Inspection Reports for Big Springs Place
131 MELISSA LANE, CEDARTOWN, GA, 30125
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 8, 2022, found no deficiencies. Earlier inspections showed a pattern of deficiencies related primarily to resident dignity and respect, staffing and supervision, and medication management. Several substantiated complaints involved staff misconduct such as verbal abuse, exploitation through inappropriate social media posts, and medication tampering, with staff terminations and police involvement in some cases. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with the most recent inspections having no cited violations after earlier issues were addressed.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00217895 and #GA00217976.
Complaint Details
Investigation of intake #GA00217895 and #GA00217976; no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 5, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00222095 and conduct the compliance inspection.
Complaint Details
Investigation of intake GA00222095; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 23, 2021
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00216042, #GA00215505, #GA00215709, #GA00216475, and #GA00216613) related to complaints against the facility.
Complaint Details
The investigation was triggered by complaints regarding mental abuse of Resident #3 by Staff C and Staff D. The complaint was substantiated as the facility conducted an investigation, terminated the staff involved, and notified police. Resident #3 was moved to another facility due to family concerns.
Findings
The facility failed to treat a resident with dignity and respect, evidenced by staff taking pictures and videotaping a resident having a bowel movement in the hallway and laughing about the incident. The staff involved were terminated following an investigation and a police report was filed.
Deficiencies (1)
Failure to treat each resident with dignity, kindness, consideration and respect, including privacy in personal care; staff took pictures and videotaped a resident having a bowel movement in the hallway and laughed about it.
Report Facts
Intake numbers investigated: 5
Incident date: Jul 2, 2021
Staff termination dates: Jul 2, 2021
Resident admit date: Jul 1, 2020
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 4
Date: Jun 14, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00214992. An onsite visit was made on 6/14/2021 and the investigation was completed on 6/29/2021.
Complaint Details
The investigation was triggered by intake #GA00214992 regarding Resident #1 eloping from the facility on 6/4/2021. The resident was found several blocks away and returned by an unidentified individual. The family and physician were notified. Resident #1 had a history of elopement and required 24-hour supervision. The complaint was substantiated based on findings of inadequate staffing, failure to monitor exit doors, and failure to provide adequate care.
Findings
The facility failed to provide adequate oversight and staffing to prevent Resident #1 from eloping through an unsecured memory care unit (MCU) exit door. Staff did not monitor the exit door during a resident move-out, and alarms were either not heard or disarmed. Resident #1 was found confused and dazed several blocks from the facility. The facility also failed to provide adequate care and services in compliance with regulations for Resident #1, who had a history of elopement and required 24-hour supervision.
Deficiencies (4)
Failed to provide oversight to ensure compliance with applicable requirements for Resident #1 who eloped from the facility.
Failed to have sufficient qualified and trained staff on duty to safeguard residents, with only two caregivers for twenty residents on the shift of the incident.
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping; MCU back exit door alarm was disarmed or not heard.
Failed to ensure each resident received adequate and appropriate care and services in compliance with federal and state law for Resident #1.
Report Facts
Residents on duty: 20
Caregivers scheduled: 2
Caregivers normally scheduled: 3
Resident supervision requirement: 24
Temperature high: 82
Temperature low: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1 elopement and facility oversight | |
| Staff B | Interviewed about staffing and Resident #1 elopement on 6/4/2021 shift | |
| Staff C | Interviewed about Resident #1 behavior and elopement circumstances | |
| Staff D | Interviewed about MCU exit door being unsecured during resident move-out | |
| Staff E | Returned Resident #1 to MCU and provided care after elopement | |
| Staff F | Interviewed about staffing, Resident #1 elopement, and alarm system | |
| GG | Notified of Resident #1 elopement and provided history of elopement |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 26, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00208358 and #GA00208371. The inspection started on 2020-10-06 and was completed on 2020-10-26.
Complaint Details
The investigation was complaint-driven based on intake numbers GA00208358 and GA00208371. The complaint was substantiated as staff misconduct involving exploitation of a resident through inappropriate social media posting. Staff C, D, and E were terminated. Resident #1's family and corporate office were contacted, and the Department was notified.
Findings
The facility failed to keep one resident free from exploitation when staff played an inappropriate song titled 'Wet Ass Pussy' (WAP), made a sign with the song's explicit words, and took a picture of the resident holding the sign which was posted on Snapchat. Several staff members involved were terminated. The facility failed to follow social media policies and resident abuse reporting guidelines.
Deficiencies (2)
Facility failed to keep resident free from exploitation related to inappropriate social media posting involving a resident holding a sign with explicit language.
Facility failed to ensure resident is free from exploitation and follow Long Term Care Resident Abuse Reporting guidelines.
Report Facts
Residents involved: 13
Staff termination count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Involved in making the sign, taking the picture, and posting on Snapchat; terminated | |
| Staff D | Played the inappropriate song, involved in the incident; terminated | |
| Staff E | Witnessed the incident, did not report it; terminated | |
| Staff F | Received the picture, reported the incident to Staff B | |
| Staff B | Reported the incident, contacted resident's family, corporate office, and Department | |
| Staff A | Informed about the incident, instructed Staff F to delete the picture | |
| CC | Contacted Adult Protective Services (APS) after being shown the picture |
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2019
Visit Reason
The purpose of this visit was to investigate intake GA00199910.
Complaint Details
Investigation of intake GA00199910 with no violations cited.
Findings
No violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00198818 and #GA00198879 at the facility.
Complaint Details
The investigation was related to complaint intakes #GA00198818 and #GA00198879. The allegations of verbal abuse by Staff B were substantiated.
Findings
The facility failed to treat residents with dignity, kindness, consideration, and respect as evidenced by substantiated allegations of verbal abuse by Staff B against Resident #2, supported by multiple staff interviews and written statements.
Deficiencies (1)
Failure to treat each resident with dignity, kindness, consideration and respect, including substantiated verbal abuse by Staff B against Resident #2.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00197573 regarding medication tampering at the facility.
Complaint Details
Investigation of intake # GA00197573 regarding medication tampering. Local law enforcement case # 19-6349 was assigned. Staff B was terminated for opening medication packets and replacing pills with Tylenol.
Findings
The facility failed to ensure reasonable safeguards for the protection and security of residents' personal property, as evidenced by tampering with medication packs for Resident #08 where Hydrocodone was replaced with over-the-counter acetaminophen. Staff B was terminated following the discovery, and local law enforcement was involved in the investigation.
Deficiencies (1)
Failure to ensure reasonable safeguards for the protection and security of residents' personal property, specifically medication tampering for Resident #08.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in medication tampering finding and termination. | |
| Staff A | Interviewed regarding medication tampering and Staff B termination. | |
| Staff C | Interviewed regarding discovery of tampered medication packs. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 8, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00196251. An on-site visit was made to the facility on 5/8/19 and the investigation was completed on 5/15/19.
Complaint Details
Investigation was initiated due to intake # GA00196251 concerning theft by taking of narcotic medications. The investigation was inconclusive but corrective action was taken against staff for not following medication procedures.
Findings
The governing body failed to provide necessary oversight to ensure compliance with applicable regulations. An investigation was conducted following a report of missing narcotic medications from the memory care medication cart, which led to corrective actions for staff not following medication procedures.
Deficiencies (1)
The governing body failed to provide oversight to ensure compliance with applicable requirements, including proper medication management and documentation.
Report Facts
Date of law enforcement report: Apr 19, 2019
Number of staff with disciplinary warnings: 6
Medication duration: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 15, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00195924.
Complaint Details
Investigation of intake # GA00195924 regarding admission of a non-ambulatory resident.
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 #2 who was bedbound and dependent on two-person assistance for all activities of daily living.
Deficiencies (1)
The home admitted and retained a bedbound resident requiring two-person assistance and dependent on all ADLs, contrary to admission requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 21, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection and to investigate complaint #GA00179213 and #GA00179175.
Complaint Details
Investigation of complaints #GA00179213 and #GA00179175 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 9, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00177741 with an on-site visit made to the facility on 8/9/17.
Complaint Details
Complaint #GA00177741 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 16, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA00176143.
Complaint Details
Complaint GA00176143 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 12, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00174239, #GA00174425, and #GA00174893 with on-site visits made on 5/9/17 and 5/16/17, and the investigation completed on 6/12/17.
Complaint Details
Investigation was complaint-driven based on three complaint numbers. The complaints were substantiated by findings related to fire safety and medication administration documentation.
Findings
The facility failed to maintain compliance with fire and safety rules, including lack of panic hardware on kitchen exit doors, issues with the fire alarm system and doors not closing during alarms. Additionally, the facility failed to ensure medication administration records (MAR) were properly updated for one of nine residents sampled.
Deficiencies (4)
No panic hardware on exit doors in kitchen.
Question of the system in the kitchen being monitored.
Doors in personal care home not closing when fire alarm activates.
Staff failed to update Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 9 residents sampled.
Report Facts
Residents sampled: 9
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication administration documentation failure | |
| Staff C | Named as the staff who failed to document medication administration on MAR | |
| EE | Interviewed regarding fire alarm and door issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 11, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00173289 with an on-site visit made to the facility on 2017-04-11.
Complaint Details
Complaint #GA00173289 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
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