Inspection Reports for Bountiful Hills
200 BOLTON DRIVE, COMMERCE, GA, 30529
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 30, 2024, identified deficiencies related to timely procurement of prescribed medications, which led to interruptions in routine dosing for one resident. Earlier inspections showed a pattern of issues including medication refill delays, inadequate staffing—especially in the memory care unit—lack of required staff training, and maintenance problems with the physical plant. Complaint investigations substantiated concerns about resident care, such as missed medication doses causing a seizure episode and a resident injury due to untrained staff, as well as repeated findings of disrespectful staff behavior toward residents. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with medication management and staffing, with some improvement in recent months but persistent areas needing attention.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 30, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245786. An onsite visit was made on 4/30/24 and the investigation was completed on 5/6/24.
Complaint Details
Investigation was initiated due to intake #GA00245786. The complaint was substantiated as the facility failed to timely obtain medication refills, leading to a seizure episode for Resident #1 who had a history of Klonopin withdrawal seizures.
Findings
The facility failed to ensure timely procurement of prescribed medications, resulting in interruptions in routine dosing for one sampled resident. Specifically, medications such as Clonazepam and others were not administered on multiple dates due to unavailability or lack of orders.
Deficiencies (1)
Failure to ensure timely refills of prescribed medications resulting in interruptions in routine dosing for Resident #1.
Report Facts
Dates medication not administered: 20
Previous violation date: Dec 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Interviewed regarding medication ordering problems; stated not administrator during Resident #1's residency. |
| AA | Interviewed; took Resident #1 to neurologist and hospital; reported medication not administered as scheduled. |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 6
Date: Nov 28, 2023
Visit Reason
The purpose of this survey was to investigate complaints #GA00238787 and #GA00240480 and conduct a compliance inspection.
Complaint Details
The investigation was initiated based on complaints #GA00238787 and #GA00240480. The findings included failure to conduct fire drills, inadequate staffing, medication administration issues, and lack of care plans.
Findings
The facility failed to complete required fire drills in 2023, maintain clean and repaired physical plant conditions, maintain minimum staffing in the memory care unit, ensure timely medication refills for residents, maintain a three-day emergency food supply, and have a care plan for one sampled resident.
Deficiencies (6)
Facility failed to complete fire drills as required; no fire drills conducted in 2023.
Facility failed to keep ceilings clean and in good repair; kitchen floor had brown substances, ceiling tile not securely attached, and missing floor tiles in memory care unit.
Facility failed to maintain minimum staffing requirements in the memory care unit at all times.
Facility failed to ensure timely refills of prescribed medications resulting in missed doses for 4 of 5 sampled residents.
Facility failed to maintain a three day supply of non-perishable food and water for emergency needs.
Facility failed to have a care plan for 1 of 5 sampled residents (Resident #3).
Report Facts
Resident census: 24
Residents in memory care unit: 6
Staff assigned on 10/26/2023: 3
Missed medication doses: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and made aware of findings; stated hiring of cook and med-techs; acknowledged lack of care plan for Resident #3 | |
| Staff C | Interviewed regarding lack of fire drills, staffing, and emergency food supply | |
| AA | Interviewed regarding medication administration issues for Resident #5 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00237420.
Complaint Details
Investigation of intake# GA00237420 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: May 16, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00234785. An on-site visit was made to the facility on 5/16/23 and the investigation was completed on 5/19/23.
Complaint Details
The visit was complaint-related, investigating intake #GA00234785. The complaint involved multiple deficiencies related to staff training, resident care, facility cleanliness, and regulatory compliance.
Findings
The facility failed to ensure that staff received required work-related training within the first sixty days of employment, including first aid, CPR, medical and social needs training, abuse and neglect reporting training, physical examinations and tuberculosis screening, and criminal records checks. Additionally, the facility failed to provide adequate staffing to meet residents' needs, maintain clean and comfortable resident rooms, provide proper laundry services, ensure residents had required physical examinations prior to admission, and maintain valid food service permits and posted menus.
Deficiencies (12)
Failed to ensure work-related training within first sixty days for 5 of 5 sampled staff.
Failed to ensure current CPR certification with competency demonstration for 5 of 5 staff.
Failed to provide training in medical, social needs and characteristics of resident population for 5 of 5 staff.
Failed to provide training on abuse, neglect, exploitation and reporting requirements for 1 of 5 staff.
Failed to ensure physical examination and tuberculosis screening within twelve months prior to employment for 3 of 5 staff.
Failed to obtain satisfactory criminal records check including fingerprints prior to employment for 3 of 5 staff.
Failed to provide staffing to meet specific residents' health, safety, and care needs for 1 of 4 sampled residents.
Failed to provide residents a comfortable and clean room; trash not emptied and light odor present.
Failed to provide laundry services preventing cross-contamination of clean and dirty laundry for 2 residents.
Failed to ensure residents had physical examination dated within 30 days prior to admission for 2 of 5 sampled residents.
Failed to provide a valid food service permit issued through the Department of Public Health.
Failed to maintain a posted menu of foods served as required.
Report Facts
Sampled staff: 5
Sampled residents: 5
Sampled residents with staffing issue: 1
Sampled residents with laundry issue: 2
Inspection dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in multiple findings related to training deficiencies and interviews | |
| Staff B | Named in findings related to training, physical exams, and criminal records check | |
| Staff C | Named in findings related to training, abuse reporting, and criminal records check | |
| Staff D | Named in findings related to training, physical exams, and criminal records check | |
| Staff E | Named in findings related to training and physical exams |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Dec 2, 2022
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaint #GA00230130. The onsite visit was conducted on 12/2/2022 and the survey was completed on 12/09/2022.
Complaint Details
The inspection was conducted as a complaint investigation for complaint #GA00230130.
Findings
The facility failed to comply with fire safety regulations including lack of fire drills in 2022 and failure to have fire extinguishers checked annually. Additionally, ceilings and floors were not maintained in good repair, staff lacked required dementia care training, and medication refills were not obtained timely for two residents, causing potential interruptions in routine dosing.
Deficiencies (5)
Facility failed to conduct fire drills during 2022 as required by fire commissioner rules.
Facility failed to ensure fire extinguishers were checked annually; last check was November 2021.
Facility failed to keep ceilings clean and floors in good repair; observed ripped carpet and stained, peeling ceilings.
Facility failed to ensure direct care staff received required dementia care orientation training within 30 days for 2 of 5 sampled staff.
Facility failed to ensure timely refills of prescribed medications for 2 of 4 sampled residents, risking interruption in routine dosing.
Report Facts
Number of sampled staff lacking dementia training: 2
Number of sampled residents with medication refill issues: 2
Date of last fire extinguisher check: 202111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff A was interviewed and made aware of multiple findings including fire drills, fire extinguisher checks, ceiling and floor conditions, dementia training, and medication refill issues. | |
| Staff B | Staff B was observed working in memory care unit and lacked required dementia care training. | |
| Staff C | Staff C was observed working in memory care unit and lacked required dementia care training. | |
| Staff E | Staff E stated that fire drills did not occur throughout 2022. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 17, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00228735. The investigation began on 11/17/22, an onsite visit was made on 11/17/22, and the investigation was completed on 11/18/22.
Complaint Details
Investigation was initiated due to intake #GA00228735. The complaint was substantiated based on observations and interviews confirming facility deficiencies.
Findings
The facility failed to maintain a clean and orderly appearance, with strong odors, food crumbs, and soiled areas observed in multiple rooms. Additionally, the facility failed to ensure that two direct care staff persons were onsite at all times in the memory care unit.
Deficiencies (2)
Facility failed to present a clean and orderly appearance, including strong odor of urine, food crumbs and wrappers on floors, discolored kitchen countertops, and soiled resident rooms.
Facility failed to ensure that two direct care staff persons were onsite at all times in the memory care unit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed working alone in the memory care unit. | |
| Staff A | Aware of staffing findings and provided interview statements. | |
| AA | Provided interviews regarding facility cleanliness and staffing issues. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 1, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00224043 and #GA00224272. An on-site visit was made to the facility on 6/1/22 and the investigation was completed on 7/5/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00224043 and #GA00224272. The investigation found substantiated deficiencies related to medication administration, medication refill delays, and failure to notify representatives of adverse changes.
Findings
The facility failed to ensure sufficient staff time for medication administration for 2 of 3 residents, failed to obtain timely medication refills for 1 resident causing interruptions in dosing, and failed to appropriately notify the resident's representative and retain records of adverse changes in condition for 1 resident.
Deficiencies (3)
Failed to ensure sufficient staff time was provided so that each resident received treatment, medication, and diet as prescribed for 2 of 3 residents.
Failed to ensure that refills of prescribed medications were obtained timely so there was no interruption in routine dosing for 1 of 3 sampled residents.
Failed to take appropriate actions to address needs during a sudden adverse change in condition including notifying the resident's representative and retaining a record for 1 of 3 sampled residents.
Report Facts
Residents with medication administration issues: 2
Days medications missed: 5
Days medications missed: 4
Date of medication administration failure: May 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication administration and follow-up; documented staff notes about medication issues. | |
| Staff B | Interviewed regarding medication administration issues and notification delays; worked for Staff C due to no call/no show. | |
| Staff C | Scheduled proxy caregiver on 5/13/22; no call/no show causing medication administration delays. | |
| AA | Interviewed regarding medication administration and notification of medication shortages. | |
| BB | Received calls from facility caregivers about resident condition and medication shortages. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 4, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223263. An on-site visit was made to the facility on 5/4/22 and the investigation was completed on 5/5/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00223263. The complaint involved inadequate staff training and a resident injury due to improper transfer by untrained staff. Staff C stated it was his/her first night working with no official training, and Staff B had no training on transfers. The resident sustained injuries requiring stitches and hospital care.
Findings
The facility failed to ensure that at least one staff person had completed the minimum training requirements during the night shift of 4/12/22, with two of five staff lacking required training. Additionally, the facility failed to ensure direct care orientation training was completed within the first thirty days for two staff. A resident (Resident #1) suffered a fall resulting in injuries due to improper transfer by untrained staff, who were the only two on duty that night.
Deficiencies (3)
Facility failed to ensure at least one staff person had completed minimum training requirements during the night shift of 4/12/22 for 2 of 5 staff (Staff B and Staff C).
Facility failed to ensure direct care orientation training within the first thirty days for 2 of 5 staff (Staff B and Staff C) including specialized dementia care training.
Facility failed to ensure each resident received adequate care and services; Resident #1 fell on 4/13/22 due to improper transfer by untrained staff, resulting in foot laceration and fractures.
Report Facts
Staff involved: 2
Resident injured: 1
Stitches required: 7
Incident date: Apr 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings for lack of required training and involvement in resident fall. | |
| Staff C | Named in findings for lack of required training and involvement in resident fall; stated it was first night working with no official training. | |
| Staff A | Interviewed and stated awareness that Staff B and Staff C lacked required training and were the only two staff on duty during the incident. | |
| Staff D | Assisted with resident after fall. | |
| Staff E | Nurse who examined resident after fall. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220750 with on-site visits made on 2022-02-02 and 2022-02-16, and the investigation completed on 2022-03-08.
Complaint Details
Investigation was complaint-related based on intake #GA00220750. The allegation involved Staff C being rude and disrespectful to residents, with substantiation implied by the citation of the deficiency and multiple interviews confirming the behavior. The allegation was previously cited on 2021-08-27.
Findings
The facility failed to ensure that 3 of 7 residents were treated with dignity, kindness, consideration, and respect. Multiple interviews and record reviews revealed repeated rude and disrespectful behavior by Staff C towards residents, including verbal altercations and inappropriate treatment.
Deficiencies (1)
Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect for 3 of 7 residents (Resident #01, Resident #02, and Resident #4).
Report Facts
Residents involved: 3
Residents reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in multiple findings related to rude and disrespectful behavior towards residents. | |
| Staff I | Administrator | New administrator aware of the finding. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220028.
Complaint Details
Investigation was conducted related to intake #GA00220028 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Aug 27, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint numbers GA00214131, GA00215122, GA00215110, and GA00215245. The investigation started on 2021-05-27 and was completed on 2021-08-27.
Complaint Details
The investigation was complaint-driven, investigating multiple complaint numbers. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including allowing a staff member who was also a governing body member to serve as a resident's representative, insufficient staffing to provide treatments and care, failure to maintain the physical plant in good repair, retaining residents requiring care beyond the facility's capacity, failure to ensure staff in the memory care unit received required orientation and training, failure to obtain medication refills timely causing interruptions in medication administration, failure to support residents' rights to make choices, and failure to treat residents with dignity and respect.
Deficiencies (9)
Facility failed to ensure governing body members or staff do not serve as representatives for residents, evidenced by Staff A acting as representative and signing documents for Resident #10 without resident consent.
Facility failed to provide sufficient staff time for treatments and care for 2 of 14 sampled residents (Resident #2 and Resident #6).
Facility failed to keep ceilings and floors in good repair; observed peeling paint and buckling laminate flooring in memory care unit.
Facility retained residents (Resident #2 and Resident #6) who required care beyond what the facility was permitted to provide.
Facility failed to ensure memory care unit was staffed at all times with sufficient specially trained staff; Staff D and Staff F lacked required orientation documentation.
Facility failed to provide initial staff training within first six months of employment for Staff D and Staff F in required dementia care topics.
Facility failed to obtain medication refills timely, causing interruptions in routine dosing for Resident #2 and Resident #3.
Facility failed to ensure residents make choices about significant aspects of their life; Resident #10's preferences were overridden by Staff A acting as representative without resident consent.
Facility failed to treat residents with dignity, kindness, consideration and respect; reports of Staff F being rude, disrespectful, and physically aggressive towards residents.
Report Facts
Sampled residents: 14
Sampled staff: 11
Residents with medication issues: 2
Residents requiring care beyond facility capacity: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Acted as representative for Resident #10, involved in hospice care decisions, acknowledged findings |
| Staff C | Involved in obtaining power of attorney and DNR signatures from Resident #10 | |
| Staff D | Memory care staff lacking orientation and training, removed from memory care unit until training completed | |
| Staff F | Memory care staff lacking orientation and training, reported to be disrespectful and aggressive to residents |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 18, 2021
Visit Reason
The purpose of this visit was to investigate complaint GA00215890, with the investigation starting on 2021-07-29, an onsite visit on 2021-08-18, and completion on 2021-08-27.
Complaint Details
Investigation of complaint GA00215890 regarding mail delivery and residents' rights. The complaint was substantiated as staff intercepted Resident #1's mail and gave it to the resident's guardian contrary to facility policy and court order.
Findings
The facility failed to ensure that each resident's mail was delivered unopened to the resident on the day it was delivered to the home. Specifically, Resident #1 did not receive mail timely as staff intercepted mail and gave it to the resident's relative or guardian without the resident's consent, violating residents' rights.
Deficiencies (1)
Facility failed to ensure each resident's mail was delivered unopened to the resident on the day it was delivered; outgoing correspondence was opened or tampered with for Resident #1.
Report Facts
Dates of investigation: Investigation started 2021-07-29, onsite visit 2021-08-18, completed 2021-08-27
Number of sampled residents with mail issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in mail interception and mail delivery issues | |
| AA | Interviewed regarding mail delivery and package opening | |
| BB | Interviewed regarding receipt of Resident #1's mail and guardian status | |
| CC | Interviewed regarding Resident #1's mail receipt and visitation rights | |
| DD | Guardian of Resident #1 involved in mail receipt and visitation rights |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 7, 2021
Visit Reason
The purpose of this survey was to investigate complaint #GA00209422, with the investigation starting on 2020-11-20 and completed on 2021-01-07.
Complaint Details
Investigation of complaint #GA00209422 regarding infection control practices, substantiation status not explicitly stated.
Findings
The facility failed to demonstrate proper infection control practices during the COVID-19 pandemic for 1 of 5 staff identified (Staff E), including residents and staff not wearing masks as required by facility policy.
Deficiencies (1)
Failure to demonstrate proper infection control practices during the pandemic for 1 of 5 staff identified (Staff E), including not wearing PPE such as a mask.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Identified as not wearing PPE such as a mask during the infection control observation. | |
| Staff A | Interviewed and acknowledged awareness of residents and staff not wearing masks and the need to improve practices. |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 16, 2020
Visit Reason
The purpose of this inspection was to increase capacity.
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
Original Licensing
Deficiencies: 6
Date: Nov 11, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to ensure staff obtained current certification in emergency first aid and CPR within the first sixty days of employment for 3 of 4 staff. Additionally, fingerprint and criminal background checks were not obtained prior to employment for certain staff. The facility also failed to conduct required fire drills for the first quarter of 2019 and admitted residents who were not ambulatory and capable of self-preservation without minimal assistance.
Deficiencies (6)
Failed to ensure staff obtained current certification in emergency first aid within the first sixty days of employment for 3 of 4 staff (Staff A, Staff B, and Staff C).
Failed to ensure staff received current certification in cardiopulmonary resuscitation (CPR) where training required return demonstration of competency for 3 of 4 staff (Staff A, Staff B, and Staff C).
Failed to obtain a satisfactory fingerprint records check determination for the director, administrator or manager prior to employment for 1 of 4 sampled staff (Staff A).
Failed to obtain a satisfactory criminal records check prior to employment for 1 of 4 sampled staff (Staff B).
Failed to ensure compliance with fire and safety rules requiring fire drills at least quarterly on each shift and at least two drills during sleep hours per calendar year; no fire drills conducted for January, February, and March 2019.
Failed to ensure the home admitted and retained only ambulatory residents capable of self-preservation with minimal assistance for 2 of 4 sampled residents (Resident #1 and Resident #2).
Report Facts
Staff without emergency first aid certification: 3
Staff without CPR certification: 3
Staff without fingerprint records check: 1
Staff without criminal records check: 1
Months with no fire drills: 3
Residents not ambulatory: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to lack of emergency first aid and CPR certification, fingerprint records check, and fire drill interview | |
| Staff B | Named in findings related to lack of emergency first aid and CPR certification, and criminal records check | |
| Staff C | Named in findings related to lack of emergency first aid and CPR certification | |
| BB | Interviewed regarding residents' mobility and assistance needs | |
| CC | Interviewed regarding residents' mobility and assistance needs |
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