according to physicians' orders for Resident #1, resulting in missed insulin doses and refusal documentation.
Failure to provide adequate and appropriate care and services in compliance with state law for Resident #1, including allowing self-administration of insulin without mental capacity.
Failure to immediately take appropriate actions for sudden adverse change in Resident #1's condition, including failure to notify representative and retain documentation.
Report Facts
Missed insulin doses: 8
Missed Levemir doses: 3
Missed Novolog doses: 5
Blood glucose level: 600
Date of death: 21
Missed blood glucose monitoring opportunities: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Reported Resident #1's condition and medication refusals; observed Resident #1's altered state and called ambulance. | |
| Staff B | Informed about Resident #1's insulin refusals; was not notified of all refusals until late on 1/15/18. | |
| Staff H | Observed Resident #1 awake, mumbling, and wandering the hallways prior to hospital admission. | |
| CC | Family member who was notified of Resident #1's condition and accompanied Resident #1 to hospital. | |
| BB | Witnessed Resident #1 self-administer insulin with improper technique. | |
| DD | Reported staff did not notify anyone of Resident #1's medication refusals. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184828 with an on-site visit made on 2/12/18 and the investigation completed on 2/16/18.
Complaint Details
Complaint #GA00184828 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: 1
Date: Dec 18, 2017
Visit Reason
The purpose of this visit was to conduct a follow up visit to the 9/1/17 annual inspection and self reported complaint #GA00179228 complaint investigation.
Complaint Details
This visit included a follow up to a self reported complaint #GA00179228 complaint investigation.
Findings
The community failed to obtain a criminal records check determination in compliance with the provisions of O.C.G.A 31-7-250- et seq. for 1 of 3 sampled staff (Staff C). The violation was previously cited on 9/1/17 and remains uncorrected at the time of this follow-up visit.
Deficiencies (1)
Failed to obtain a criminal records check determination for 1 of 3 sampled staff (Staff C) in compliance with O.C.G.A 31-7-250 et seq.
Report Facts
Sampled staff: 3
Staff with missing criminal record check: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 17, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00180462 regarding failure to conduct immediate investigations and report serious incidents involving a resident.
Complaint Details
Complaint #GA00180462 triggered the investigation. The complaint involved failure to investigate and report incidents related to Resident #1. The complaint was substantiated based on findings.
Findings
The facility failed to conduct immediate investigations of accidents involving Resident #1 and did not maintain required reports. Additionally, the facility failed to notify the Department of serious incidents within 24 hours as required for Resident #1's falls on 3/15/17 and 7/17/17.
Deficiencies (2)
Failure to conduct immediate investigation of the cause of an accident and maintain a copy of the report in the resident's file and a central file for quality assurance review for Resident #1.
Failure to notify the Department of a serious incident within 24 hours after the incident occurred for Resident #1.
Report Facts
Number of sampled residents with deficiencies: 1
Incident dates: 3
Inspection Report
Renewal
Deficiencies: 8
Date: Aug 30, 2017
Visit Reason
The purpose of this visit was to conduct a re-licensure inspection and to investigate self-reported complaint #GA00179228. The on-site visit was made on 8/30/17 and the inspection/investigation was completed on 9/1/17.
Complaint Details
The complaint investigation was substantiated. Staff F was witnessed hitting and pulling hair of Resident #6 and hitting Resident #7 on the face, causing injuries including a nosebleed and bruising. Police were notified, and Staff F was arrested and suspended pending investigation.
Findings
The inspection identified multiple deficiencies including failure to ensure staff had current emergency first aid certification, tuberculosis screening, physical examinations, and criminal background checks. The facility also failed to maintain updated medication administration records, conduct quarterly medication observations, and timely manage medication procurement. Additionally, there was substantiated abuse involving two residents by a staff member, resulting in police involvement and staff suspension.
Deficiencies (8)
Facility failed to ensure staff had current certification in emergency first aid training for 2 of 6 sampled staff.
Facility failed to ensure staff received tuberculosis screening and physical examination within twelve months for 2 of 6 sampled staff.
Facility failed to obtain criminal records check for 1 of 6 sampled staff.
Facility failed to ensure residents had physical examination within 30 days prior to admission reflecting freedom from active tuberculosis for 4 of 5 sampled residents.
Facility failed to ensure quarterly random medication administration observations were completed by a licensed nurse or pharmacist.
Facility failed to maintain an updated medication administration record for 1 of 5 sampled residents.
Facility failed to notify physician of unavailability of prescription and obtain timely refills for 1 of 5 sampled residents.
Facility failed to protect residents from mental, verbal, sexual and physical abuse, neglect and exploitation for 2 of 8 sampled residents.
Report Facts
Sampled staff: 6
Sampled residents: 5
Residents involved in abuse incident: 2
Employees scheduled on incident date: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in abuse incident involving Residents #6 and #7; suspended and arrested | |
| Staff H | Witnessed abuse incident and reported to police and facility staff | |
| Staff A | Interviewed regarding missing physical exams and abuse incident; suspended Staff F | |
| Staff N | Interviewed regarding medication administration observations and abuse incident assessment | |
| Staff O | Interviewed regarding medication administration and documentation | |
| AA | Interviewed regarding Staff F incarceration |
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