Inspection Report Summary
The most recent inspection on November 21, 2019, found deficiencies related to staff CPR certification, training on Alzheimer's disease and dementias, tuberculosis screening, and National Sex Offender Registry searches. Earlier inspections, including the November 15, 2017 annual inspection, also identified multiple deficiencies primarily involving staff training in health and safety topics, participant documentation, and admission procedures. Complaint investigations were included in the 2017 inspection, but no enforcement actions, fines, or license suspensions were listed in the available reports. The main themes across inspections involved staff training and participant admission requirements. The pattern of findings suggests ongoing challenges in these areas without clear evidence of improvement or worsening over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 4
Date: Nov 21, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection of the facility.
Findings
The facility failed to ensure all staff had current CPR certification with return demonstration of competency, failed to provide training on Alzheimer's disease and other dementias for 4 of 6 sampled staff, failed to ensure TB screening within 12 months prior to admission for 3 of 4 sampled participants, and failed to complete National Sex Offender Registry searches for 4 of 4 sampled participants.
Deficiencies (4)
Facility failed to ensure all staff have current certification in cardiopulmonary resuscitation (CPR) with return demonstration of competency.
Facility failed to ensure staff received training on Alzheimer's disease and other dementias including communicating and responding to behaviors for 4 of 6 sampled staff.
Facility failed to ensure each participant is free of active tuberculosis based on negative tuberculin skin test or chest x-ray within 12 months prior to admission for 3 of 4 sampled participants.
Facility failed to ensure the Director or designee completed a search of the National Sex Offender Registry website at the time of admission for 4 of 4 sampled participants.
Report Facts
Sampled staff: 6
Staff lacking training: 4
Sampled participants: 4
Participants lacking TB screening: 3
Participants lacking NSOR search: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in CPR training deficiency and Alzheimer's disease training deficiency | |
| Staff C | Named in Alzheimer's disease training deficiency | |
| Staff E | Named in Alzheimer's disease training deficiency | |
| Staff F | Named in Alzheimer's disease training deficiency | |
| Staff A | Interviewed regarding Alzheimer's disease training and NSOR search deficiencies | |
| Staff B | Interviewed regarding TB screening deficiency |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Nov 15, 2017
Visit Reason
The purpose of this visit was to complete an annual inspection and investigate complaint #GA00181524. An onsite visit was made on 11/15/17 and the investigation was completed on 11/17/17.
Complaint Details
The inspection included investigation of complaint #GA00181524 as part of the annual inspection.
Findings
The facility failed to ensure staff received required training in multiple areas including standard precautions, infection control, elder abuse identification, participants' rights, influenza vaccination, and Alzheimer's disease for sampled staff. Additionally, the facility failed to ensure physical exams, tuberculosis screenings, National Sex Offender Registry searches, provision of policies and procedures, emergency contacts, authorized representative documentation, signed HIPAA authorizations, and emergency medical care authorizations were properly documented for sampled participants.
Deficiencies (13)
Facility failed to ensure staff received training in standard precautions, infection control and latex safety within 90 days of hire for 1 of 2 sampled staff (Staff D).
Facility failed to ensure staff received training in identifying participants who may be victims of elder abuse or self-neglect for 1 of 2 sampled staff (Staff D).
Facility failed to ensure staff received training in participants' rights including prevention and reporting of abuse, neglect or exploitation within 90 days of hire for 1 of 2 sampled staff (Staff D).
Facility failed to ensure staff received training on the nature of influenza and the role of vaccination within 90 days of hire for 1 of 2 sampled staff (Staff D).
Facility failed to ensure staff received training on Alzheimer's disease and other dementias including communicating and responding to behaviors for 1 of 2 sampled staff (Staff D).
Facility failed to ensure all staff had received a physical exam by an authorized healthcare professional within twelve months prior to employment for 3 of 3 sampled staff (B, C, D).
Facility failed to ensure each participant is free of active tuberculosis based on negative test within 12 months prior to admission for 2 of 2 sampled participants (#2 and #3).
Facility failed to ensure the Director or designee completed a search of the National Sex Offender Registry at admission for 2 of 2 sampled participants (#2 and #3).
Facility failed to ensure participant and representative received a copy of the center's policies and procedures at admission for 1 of 2 sampled participants (#2).
Facility failed to document at least two emergency contacts including name, address, telephone number, and relationship for 2 of 2 sampled participants (#2 and #3).
Facility failed to include copies of powers of attorney, guardianship orders, or other documents identifying authorized representatives for 1 of 2 sampled participants (#3).
Facility failed to have copies of signed authorizations for the center to receive and provide confidential information for 2 of 2 sampled participants (#2 and #3).
Facility failed to include signed authorization for emergency medical care for 2 of 2 sampled participants (#2 and #3).
Report Facts
Sampled staff: 2
Sampled staff: 3
Sampled participants: 2
Sampled participants: 1
Sampled participants: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in multiple training and physical exam deficiencies | |
| Staff B | Named in physical exam deficiency | |
| Staff C | Named in physical exam deficiency | |
| Staff E | Interviewed staff who acknowledged deficiencies and stated issues would be corrected | |
| Staff A | Interviewed staff unaware of emergency contact documentation rule |
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