Inspection Reports for Azalea Manor Personal Care Home
557 EAST WATERMAN STREET, MARIETTA, GA, 30060
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 1, 2025, identified deficiencies related to the facility’s failure to conduct required monthly fire drills and to provide well-balanced, nutritious meals with sufficient quantity and snacks for some residents. Earlier inspections showed a pattern of issues involving staff training and certification, emergency preparedness including fire drills, resident care documentation, and food service concerns. Several complaint investigations substantiated deficiencies in resident care, medication management, and safety measures, including failure to notify representatives of adverse events and inadequate supervision of residents at risk of eloping. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with compliance in key areas, with some recurring themes persisting over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
8.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
12 residents
Based on a December 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Deficiencies: 2
Date: May 1, 2025
Visit Reason
The visit was conducted to complete a re-licensure inspection and to investigate intake numbers GA50000199, GA50000213, and GA50002038. The inspection started on 2025-03-26 and completed on 2025-04-25.
Findings
The facility failed to complete required monthly fire drills for 2024 and 2025, and failed to provide well-balanced, nutritious meals with sufficient quantity and snacks for 2 of 3 sampled residents. Interviews revealed lack of snack availability and recent staffing changes in the kitchen.
Deficiencies (2)
Facility failed to complete required monthly fire drills for any months in 2024 or 2025.
Facility failed to provide well-balanced, nutritious meals sufficient in quantity and did not offer at least one nutritious snack each mid-afternoon and evening for 2 of 3 sampled residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding lack of fire drill documentation and kitchen staffing issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 29, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00248993. An onsite visit was made on 8/29/24 and the investigation was completed on 8/30/24.
Complaint Details
The visit was complaint-related, investigating intake # GA00248993. The complaint was substantiated by findings that the facility failed to document and report a resident's fall and failed to notify responsible parties.
Findings
The facility failed to take appropriate actions to address the needs of a resident during a sudden adverse change in condition, including failure to notify the resident's representative and failure to document the incident of a fall for 1 of 3 sampled residents (Resident #1).
Deficiencies (1)
Failed to take appropriate actions to address the needs of the resident during a sudden adverse change in condition, including failure to notify the resident's representative and failure to retain a record of the adverse change for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding failure to document and report Resident #1's fall and stated intention to train staff on incident reporting and documentation. | |
| BB | Former employee interviewed who stated awareness that staff members were failing to notify responsible parties for incidents. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00243855, GA00244477, and GA00243853.
Complaint Details
Investigation of intakes #GA00243855, GA00244477, and GA00243853; no violations found.
Findings
No violations were cited as a result of this survey conducted on 3/5/24.
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jan 25, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242089 and conduct a compliance visit at the facility. The on-site inspection was conducted from 2024-01-25 to 2024-01-26.
Complaint Details
The visit was complaint-related, investigating intake #GA00242089. The complaint was substantiated by findings of multiple deficiencies in staff training, certification, personnel documentation, fire safety, and proxy caregiver consent.
Findings
The facility failed to ensure that staff had current certification in emergency first aid and cardiopulmonary resuscitation, did not provide required annual training hours, lacked documentation of satisfactory personnel determinations, failed to conduct monthly fire drills since March 2023, and did not maintain required proxy caregiver consent and competency documentation.
Deficiencies (7)
Facility failed to ensure staff had evidence of current certification in emergency first aid for 3 of 4 sampled staff (Staff B, Staff C, Staff D).
Facility failed to ensure staff had evidence of current certification in cardiopulmonary resuscitation for 3 of 4 sampled staff (Staff B, Staff C, Staff D).
Facility failed to ensure each staff received at least sixteen (16) hours of training per year for Staff B, Staff C, and Staff D.
Facility failed to ensure the number of documented fire drills met the minimum of one per month covering all shifts; last fire drill was in March 2023.
Facility failed to ensure personnel files had evidence of satisfactory determination for Staff B, Staff C, Staff D, and Staff E.
Facility failed to maintain Proxy Care Informed Consent forms for proxy caregivers for 3 of 5 sampled resident files (Resident #3, Resident #4, Resident #5).
Facility failed to ensure documentation of competency-based skills checklist completed by licensed healthcare professional for 2 of 3 sampled staff (Staff B and Staff D) who administer medication.
Report Facts
Sampled staff: 4
Sampled residents: 5
Deficiencies cited: 7
Training hours required: 16
Date of last fire drill: 202303
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding training and documentation deficiencies | |
| Staff B | Named in multiple deficiencies including lack of emergency first aid and CPR certification, training hours, personnel file documentation, and competency checklist | |
| Staff C | Named in deficiencies related to lack of emergency first aid and CPR certification, training hours, and personnel file documentation | |
| Staff D | Named in deficiencies including lack of emergency first aid and CPR certification, training hours, personnel file documentation, and competency checklist | |
| Staff E | Named in deficiency related to personnel file documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241421. The onsite visit was made on 12/1/23 and 12/4/23.
Complaint Details
Investigation of intake #GA00241421 with no violations cited.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 3, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00236103 and GA00236099.
Complaint Details
Investigation of intakes #GA00236103 and GA00236099 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 20, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00231384 and conduct the compliance inspection.
Complaint Details
Investigation of intake GA00231384 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 12
Deficiencies: 2
Date: Dec 7, 2022
Visit Reason
The visit was conducted to investigate complaint intakes #GA00229304 and #GA00229376, with an onsite visit on 2022-11-29 and investigation completion on 2022-12-08.
Complaint Details
The investigation was triggered by complaints regarding Resident #1 who eloped on 10/30/22 and 10/31/22, requiring police intervention and hospital assessment. The resident was discharged to a memory care facility on 11/8/22. The complaint intakes investigated were #GA00229304 and #GA00229376.
Findings
The facility failed to admit or retain only residents whose needs are within the home's capabilities and failed to ensure adequate and appropriate care for one sampled resident who eloped twice and required a locked memory care facility, resulting in the resident's discharge to a memory care facility.
Deficiencies (2)
Facility failed to admit or retain only residents whose needs and care are not beyond which the home is permitted to provide for 1 of 3 sampled residents (Resident #1).
Facility failed to ensure each resident received care and services which were adequate and appropriate for 1 of 3 sampled residents (Resident #1).
Report Facts
Residents observed during tour: 12
Sampled residents: 3
Distance Resident #1 eloped: 0.3
Date Resident #1 discharged: Nov 8, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported Resident #1 had dementia and eloped; stated resident was given 30 day notice and discharged | |
| Staff B | Observed during tour; stated Resident #1 eloped on 10/31/22 | |
| Staff C | Observed during tour; stated Resident #1 eloped and went 0.3 miles up the street | |
| AA | Interviewed; stated patrol officer responded to incident and report was filed | |
| BB | Interviewed; stated contact on day Resident #1 eloped and confirmed discharge |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 12, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00228020 and #GA00228034. An on-site visit was made on 2022-10-04, and the investigation was completed on 2022-10-12.
Complaint Details
The investigation was initiated due to intake #GA00228020 and #GA00228034. Resident #1 was found approximately 0.5 miles from the facility on 9/17/22 by law enforcement and returned to the facility. Resident #1 had eloped on two other occasions without incident reports. The resident has cognitive issues and requires supervision when ambulating.
Findings
The facility failed to ensure staff had documented residents' rights training for 3 sampled staff members. Additionally, the facility failed to utilize appropriate effective safety devices to protect a resident at risk of eloping, as evidenced by Resident #1 being found approximately 0.5 miles from the facility and multiple exit doors lacking audible alert devices.
Deficiencies (2)
Failure to ensure staff had work-related residents' rights training for 3 sampled staff members.
Failure to utilize appropriate effective safety devices to protect residents at risk of eloping, including lack of audible alert devices on exit doors.
Report Facts
Date of incident report: Sep 17, 2022
Date of police report: Sep 17, 2022
Number of exit doors without audible alert devices: 6
Number of stairs to basement exit: 15
Distance Resident #1 was found from facility: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in residents' rights training deficiency and elopement incident | |
| Staff B | Named in residents' rights training deficiency and elopement incident | |
| Staff D | Named in residents' rights training deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2022
Visit Reason
The visit was conducted to investigate intake #GA00221617, with the onsite visit occurring on 3/1/22 and the investigation completed on 5/09/22.
Complaint Details
Investigation of intake #GA00221617 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 2, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216910 and #GA00217106, which were opened on 11/23/21 and completed on 12/2/21.
Complaint Details
Investigation of intake #GA00216910 and #GA00217106; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 9, 2021
Visit Reason
An on-site visit was made to the facility to investigate multiple intakes (#GA00210637, #GA0021321, #GA00211105, and #GA00211184) on 2021-01-12. The investigation was completed on 2021-08-09.
Complaint Details
Investigation of intakes #GA00210637, #GA0021321, #GA00211105, and #GA00211184 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 5, 2021
Visit Reason
The purpose of this inspection was to investigate intake # GA00215786.
Complaint Details
Investigation of intake # GA00215786 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 3, 2021
Visit Reason
The purpose of this inspection was to investigate intake # GA00214597.
Complaint Details
Investigation began on 2021-06-01 and was completed on 2021-06-04. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Apr 14, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00213198, #GA00213495 and conduct the initial inspection.
Findings
No rule violations were cited as a result of this inspection.
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: 2
Date: Apr 2, 2020
Visit Reason
The purpose of the visit was to investigate complaint intakes #GA00203276 and #GA00203329, started on 2020-03-24 and completed on 2020-04-02.
Complaint Details
The investigation was based on complaint intakes #GA00203276 and #GA00203329. Staff B verified that his/her signature on the controlled substance log for Resident #2 was forged.
Findings
The facility failed to have work performance reviews for unlicensed staff performing specialized tasks such as medication administration, and failed to ensure medication administration records (MAR) were updated each time medication was taken. Additionally, forged signatures were found on controlled substance logs for medication administration.
Deficiencies (2)
Failed to have work performance reviews, including skills competency checklists, for unlicensed staff performing medication administration.
Failed to ensure staff updated the medication administration record (MAR) each time medication was offered or taken.
Report Facts
Number of sampled residents with deficiencies: 3
Dates of controlled substance logs reviewed: Logs dated 2/17/20 and 2/18/20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Unlicensed staff who performed medication administration without documented competency training | |
| Staff B | Staff whose signature was forged on controlled substance log | |
| Staff C | Staff who shadowed Staff D and signed medication logs | |
| Staff A | Staff who provided information about training and scheduling | |
| Staff E | Staff who provided information about training and scheduling | |
| AA | Interviewed staff who reported no trained proxy caregiver worked with Staff D | |
| BB | Interviewed staff who received report about Staff D administering medication without proper training |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Date: Mar 19, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00202896 and #GA00202917 with an onsite visit made on 3/3/20 and the investigation completed on 3/19/20.
Complaint Details
The visit was complaint-related, investigating intake #GA00202896 and #GA00202917. The investigation found substantiated deficiencies including inadequate staffing, environmental issues, recordkeeping failures, and failure to report a serious injury.
Findings
The facility failed to ensure adequate staffing to meet residents' safety and care needs, failed to maintain proper ventilation and temperature in resident rooms, improperly allowed use of space heaters, failed to maintain resident files, and failed to report a serious injury to the Department.
Deficiencies (5)
Failed to ensure adequate staffing to meet the specific safety, health and care needs of residents, including one resident requiring two-person transfer with only one direct care staff on overnight shifts.
Failed to ensure each bedroom was well ventilated and maintained at a comfortable temperature; vent in Resident #1's room was inoperable.
Failed to ensure space heaters were not in use except during emergency with proper approval; space heater was observed in Resident #1's bedroom.
Failed to maintain and make available resident file for Resident #5.
Failed to report to the Department a serious injury to Resident #4 that required medical treatment after a fall in January 2020.
Report Facts
Residents observed: 22
Direct care staff scheduled overnight: 1
Two-person transfers: 2
Sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staffing, vent issues, space heater use, and resident file availability. | |
| Staff G | Interviewed regarding Resident #4's fall and reporting. | |
| DD | Interviewed regarding staffing and two-person transfers. | |
| CC | Interviewed regarding overnight staffing and two-person transfers. | |
| EE | Interviewed regarding staffing adequacy for emergency evacuation. | |
| BB | Interviewed regarding notification of Resident #4's fall and hospital visit. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Feb 4, 2020
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00202293.
Complaint Details
The inspection was conducted to investigate intake #GA00202293.
Findings
The facility was found deficient in multiple areas including failure to obtain satisfactory criminal records checks for employees, failure to maintain personnel files, lack of work performance reviews for unlicensed staff, insufficient staff time for resident hygiene assistance, failure to conduct fire drills, improper storage of hazardous materials, excessively hot water temperature, lack of sufficient activities for residents, failure to provide nutritious snacks, presence of expired food items, and failure to maintain a three-day supply of non-perishable food and water for emergencies.
Deficiencies (11)
Failed to obtain a satisfactory criminal records check prior to employment for 1 of 5 sampled staff (Staff E).
Failed to maintain personnel files for 1 of 6 sampled staff (Staff C) available for inspection.
Failed to have work performance reviews for 1 of 3 unlicensed staff (Staff D) performing specialized tasks.
Failed to provide sufficient staff time for daily hygiene assistance for 2 of 4 sampled residents (Resident #2 and Resident #4).
Failed to conduct fire drills; no documentation of fire drills conducted for 2019.
Failed to ensure poisons, caustics, and dangerous materials were stored away from food preparation and storage areas.
Failed to ensure hot water temperature did not exceed 120 degrees Fahrenheit; measured at 169.3 degrees Fahrenheit.
Failed to provide sufficient activities to promote physical, mental, and social well-being of residents.
Failed to offer one nutritious snack each mid-afternoon and evening.
Failed to provide food free from spoilage; expired canned goods observed.
Failed to maintain a three day supply of non-perishable food and water for emergency needs.
Report Facts
Number of sampled staff without satisfactory criminal records check: 1
Number of sampled staff without personnel files available: 1
Number of unlicensed staff without work performance reviews: 1
Number of sampled residents lacking sufficient hygiene assistance: 2
Water temperature measured: 169.3
Expired canned goods observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Failed to have satisfactory criminal records check prior to employment | |
| Staff C | Personnel file not maintained or available for inspection | |
| Staff D | No documentation of proxy caregiver training and no work performance reviews | |
| Staff A | Interviewed regarding multiple deficiencies including criminal records check, personnel files, proxy caregiver training, fire drills, and hot water temperature | |
| Staff F | Interviewed regarding removal of expired canned goods and obtaining emergency food and water supply |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 14, 2020
Visit Reason
The purpose of this visit was to investigate intake # GA00201911. An on-site visit was made to the facility on 1/14/20 and the investigation was completed on 1/16/20.
Complaint Details
Investigation of intake # GA00201911; visit was complaint-related.
Findings
The facility failed to have an effective system to manage medications, including storing medications under lock and key. During a tour, two medication carts were observed unlocked, and staff admitted forgetting to lock them.
Deficiencies (1)
Failed to have an effective system to manage medications including storing medications under lock and key; two medication carts were observed unlocked.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 23, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/08/19 compliance inspection and complaint investigation.
Complaint Details
This inspection was a follow-up to a previous complaint investigation conducted on 4/08/19.
Findings
The facility failed to ensure that 1 of 3 sampled staff (Staff F) had current certification in emergency first aid and cardiopulmonary resuscitation (CPR) within the first sixty days of employment. Staff F completed the required trainings on 10/23/19, the last day of the inspection.
Deficiencies (2)
Facility failed to ensure that 1 of 3 sampled staff (Staff F) had obtained current certification in emergency first aid within the first sixty days of employment.
Facility failed to ensure that 1 of 3 sampled staff (Staff F) had current certification in cardiopulmonary resuscitation (CPR) where the training required return demonstration of competency.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in findings for lack of emergency first aid and CPR certification. | |
| Staff A | Interviewed and responsible for emailing required training documentation. | |
| Staff E | Interviewed and stated Staff F did not have required training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 21, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00200107, with an on-site visit made on 10/21/19 and the investigation completed on 11/18/19.
Complaint Details
Investigation intake #GA00200107 was conducted due to complaints regarding staff file maintenance and resident care deficiencies. The complaint was substantiated based on findings.
Findings
The facility failed to maintain staff files for a departed employee and failed to ensure adequate and appropriate care for 4 of 8 sampled residents, including delayed staff response to calls for assistance, residents' beds soaked with urine, and improper administration of Fentanyl patches.
Deficiencies (2)
Facility failed to maintain staff files for a period of three years after staff departure for 1 of 5 sampled staff (Staff D).
Facility failed to ensure each resident received adequate, appropriate care and services for 4 of 8 sampled residents, including delayed response to calls for assistance and residents' beds soaked with urine.
Report Facts
Sampled residents: 8
Sampled staff: 5
Residents with care deficiencies: 4
Fentanyl patch application dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff file missing; last day of employment 8/11/19 | |
| Staff A | Interviewed regarding missing Staff D file and Fentanyl patch administration | |
| Staff B | Interviewed regarding hospice nurse instructions for Fentanyl patch re-application | |
| AA | Interviewed confirming Fentanyl patch administration on Resident #3 | |
| BB | Interviewed regarding hospice nurse instructions for Fentanyl patch administration |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2019
Visit Reason
The purpose of this visit was to investigate incident #GA00198208 and #GA00198591 with on-site visits made on 7/22/19 and 7/23/19.
Complaint Details
Investigation of incidents #GA00198208 and #GA00198591 found no rule violations.
Findings
No rule violations were cited as a result of this investigation completed on 8/12/19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00196959 and # GA00197363.
Complaint Details
Investigation of complaint intake # GA00196959 and # GA00197363 with no rule violations cited.
Findings
No rule violations were cited for this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 20, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00196562.
Complaint Details
Investigation of intake # GA00196562 with no rule violations cited.
Findings
No rule violations were cited for this visit.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 2, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00196102, #GA00196133, and #GA00196243.
Complaint Details
The visit was complaint-related, investigating three intake numbers. The complaint was substantiated by findings of plumbing issues and medication refill failures.
Findings
The facility failed to maintain bathroom plumbing and fixtures in good working order, as evidenced by shower knobs both marked cold in Resident #1's bathroom. Additionally, the facility failed to ensure timely refills of prescribed medications for Resident #2, resulting in interruption of routine dosing.
Deficiencies (2)
Bathroom plumbing and fixtures were not maintained in good working order; shower knobs both indicated cold water.
Refills of prescribed medications were not obtained timely, causing interruption in routine dosing for Resident #2.
Report Facts
Medications not given or offered: 10
Date of admission: Apr 8, 2019
Date of pharmacy packing slip: Apr 17, 2019
Date medications delivered: Apr 18, 2019
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 8, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00195726, #GA00195620, and #GA00195605.
Complaint Details
The visit was triggered by complaint investigations related to intake #GA00195726, #GA00195620, and #GA00195605.
Findings
The facility failed to ensure work-related training within the first 60 days for staff, failed to provide and document medication training for unlicensed staff assisting with medication self-administration, failed to update Medication Assistance Records for residents, failed to obtain written informed consent for proxy caregivers for some residents, failed to maintain annual skills competency checklists for proxy caregivers, and failed to use results of the Test of Functional Health Literacy (TOFHLA) for proxy caregivers.
Deficiencies (7)
Failure to ensure work-related training within the first 60 days of employment for Staff B and Staff D.
Failure to ensure Staff D had current certification in emergency first aid within the first 60 days of employment.
Failure to provide and document medication training for Staff B assisting with self-administration of medications.
Failure to update the Medication Assistance Record each time medication was offered or taken for Resident #2 and Resident #3.
Failure to ensure written informed consent for proxy caregivers for Resident #1, Resident #2, and Resident #3.
Failure to maintain annual skills competency determinations utilizing skills competency checklists for Staff B and Staff D.
Failure to use results of the Test of Functional Health Literacy (TOFHLA) for Staff B and Staff D.
Report Facts
Number of sampled residents with missing informed consent: 3
Number of staff without documented work-related training within 60 days: 2
Number of unlicensed staff without documented medication training: 2
Number of residents with MAR not updated properly: 2
Number of proxy caregivers without skills competency checklists: 2
Number of proxy caregivers without TOFHLA results: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to receive work-related training within 60 days, lacked emergency first aid certification, lacked medication training documentation, lacked skills competency checklist, lacked TOFHLA results, identified as lead medication technician administering medications. | |
| Staff D | Failed to receive work-related training within 60 days, lacked emergency first aid certification, lacked skills competency checklist, lacked TOFHLA results, identified as proxy caregiver assisting with medications. | |
| Staff A | Interviewed staff who provided information about missing training and documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 12, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00189771. An onsite visit was made to the facility on 7/12/18 and the investigation was completed on 7/16/18.
Complaint Details
Complaint #GA00189771 was investigated during this visit. The investigation found medication administration record deficiencies and controlled drug discrepancies.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 6 sampled residents (Resident #6). Additionally, a discrepancy was found in the controlled drug record for Resident #3 regarding Alprazolam 0.25 mg tablets.
Deficiencies (2)
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for Resident #6.
Discrepancy in controlled drug record for Alprazolam 0.25 mg tablets for Resident #3.
Report Facts
Medication Assistance Record missing signatures: 2
Alprazolam tablet counts: 30
Alprazolam tablet counts: 15
Alprazolam tablet counts: 14
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 4
Date: Mar 12, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00186076.
Complaint Details
Complaint #GA00186076 was investigated. The complaint involved concerns about staff training and medication administration.
Findings
The facility failed to ensure that at least one staff member with required training was present at all times, failed to provide sufficient staff time to ensure medications were given as prescribed to a resident, failed to provide and document medication training for unlicensed staff assisting with medication self-administration, and failed to update the Medication Assistance Record each time medication was offered or taken.
Deficiencies (4)
Failed to ensure at least one staff member with required training was present at all times when residents were present.
Failed to provide sufficient staff time to ensure residents received medications as prescribed for 1 resident.
Failed to provide and document medication training for 2 unlicensed staff assisting with self-administration of medications.
Failed to update the Medication Assistance Record each time medication was offered or taken for 1 resident.
Report Facts
Resident census: 19
Resident count: 1
Staff count: 2
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 5, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 6/8/2017 complaint investigation #GA001745172 and #GA00175172.
Complaint Details
This was a follow-up visit to a complaint investigation conducted on 6/8/2017 regarding admission of non-ambulatory residents.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by Resident #1 who was non-ambulatory and bedridden without any waivers in place.
Deficiencies (1)
Facility admitted and retained a non-ambulatory resident incapable of self-preservation without required waivers.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1's ambulatory status and waiver application. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 9, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA00177646.
Complaint Details
Investigation of complaint GA00177646 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Jul 17, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/20/17 initial inspection and complaints #GA00172362 and #GA00172722.
Complaint Details
This follow-up visit was related to complaints #GA00172362 and #GA00172722.
Findings
The facility failed to ensure that all employees received required physical examinations and TB screenings prior to employment, retained a resident who required care beyond the facility's permitted level, and failed to properly document medication administration for multiple residents.
Deficiencies (3)
Facility failed to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 1 of 4 staff sampled (Staff G).
Facility retained a resident (Resident #7) who needed total assistance and was non-ambulatory, beyond the care the home is permitted to provide.
Staff failed to update the Medication Administration Record (MAR) each time medication was offered or taken for 4 of 4 residents sampled (Resident #7, #8, #9, #10).
Report Facts
Staff sampled: 4
Residents sampled: 4
Residents sampled: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Failed to have physical examination and TB screening within 12 months prior to employment | |
| Staff B | Interviewed regarding validity of Staff G's chest x-ray and medication administration documentation | |
| Staff H | Interviewed regarding Resident #7's mobility and care needs |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 5
Date: Jun 8, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA001745172 and #GA00175172. The on-site visit started on 2017-05-31 and the investigation was completed on 2017-06-08.
Complaint Details
The investigation was initiated due to complaints #GA001745172 and #GA00175172 regarding staffing inadequacies and resident care concerns.
Findings
The facility failed to maintain adequate staffing levels to meet residents' safety and care needs, admitted non-ambulatory residents without proper waivers, failed to enforce safe food handling practices, did not maintain complete resident health files, and failed to document and respond appropriately to changes in resident conditions.
Deficiencies (5)
Failed to ensure adequate staffing to meet safety, health, and care needs for 4 of 4 sampled residents.
Admitted and retained non-ambulatory residents incapable of self-preservation without waivers for 2 of 2 sampled residents.
Failed to enforce safe food handling practices, temperature requirements, and sanitation.
Failed to maintain resident files including health appraisals, diagnoses, prescribed diets, medications, and physician's instructions for 2 of 2 sampled residents.
Failed to document and maintain records of the home's response to a sudden adverse change in resident condition for 1 of 1 sampled resident.
Report Facts
Resident census: 28
Direct caregivers scheduled: 2
Residents sampled: 4
Residents sampled: 2
Residents sampled: 2
Residents sampled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding non-ambulatory residents and failure to complete incident report for Resident #1 | |
| Staff D | Interviewed regarding food temperature practices | |
| Staff F | Interviewed regarding observations of Resident #7 and Resident #1 | |
| AA | Observed Resident #1 and reported calling ambulance | |
| KK | Interviewed regarding serving cold food to residents |
Inspection Report
Original Licensing
Capacity: 42
Deficiencies: 12
Date: Mar 20, 2017
Visit Reason
The purpose of this visit was to conduct an initial inspection and investigate complaints #GA00172362 and GA00172722.
Complaint Details
The inspection included investigation of complaints #GA00172362 and GA00172722.
Findings
The facility failed to meet multiple regulatory requirements including workforce health screenings, fire safety inspections, admission criteria for residents, proper documentation of resident files, medication administration, resident rights, and incident reporting. Several deficiencies were noted related to staff qualifications, safety devices, food service permits, and resident care.
Deficiencies (12)
Facility failed to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 1 of 6 sampled staff.
Sprinkler system had not been inspected within the previous 12 months and no fire drills were conducted in 2017.
Facility admitted and retained a non-ambulatory resident who was not capable of self-preservation with minimal assistance.
Failed to obtain a physician's examination report on the Department's approved form and TB screening for 1 of 6 residents.
Failed to have an admission agreement entered into between the governing body and 1 of 6 residents.
Failed to utilize safety devices to protect residents at risk of eloping from the premises.
Failed to possess a valid food service permit for a home serving 25 or more residents.
Failed to ensure all residents had an inventory of personal belongings for 1 of 6 sampled residents.
Failed to ensure residents received a signed copy of the Resident's Rights form for 1 of 6 sampled residents.
Failed to ensure each resident received adequate and appropriate care; Resident #1 did not receive prescribed medications resulting in seizures and hospitalization.
Failed to ensure residents had the right to request and make copies of their records for 1 of 6 sampled residents.
Failed to initiate an immediate investigation and maintain a report of an accident or injury involving a resident for 1 of 6 sampled residents.
Report Facts
Licensed capacity: 42
Sampled staff: 6
Sampled residents: 6
Medication non-administration days: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed multiple times regarding deficiencies in staff health screenings, resident care, safety, and documentation |
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