Deficiencies per Year
12
9
6
3
0
Moderate
Inspection Report
Routine
Deficiencies: 0
Jul 17, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection. An unannounced visit was made on 07/17/2024.
Findings
The compliance inspection could not be completed due to renovations at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2023
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake# GA00229402.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00229402 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 20, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00218122 and #GA00218476 with an onsite visit made on 10/20/21 and the investigation completed on 10/29/21.
Findings
The facility failed to ensure that direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement for 1 of 3 sampled staff (Staff B). Staff B was arrested for abuse and had a criminal record, and the fingerprint check was still 'in process' as of 10/29/21.
Complaint Details
Investigation of complaint intakes #GA00218122 and #GA00218476. Staff B was alleged to have been arrested for abuse and had a criminal record. The fingerprint check was still pending as of the investigation completion date.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure direct care staff hired after October 1, 2019 had required criminal background check upon employment or prior to placement for 1 of 3 sampled staff (Staff B). | D |
Report Facts
Staff scheduled days in September 2021: 22
Employment duration: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Direct care staff with missing criminal background check and subject of complaint investigation. | |
| Staff E | Interviewed regarding FPC letter status for Staff B. | |
| JJ | Interviewed and stated Staff B was under review with determination pending. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 5, 2021
Visit Reason
The purpose of this inspection was to investigate intake #GA00217363. The investigation started on 2021-09-20 and was completed on 2021-10-05, with an onsite visit on 2021-09-29.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00217363 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 12, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00213953 and to perform a compliance inspection.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00213953; no violations found.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 31, 2020
Visit Reason
The purpose of this visit was to conduct a follow-up to the 1/14/20 compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 1
Jan 14, 2020
Visit Reason
The purpose of this visit was to conduct a follow-up to the 10/15/19 compliance inspection.
Findings
The facility failed to keep the ceiling in good repair as evidenced by multiple water damage areas on the kitchen ceiling measuring between 1-2 inches in diameter. This violation was previously cited on 10/15/19.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to keep the ceiling in good repair with multiple water damage areas on the kitchen ceiling. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding ceiling condition and maintenance notification |
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 15, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00199929.
Findings
The facility failed to ensure that three staff members had current certification in emergency first aid and CPR within the first sixty days of employment. Additionally, the facility was found to have a space heater in use without approval and issues with cleanliness and repair of floors, walls, and ceilings.
Complaint Details
The inspection was conducted to investigate intake #GA00199929.
Severity Breakdown
E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 3 staff had current certification in emergency first aid within the first sixty days of employment. | E |
| Failed to ensure 3 of 3 staff had current certification in cardiopulmonary resuscitation (CPR) with return demonstration of competency. | E |
| Space heaters were in use without written approval from fire safety authority. | E |
| Floors, walls, and ceilings were not kept clean and in good repair, including kitchen ceiling needing repair, unclean carpet in Resident #4's bedroom, unclean bathroom walls and wall adjacent to bed in room 11, and a torn towel bar in Resident #2's room. | E |
Report Facts
Staff without emergency first aid certification: 3
Staff without CPR certification: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings for lack of emergency first aid and CPR certification | |
| Staff D | Named in findings for lack of emergency first aid and CPR certification | |
| Staff E | Named in findings for lack of emergency first aid and CPR certification | |
| Staff A | Interviewed regarding staff training and facility issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00195804.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake # GA00195804 with no rule violations found.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 6, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the initial inspection conducted on 12/6/18.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 9
Dec 6, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to meet multiple workforce qualification and training requirements, including lack of current certification in emergency first aid, CPR, emergency evacuation procedures, and training on medical and social needs for certain staff. Additionally, the facility failed to ensure physical examinations and TB screenings were completed for some staff, maintain the physical plant in good repair, safeguard dangerous materials, maintain written plans of care for residents, and ensure proxy caregivers completed required competency checklists and training.
Severity Breakdown
D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure staff obtained current certification in emergency first aid within the first sixty days of employment for 1 of 4 sampled staff. | D |
| Failed to ensure staff received current certification in cardiopulmonary resuscitation (CPR) with competency demonstration for 1 of 4 sampled staff. | D |
| Failed to ensure staff received training in emergency evacuation procedures for 1 of 4 sampled staff. | D |
| Failed to ensure staff received training in medical and social needs of the resident population for 1 of 4 sampled staff. | D |
| Failed to ensure staff received physical examination and tuberculosis screening within 12 months prior to employment for 2 of 4 sampled staff. | D |
| Failed to keep ceilings in good repair; observed water damage, linear tear, and peeling ceiling in resident bedroom. | D |
| Failed to store and safeguard poisons, caustics, and dangerous materials away from residents, food preparation, storage, and medication areas. | D |
| Failed to maintain a copy of the written plan of care for 2 of 4 sampled residents. | D |
| Failed to ensure proxy caregivers used competency checklist forms for training for 1 of 4 sampled staff. | D |
Report Facts
Number of sampled staff with training deficiencies: 4
Number of sampled residents with missing plan of care: 2
Date of inspection: Dec 6, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in multiple findings related to lack of training, certifications, physical exam, and proxy caregiver competency | |
| Staff A | Interviewed staff providing information about Staff D's training status and facility conditions |
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