Inspection Reports for
Big Springs Place

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.

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.

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.

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.

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.

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.

The investigation was related to complaint intakes #GA00198818 and #GA00198879. The allegations of verbal abuse by Staff B were substantiated.

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.

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.

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.

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.

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.

Investigation of intake # GA00195924 regarding admission of a non-ambulatory resident.

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.

Investigation was complaint-driven based on three complaint numbers. The complaints were substantiated by findings related to fire safety and medication administration documentation.

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.