Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 13, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA00248844 and #GA00249262 with an onsite visit on 2024-08-13.
Findings
The investigation was completed on 2024-08-28 with no violations cited.
Complaint Details
Investigation of complaint intakes #GA00248844 and #GA00249262 resulted in no violations being cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 6, 2024
Visit Reason
The visit was conducted to investigate complaint intake numbers GA00247699 and GA00248362 with an onsite visit made on 08/06/2024.
Findings
No rule violations were cited as a result of this complaint investigation.
Complaint Details
Investigation of complaint intake #GA00247699 and #GA00248362 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244074.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00244074 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 25, 2024
Visit Reason
The purpose of the visit was to investigate intake #GA00242033 with an onsite visit conducted on 01/25/2024 as part of a complaint investigation.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care, specifically related to medication administration. Staff refused to administer prescribed medications due to the deletion of the resident's electronic medication assistance record, resulting in missed medications and communication failures among staff.
Complaint Details
The investigation was initiated due to intake #GA00242033. The complaint involved medication administration issues for Resident #1, including refusal by staff to administer medications and lack of communication about the medication status. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulation for Resident #1, including refusal to administer prescribed medications due to missing electronic medication assistance record. | SS= D |
Report Facts
Dates related to medication orders and events: Nov 22, 2023
Dates related to medication orders and events: Nov 23, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 13, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225319 with an onsite visit made on 7/13/22 and the investigation completed on 7/14/22.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00225319 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 24, 2022
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaint #GA00219949, with the investigation starting on 2022-02-16 and completed on 2022-02-24.
Findings
The facility failed to ensure timely refills of prescribed medications, resulting in interruptions in dosing for 2 of 7 sampled residents (Resident #2 and Resident #3). Specific medications such as anti-diarrhea and stool softeners were not available at the facility on 2022-02-16.
Complaint Details
Investigation of complaint #GA00219949 regarding medication refill delays and interruptions in dosing for residents.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure timely refills of prescribed medications for Resident #2 and Resident #3, resulting in medication unavailability. | D |
Report Facts
Sampled residents with medication issues: 2
Total sampled residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F interviewed regarding medication availability for Resident #2 | ||
| Staff E interviewed regarding medication availability for Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 31, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00218796. An onsite visit was made to the facility on 11/23/21, with the investigation starting on 11/14/21 and completing on 1/31/2022.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00218796 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 23, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217923.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began 11/23/21 and was completed 1/31/21. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 4, 2021
Visit Reason
The visit was conducted to investigate complaint intakes #GA00213685 and #GA00214177 with onsite visits on 5/4/2021 and 5/5/2021, and the investigation completed on 5/24/2021.
Findings
The facility failed to ensure that medication administration records (MARs) were not falsified or altered and failed to provide medication administration services in accordance with physician's orders for 3 of 6 sampled residents. A temporary medication technician arrived late and did not administer morning medications on time, resulting in missed doses for residents.
Complaint Details
The investigation was initiated based on complaint intakes #GA00213685 and #GA00214177. The complaint involved allegations of falsified medication administration records and failure to administer medications as prescribed. The complaint was substantiated based on observations, record reviews, and interviews.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure that records submitted to the Department as part of an inspection had not been falsified or altered. | SS=D |
| Facility failed to provide medication administration services to residents in accordance with physician's orders for 3 of 6 sampled residents. | SS=D |
Report Facts
Dates of onsite visits: 5/4/2021 and 5/5/2021
Date investigation completed: 5/24/2021
Number of sampled residents with medication administration issues: 3
Medication administration times missed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Temporary Medication Technician | Named in medication administration and MAR falsification findings; stated arrival at 10:15 a.m. and not administering 8:00 a.m. medications. |
| Staff A | Interviewed regarding MAR manipulation and medication administration on 5/4/2021. | |
| Staff E | Interviewed about medication technician arrival and administration timing. | |
| Staff F | Interviewed about medication packets not administered on 5/4/2021. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 6, 2021
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00213088.
Findings
There were no rule violations cited as a result of this inspection.
Complaint Details
Investigation was completed on 2021-04-16; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 12, 2020
Visit Reason
The visit was conducted to investigate intake #GA00207274 and GA00207390.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00207274 and GA00207390 found no rule violations.
Inspection Report
Monitoring
Deficiencies: 0
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
Complaint Investigation
Census: 76
Deficiencies: 1
Mar 12, 2020
Visit Reason
The purpose of this visit was to investigate complaints #GA00203475 and #GA00203179, with an onsite visit conducted on 3/12/2020 and the investigation completed on 05/18/2020.
Findings
The facility failed to ensure a resident's right to be free from neglect, as Resident #1 was found on the floor for at least 30 minutes after a fall before staff responded. The medical alert was announced multiple times but was not promptly addressed.
Complaint Details
Investigation of complaints #GA00203475 and #GA00203179 regarding neglect of Resident #1, substantiated by findings that Resident #1 was left on the floor for over 30 minutes after a fall despite using the medical alert system.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident has the right to be free from neglect, evidenced by Resident #1 being on the floor for at least 30 minutes before staff responded after a fall. | D |
Report Facts
Resident census: 76
Fall alert response time: 32
Medical alert announcements: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00202228 with an onsite visit made on 2/5/2020 and the investigation completed on 2/7/2020.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00202228 completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00201207 and #GA00201218.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00201207 and #GA00201218 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00200282 and intake #GA00200882 through unannounced visits on 11/19/19 and 11/20/19, with the investigation completed on 12/4/19.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00200282 and intake #GA00200882 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00199901, with the investigation starting on 2019-10-15 and completing on 2019-10-18.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00199901 completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 26, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00199390.
Findings
The facility failed to implement policies and practices supporting residents' dignity, respect, choice, independence, and privacy, resulting in delayed staff response times and inadequate oversight. Additionally, residents experienced long waits for meals, especially when ordering alternate meal options, which were not disclosed in the admission agreement.
Complaint Details
The investigation was complaint-driven based on complaint GA00199390. Interviews with residents and staff revealed delays of 30 to 60 minutes or more for staff response to calls and meal service, ignored call buttons, and lack of management oversight. Residents reported fear and dissatisfaction with care timeliness and meal options.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Governing body failed to implement policies, procedures and practices supporting residents' dignity, respect, choice, independence and privacy in a safe environment. | SS= D |
| Facility failed to ensure residents' rights to make choices about aspects of their life, including timely meal service and honoring meal choices. | SS= D |
Report Facts
Wait time for staff response: 40
Wait time for meal service: 35
Wait time for meal service: 45
Wait time for alternate meal: 50
Wait time for staff response: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff who reported difficulty hiring quality staff and acknowledged longer wait times for second option meals |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 10, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00199157.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint GA00199157 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 23, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00198465 regarding the adequacy and appropriateness of care and services provided to residents.
Findings
The facility failed to ensure adequate and appropriate care for 2 of 3 sampled residents. Resident #1 left the memory care unit unnoticed due to staff not hearing alarm sensors, and Resident #2 experienced delayed response to call pendant alerts and required assistance with ambulation and wound care.
Complaint Details
The complaint investigation revealed that Resident #1 left the memory care unit through a window and was missing for over two hours without staff awareness due to pagers not set to audible volume. Resident #2 reported slipping out of wheelchair and delayed caregiver response to call pendant alerts, with documented incidents showing multiple unanswered alerts over extended periods.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations for 2 of 3 sampled residents. | D |
Report Facts
Incident duration: 155
Call alerts sent: 9
Call alerts sent: 9
Incident date: Aug 8, 2019
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Mar 21, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00195246, #GA00195314, and #GA00195315 related to resident safety and care.
Findings
The facility failed to ensure adequate and appropriate care for 1 of 28 residents in the memory care unit who eloped from the facility through an unsecured window. The resident was found outside without proper clothing, indicating a safety risk due to inadequate security measures.
Complaint Details
The visit was complaint-related, investigating intakes #GA00195246, #GA00195314, and #GA00195315. The complaint was substantiated by findings that Resident #1 eloped from the memory care unit through an unsecured window.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate and appropriate care in compliance with state law, evidenced by Resident #1 eloping from the memory care unit through an unsecured window. | J |
Report Facts
Residents in memory care unit: 28
Incident date: Mar 2, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1 eloping from the memory care unit window |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 2
Jan 23, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00193930.
Findings
The facility failed to consistently staff at the minimum staff to resident ratios and failed to ensure residents were free from physical restraints in the memory care unit. Specifically, staffing was below the required ratio during wake hours, and three residents were physically restrained by elevated recliner footrests to prevent falls.
Complaint Details
The visit was complaint-related, investigating intake #GA00193930. The complaint was substantiated by findings of staffing deficiencies and improper use of physical restraints on residents.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to consistently staff at the minimum staff to resident ratios during wake hours. | Level D |
| Facility failed to ensure each resident was given the right to be free from physical restraints for 3 of 27 residents in memory care unit. | Level D |
Report Facts
Residents present: 61
Residents restrained: 3
Memory care residents: 27
Staff required: 4.06
Staff worked: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff B interviewed regarding staffing ratios; Staff C interviewed regarding use of physical restraints |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00188790 with an onsite visit made on 06/05/18 and the investigation completed on 06/19/18.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00188790 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 25, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA 00187616.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Complaint GA 00187616 was investigated and found to have no violations.
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 4, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate self complaint #GA00183340.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Self complaint #GA00183340 was investigated during the visit.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 14, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 10/16/2017 investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 13, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to complaint #GA00174935, #GA00175891, and #GA00176821.
Findings
No rule violations were cited as a result of the inspection.
Complaint Details
Follow-up to complaints #GA00174935, #GA00175891, and #GA00176821; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 4, 2017
Visit Reason
The purpose of the visit was to investigate complaint #GA00180240 with an on-site visit conducted on 2017-10-04 and investigation completed on 2017-10-16.
Findings
The facility failed to ensure adequate and appropriate care for residents, including failure to obtain follow-up care for a wrist fracture for Resident #1 and failure to immediately take appropriate actions for a sudden adverse change in condition for Resident #2 after a fall, resulting in delayed hospital admission for a hip fracture and subdural hematoma.
Complaint Details
Complaint #GA00180240 was investigated with findings that the facility failed to provide adequate care and follow-up for Resident #1's wrist fracture and failed to take immediate appropriate actions for Resident #2's fall and adverse condition change. The investigation included review of incident reports, hospital records, and staff interviews.
Severity Breakdown
J: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations, specifically failure to obtain follow-up care for Resident #1's wrist fracture. | J |
| Failure to immediately take appropriate actions in case of a sudden adverse change in resident's condition, including failure to notify or respond properly to Resident #2's fall and subsequent condition. | D |
Report Facts
Complaint number: 1
Sampled residents: 3
Dates of incidents: Sep 10, 2017
Dates of incidents: Sep 24, 2017
Inspection Report
Complaint Investigation
Deficiencies: 11
Jul 12, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00174935, #GA00175891, and #GA00176821 with on-site visits made on 5/16/17, 6/14/17, 6/28/17, 7/11/17, and 7/12/17.
Findings
The investigation found multiple deficiencies related to initial staff training for memory care staff, specifically that 2 of 13 sampled staff (Staff D and Staff E) lacked documentation of required training in all 10 specified dementia care topics. Additionally, the Community failed to ensure residents' rights to privacy, with 4 of 7 sampled residents experiencing privacy violations due to wandering and entering other residents' rooms.
Complaint Details
The investigation was complaint-driven based on complaints #GA00174935, #GA00175891, and #GA00176821. The complaints involved issues with staff training deficiencies and residents' rights violations, including privacy breaches by Resident #5 wandering into other residents' rooms.
Severity Breakdown
SS= D: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure memory care staff received training in the nature of Alzheimer's Disease and other dementias within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in common behavior problems and recommended behavior management techniques within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in communication skills that facilitate better resident-staff relations within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in positive therapeutic interventions and activities within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in the role of the family in caring for residents with dementia within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in environmental modifications to avoid problematic behavior within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in development of comprehensive individual service plans within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in new developments in dementia care within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in skills for recognizing physical or cognitive changes warranting medical attention within 6 months of hire. | SS= D |
| Failed to ensure memory care staff received training in skills for maintaining the safety of residents with dementia within 6 months of hire. | SS= D |
| Failed to ensure residents' right to privacy by not preventing Resident #5 from entering and sleeping in other residents' rooms and beds, affecting 4 of 7 residents sampled. | SS= D |
Report Facts
Number of sampled staff lacking training documentation: 2
Number of sampled residents with privacy violations: 4
Number of complaints investigated: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in multiple findings for lack of required memory care training documentation. | |
| Staff E | Named in multiple findings for lack of required memory care training documentation. | |
| Staff A | Interviewed and stated lack of documentation for Staff D and Staff E's memory care training; also stated Resident #5 was relocated to a private room. | |
| BB | Interviewed regarding Resident #5 wandering into other residents' rooms. | |
| CC | Interviewed regarding Resident #5's behavior invading other residents' privacy. | |
| DD | Interviewed regarding Resident #5's behavior invading other residents' privacy. | |
| EE | Interviewed regarding Resident #5's behavior invading other residents' privacy. |
Inspection Report
Annual Inspection
Deficiencies: 3
Mar 8, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
The facility failed to maintain required training records documenting at least 24 hours of continuing education within the first year of employment for 4 sampled staff. Additionally, the facility did not conduct the required number of fire drills during sleep hours in compliance with fire safety regulations. The care plans for residents in the memory care unit were not updated at least annually or more frequently as needed for 8 of 11 sampled residents.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to maintain training records documenting at least 24 hours of continuing education within the first year of employment for 4 sampled staff. | SS= D |
| Facility failed to ensure fire drills were conducted in compliance with fire safety regulations, missing the second required fire drill during sleep hours. | SS= D |
| Facility failed to ensure care plans were updated at least annually and more frequently when resident needs changed for 8 of 11 sampled residents in the memory care unit. | SS= D |
Report Facts
Continuing education hours required: 24
Staff with insufficient training: 4
Fire drills during sleep hours required: 2
Fire drills during sleep hours conducted: 1
Residents with outdated care plans: 8
Sampled residents: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff aware of training and fire drill deficiencies and care plan updates. | |
| Staff B | Sampled staff with insufficient continuing education hours. | |
| Staff C | Sampled staff with insufficient continuing education hours. | |
| Staff D | Sampled staff with insufficient continuing education hours. | |
| Staff E | Sampled staff with insufficient continuing education hours. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 30, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA001707156.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Complaint #GA001707156 was investigated and found to have no violations.
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