Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00248888.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00248888 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 15, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245113 with an on-site visit made on 4/15/24 and the investigation completed on 4/18/24.
Findings
The facility failed to maintain minimum staffing requirements by not having a certified medication aide on site during required shifts. Medication Assistance Records were not properly updated for medications given to Resident #2, and Resident #2 did not receive full assistance with medication administration. Additionally, a staff member spoke to Resident #1 in an aggressive and demeaning manner, violating residents' rights.
Complaint Details
Investigation of intake #GA00245113 regarding staffing, medication administration, and resident treatment. Substantiated findings include staffing shortages, medication record errors, inadequate medication assistance, and inappropriate staff behavior toward residents.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain minimum staffing requirements by not having a certified medication aide on site during required shifts on 4/15/24. | D |
| Failed to update Medication Assistance Record (MAR) each time medication was offered or taken for Resident #2 on 4/15/24. | D |
| Failed to ensure Resident #2 received adequate medication assistance; resident was given medication cup and left without assistance. | D |
| Failed to treat Resident #1 with dignity and respect; staff spoke in an aggressive and demeaning manner and refused prescribed pain medication. | D |
Report Facts
Deficiencies cited: 4
Medication dosage: 2.5
Medication dosage: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings for failing to update MAR and not assisting Resident #2 with medication administration. | |
| Staff A | Interviewed regarding staffing and medication administration issues; assured corrective action for Staff H. | |
| Staff H | Spoke aggressively to Resident #1 and refused prescribed pain medication; received verbal corrective action. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 6, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00242819 and #GA00243211 with an on-site visit made on 2024-02-06.
Findings
The facility failed to update the care plan for a resident with changed needs, failed to provide adequate and appropriate care for 5 of 7 sampled residents including toileting and supervision issues, and did not have proper documentation or physician orders regarding alcohol use for one resident exhibiting intoxication and behavioral changes.
Complaint Details
The investigation was initiated due to complaint intakes #GA00242819 and #GA00243211. The complaint involved concerns about care plan updates, resident intoxication, inadequate toileting and supervision, and failure to follow physician orders or document care properly.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to update the care plan when the needs of Resident #7 changed, including new onset of agitation, wandering, and physical/verbal aggression related to alcohol use. | SS= D |
| Failed to ensure adequate, appropriate care and services for 5 of 7 sampled residents, including failure to provide toileting assistance during the night and lack of documentation of two-hour checks. | SS= D |
Report Facts
Sampled residents with care deficiencies: 5
Sampled residents reviewed: 7
Dates of resident admissions: Resident #7 admitted 2023-11-10; Resident #2 admitted 2023-06-28; Resident #4 admitted 2023-07-25; Resident #5 admitted 2023-06-30; Resident #6 admitted 2023-08-14.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #7's intoxication, care plan issues, and toileting policies. | |
| Staff E | Reported residents being soaked and wet upon arrival for shift. | |
| Staff F | Reported overnight staff not toileting residents and finding residents soaked in urine. | |
| AA | Reported concerns about giving Resident #7 liquor and lack of physician orders. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Oct 20, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00238249, #GA00239700, #GA00238913 and conduct the compliance inspection.
Findings
The facility was found deficient in multiple areas including failure to ensure employees received required physical examinations prior to employment, failure to maintain clean and well-repaired floors and carpets, lack of documentation for medication skills competency and Certified Medication Aide (CMA) registry checks, failure to conduct quarterly medication administration observations, and improper medication administration practices by CMAs.
Complaint Details
The visit was complaint-related, investigating multiple intakes (#GA00238249, #GA00239700, #GA00238913).
Severity Breakdown
SS= D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility failed to ensure each employee received a physical examination by a licensed provider within 12 months prior to employment for 1 of 4 sampled staff (Staff E). | SS= D |
| Facility failed to keep floors clean and in good repair; observed loose dirt particles and frayed, stained carpets in various areas including Resident #1 and #2 bedrooms. | SS= D |
| Facility failed to have documentation of medication skill competency for 1 of 3 unlicensed staff (Staff F) providing assistance with or supervision of self-administered medications. | SS= D |
| Facility failed to check the state Certified Medication Aide Registry to ensure medication aides were in good standing for 1 of 3 sampled staff (Staff F). | SS= D |
| Facility failed to use a licensed registered professional nurse or pharmacist to conduct quarterly medication administration observations for Certified Medication Aides (Staff E and Staff H). | SS= D |
| Facility failed to ensure Certified Medication Aides only completed tasks related to administration of medications utilizing unit or multidose packaging; CMAs removed and cut tablets from multidose packages contrary to policy. | SS= D |
Report Facts
Staff sampled: 4
Staff sampled: 3
Dates of hire: 2023
Medication dosage: 50
Inspection visit dates: Oct 20, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in deficiency for missing physical examination and missing quarterly medication administration observations | |
| Staff F | Named in deficiencies for missing medication skill competency documentation, missing CMA registry check, and providing medication administration | |
| Staff H | Named in deficiency for missing quarterly medication administration observations | |
| Staff A | Interviewed staff aware of deficiencies and facility practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 19, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00232259 during an onsite visit on 5/19/2023.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00232259 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214635, which started on 2021-06-01 and was completed on 2021-06-15.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00214635 was conducted with no rule violations found.
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