Inspection Reports for Coventry Place

The purpose of this visit was to investigate intake #GA50004893. The onsite visit and investigation were conducted on 8/27/25.

The facility failed to ensure that floors, walls, and ceilings were clean and in good repair, evidenced by water stains in Resident #2's apartment ceiling. Additionally, the facility failed to ensure that criminal history background checks were completed for 3 of 3 sampled staff members prior to employment.

The visit was complaint-related, investigating intake #GA50004893. The investigation was completed on 8/27/25.

The purpose of this visit was to investigate intake #GA00238825, starting on 10/11/2023 and completed on 11/1/2023.

The facility failed to ensure that walls, floors, and ceilings were kept clean and in good repair, with observations including stained carpets, stained toilets, sticky floors, old food in the refrigerator, scattered items and strong odors in resident rooms, and a hole in the wall near the baseboard.

Investigation was initiated due to intake #GA00238825.

The purpose of this visit was to investigate intake #GA00231057, GA00230038, and GA00229700.

No rule violations were cited during the investigation.

Investigation was started on 2/1/2023 and completed on 2/10/2023. No rule violations were found.

The purpose of this visit was to investigate intake# GA00227187 regarding an incident where Resident #1 received incorrect medications.

The facility failed to provide and document medication training for Staff B, who was not proxy trained or certified and dispensed incorrect medications to Resident #1. Resident #1 received another resident's medications, was transported to the ER, and never returned to the facility.

The investigation was triggered by a complaint intake# GA00227187 concerning a medication error on 8/17/22 where Staff B dispensed incorrect medications to Resident #1. The incident was substantiated by interviews and review of the facility incident report. Resident #1 was transported to the ER after 911 was called and did not return to the facility.

The purpose of this visit was to investigate intake #GA00223018.

No rule violations were cited as a result of this investigation.

Investigation started on 2022-04-19 and was completed on 2022-04-27. No rule violations were found.

The purpose of this survey was to conduct a compliance inspection and investigate complaints #GA0022463, #GA0022463, #GA00221961, and #GA00221852. The investigation started on 2022-03-15, with an onsite visit on 2022-03-31.

The facility failed to comply with disaster preparedness plans, including no fire drills conducted in 2021, failed to ensure direct care staff had at least 16 hours of annual training for 2 of 4 sampled staff, failed to comply with local fire safety ordinances due to a window that could not be opened manually, failed to keep ceilings and floors in good repair, and failed to update the medication administration record (MAR) for one resident.

The investigation was complaint-driven, investigating complaints #GA0022463, #GA0022463, #GA00221961, and #GA00221852. The investigation started on 2022-03-15, with onsite visit on 2022-03-31. Staff and resident interviews confirmed awareness of findings.

The visit was conducted to investigate intake #GA00219915.

No rule violations were cited as a result of this investigation.

Investigation of intake #GA00219915 with no rule violations found.

The purpose of this visit was to investigate intake #GA00216778.

No rule violations were cited as a result of this inspection.

Investigation of intake #GA00216778 completed with no rule violations cited.

The purpose of this inspection was to investigate intake #GA00212738 and #GA00213013, and conduct the compliance inspection. An unannounced visit was made to the facility on 3/26/21, with the investigation starting on 3/22/21 and completed on 4/9/21.

The facility failed to maintain required physical examinations for staff, did not ensure satisfactory criminal background checks prior to employment for some staff, failed to maintain staff files for inspection, and lacked a three-day supply of non-perishable food and water for emergency needs.

The inspection was initiated to investigate complaint intake numbers GA00212738 and GA00213013.

The purpose of this inspection was to investigate complaint intakes GA00211797 and GA00211972.

No rule violations were cited as a result of this inspection.

Investigation began on 2021-02-08 and was completed on 2021-02-11. No rule violations were found.

The purpose of this review is to monitor COVID 19 cases and assess infection control processes.

The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control measures.

The purpose of this visit was to conduct a follow-up to the 10/25/19 complaint investigation.

No rule violations were cited as a result of this inspection.

Follow-up to the 10/25/19 complaint investigation; no rule violations cited.

The purpose of this visit was to investigate complaint intakes #GA00200021 and #GA00199935 with an on-site visit conducted on 10/16/2019 and investigation completed on 10/25/2019.

The facility failed to ensure effective safety devices to protect residents at risk of elopement, resulting in two residents eloping. Additionally, the facility failed to provide adequate care and services for a resident at elopement risk, failed to report a serious injury requiring medical treatment, and staff knowingly falsified documentation regarding resident checks.

The investigation was triggered by complaint intakes #GA00200021 and #GA00199935. The complaint involved residents eloping from the facility, inadequate care, failure to report serious injury, and falsification of resident check documentation. The complaint was substantiated based on observations, interviews, and record reviews.

The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00195495 following a complaint about an unknown person entering the facility and stealing property.

The facility failed to ensure personnel files included evidence of a satisfactory fingerprint record check for the director/administrator. Additionally, the facility failed to provide reasonable safeguards for resident personal property after an unknown person entered through an unsecured door and stole items from a resident's apartment.

The complaint investigation was triggered by intake #GA00195495 regarding an unknown person entering the facility on 3/9/19 at approximately 1:00 a.m. through an unsecured door, wandering the facility, and stealing clothes and a cell phone from Resident #2's apartment. Police responded but did not locate the suspect.

The purpose of this visit was to conduct a follow-up to the 3/2/18 inspection.

The facility failed to display the plan of correction from the previous inspection and did not utilize effective safety devices to protect residents at risk of eloping, particularly on the fourth and fifth floors. Cameras were added but were not monitored 24 hours a day, and no safety devices were installed on stairwell doors.

The purpose of this visit was to investigate complaints #GA00186363 and GA00186563. The investigation started on 2018-03-21 and was completed on 2018-03-27.

The facility failed to properly dispose of unused medications for one discharged resident and failed to ensure that non-perishable emergency food supplies were rotated according to shelf life, with expired cereal observed in storage.

The visit was complaint-related, investigating complaints #GA00186363 and GA00186563. The investigation was substantiated by findings of medication disposal and emergency food storage deficiencies.

The purpose of this visit was to investigate complaint #GA00184920 and #GA00185447 with an on-site visit made on 2/20/18 and the investigation completed on 3/2/18.

The facility failed to provide adequate personal assistance to residents unable to keep themselves neat and clean, locked a resident into his/her room against regulations, failed to utilize appropriate safety devices to protect residents at risk of elopement, and failed to report an elopement incident to the Department within required timeframes.

The visit was complaint-related, investigating complaints #GA00184920 and #GA00185447. The investigation found substantiated issues including failure to provide personal assistance, improper locking of a resident's room, lack of safety devices for elopement risk, and failure to report an elopement incident.

The purpose of this visit was to conduct an annual inspection.

No rule violations were cited as a result of this inspection.

The purpose of this visit was to investigate self-reported incident #GA00179817 involving a resident who experienced a sudden change in condition.

The facility failed to initiate cardiopulmonary resuscitation immediately when Resident #1 experienced cardiac or respiratory arrest, despite no valid Do Not Resuscitate order being present. Staff did not perform CPR as they were unaware it was required, and the facility lacked policies or procedures for handling changes in resident condition.

Investigation of self-reported incident #GA00179817 regarding failure to perform CPR on Resident #1 who was found unresponsive and later pronounced dead. Staff did not perform CPR due to lack of knowledge and facility lacked policies for change in resident condition.

The purpose of this visit was to investigate intake #GA00176643.

The facility failed to ensure that at least one staff member with required training was present at all times when residents were present, specifically Staff E lacked CPR and First Aid certification. Additionally, the facility failed to maintain a personnel file for Staff E, who was a volunteer driving transport vehicles for approximately one month.

Visit was complaint-related to intake #GA00176643. The complaint was substantiated based on findings of training and personnel file deficiencies.

The purpose of this visit was to investigate complaint #GA00174667.

The facility was found deficient in multiple areas including failure of the governing body to provide proper oversight, incomplete written care plans lacking descriptions of social needs, preferences, responsible staff, and family involvement for Resident #1, inadequate Medication Assistance Record (MAR) documentation, and unsafe food handling practices in the kitchen.

The visit was complaint-related, investigating complaint #GA00174667.

The purpose of this visit was to investigate complaint GA00172448.

No rule violations were cited as a result of this inspection.

Complaint GA00172448 was investigated and found to have no rule violations.

The purpose of this visit was to conduct a follow-up to the 10/11/2016 complaint investigation.

The facility failed to provide sufficient staff time to keep residents comfortable and clean, as evidenced by a resident found lying on the floor with food-stained clothing and poor living conditions. Additionally, the facility failed to keep floors clean and in good repair, with stained carpets, food debris, and presence of a dead cockroach observed.

This was a follow-up visit to a complaint investigation originally conducted on 10/11/2016.

The purpose of this visit was to investigate complaint #GA00170573.

The facility failed to ensure that each resident had the right to choose activities and schedules consistent with their interests and assessments, as evidenced by Resident #1 being awakened early in the morning on multiple days to be dressed despite being asleep.

Complaint #GA00170573 was investigated. Resident #1 was awakened early in the morning on multiple days to be dressed, which did not respect the resident's right to choose activities and schedules. Resident #1 reported no upset feelings about this. Staff indicated that if this was a problem, the night shift could place Resident #1 last on their list for continent care and dressing.