Inspection Reports for
Avery Place

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Investigation of intake #GA00212501 with substantiated findings related to medication administration and timely medication refills.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted to investigate intake #GA00191284.

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.

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.

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.

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.

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.

This visit included a follow up to a self reported complaint #GA00179228 complaint investigation.

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.

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.

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.

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.

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.