Inspection Reports for Garden Plaza at Lawrenceville
230 Collins Industrial Way, Lawrenceville, GA 30043, GA, 30043
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Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00245927 and #GA00245922.
Findings
An on-site visit was made on 5/22/24. No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intakes #GA00245927 and #GA00245922 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245706 and #GA00245732 through an on-site visit made on 4/29/24 with the investigation completed on 4/30/24.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00245706 and #GA00245732 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 26, 2024
Visit Reason
The visit was conducted to perform a compliance inspection and investigate complaint intakes #GA00244407, GA0024412, and GA002423977.
Findings
The facility was found to be licensed as a personal care home but was advertising and functioning as an assisted living facility, which is not permitted under its current license.
Complaint Details
The investigation was complaint-driven based on multiple intakes. The report does not explicitly state substantiation status.
Deficiencies (1)
| Description |
|---|
| The facility advertised on its website that it functioned as an assisted living facility while only licensed as a personal care home. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244733 during an onsite visit on 4/1/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00244733 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 2, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232651. An on-site visit was made to the facility on 3/2/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 3/2/23 and was completed on 3/20/23. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00230009. An on-site visit was made to the facility on 02/21/23. The investigation started on 02/20/23 and was completed on 02/22/23.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00230009 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 1, 2022
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00228206 and #GA00228348.
Findings
The facility failed to obtain a satisfactory fingerprint background check for 2 of 5 sampled staff (Staff C and Staff D).
Complaint Details
Investigation of intake #GA00228206 and #GA00228348 regarding fingerprint background checks for staff.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory fingerprint background check for Staff C and Staff D. | D |
Report Facts
Number of sampled staff without fingerprint background check: 2
Hire date for Staff C: Aug 29, 2022
Hire date for Staff D: Jun 9, 2017
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Aug 4, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00213956, including an onsite visit on 2021-05-11 and completion of the investigation on 2021-08-04.
Findings
The facility failed to ensure adequate oversight to prevent elopement of Resident #1, who exited the facility through a side exit door setting off an alarm that staff did not respond to. Resident #1 was found approximately 50 feet away from the facility. The resident was identified as at risk for elopement and had multiple diagnoses including vascular dementia.
Complaint Details
The investigation was triggered by intake #GA00213956 regarding Resident #1 eloping from the facility on 4/25/21. The complaint was substantiated based on record review and staff interviews confirming failure to respond to the exit alarm and inadequate oversight.
Severity Breakdown
SS=K: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide oversight to ensure the home operated in compliance with applicable rules and regulations, resulting in Resident #1 eloping from the facility without staff response to the alarm. | SS=K |
| Failure to ensure each resident received adequate and appropriate care and services in compliance with federal and state law, evidenced by Resident #1 eloping and staff not responding to the alarm. | SS=K |
Report Facts
Facility census: 28
Incontinent residents: 12
Staff on duty: 7
Incident time: 12.03
Alarm restored time: 12.04
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1 elopement and alarm notification | |
| Staff B | Interviewed; did not respond to alarm during lunch preparation | |
| Staff D | Interviewed; stated staff should have responded to alarm and commented on Resident #1's care needs | |
| AA | Found Resident #1 after elopement and assisted with personal items |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00208686. The investigation began on 2020-10-19 and was completed on 2020-11-30.
Findings
The report does not provide specific findings or deficiencies within the extracted text.
Complaint Details
Investigation of complaint #GA00208686 conducted from 2020-10-19 to 2020-11-30. No substantiation status or further details provided.
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 4
Apr 30, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204120, which involved an elopement incident of Resident #3 from the facility.
Findings
The facility failed to provide adequate oversight and safety measures to prevent Resident #3 from eloping. The exit doors were equipped with chimes instead of alarms, and staff were unaware of the alarm system changes. Staffing levels were insufficient to safeguard residents properly. Resident #3 was at risk for elopement and was diagnosed with major depressive disorder.
Complaint Details
The investigation was initiated due to intake #GA00204120 concerning Resident #3 eloping from the facility on 3/31/20. The resident was found about one-fourth of a mile from the facility and returned unharmed. The facility was found to have inadequate safety measures and staffing to prevent elopement. Resident #3 was at risk for elopement and had a diagnosis of major depressive disorder.
Severity Breakdown
J: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide oversight necessary to ensure compliance, resulting in Resident #3 eloping from the facility. | J |
| Failed to have sufficient qualified and trained staff on duty to safeguard residents, contributing to Resident #3's elopement. | J |
| Failed to utilize appropriate effective safety devices to protect residents at risk of elopement; exit door alarms were inaudible or disabled. | J |
| Failed to ensure each resident received adequate and appropriate care and services in compliance with laws and regulations, related to Resident #3's elopement incident. | J |
Report Facts
Residents present: 38
Staff working: 5
Residents with dementia: 16
Residents on first floor: 18
Residents on second floor: 20
Temperature: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #3 elopement and exit door alarm system | |
| Staff B | Interviewed regarding Resident #3 elopement, staffing, and alarm system | |
| Staff C | Interviewed and unaware of Resident #3 elopement risk | |
| FF | Witnessed Resident #3 walking and notified facility | |
| GG | Witnessed Resident #3 walking and assisted in returning resident to facility |
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
Deficiencies: 0
Aug 26, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198901.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00198901 found no rule violations.
Inspection Report
Routine
Deficiencies: 5
Nov 29, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection at The Bridge at Lawrenceville.
Findings
The facility failed to maintain required staff recertifications and work performance reviews for unlicensed staff, admitted and retained a resident not meeting ambulatory requirements, and lacked individual written care plans and informed consents for several residents.
Severity Breakdown
D: 4
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain current recertification in emergency first aid and CPR for 1 of 7 sampled staff (Staff B). | D |
| Failed to have initial and/or annual work performance reviews for 2 of 7 sampled unlicensed staff (Staff B and Staff C) performing specialized tasks for medication administration to 3 of 6 sampled residents. | D |
| Admitted and retained a resident (Resident #1) who was not ambulatory and required total assistance, contrary to facility admission requirements. | E |
| Failed to ensure individual written care plans for 3 of 6 sampled residents (Resident #1, Resident #3, Resident #6). | D |
| Failed to obtain informed written consents designating proxy caregivers for health maintenance activities for 3 of 6 sampled residents (Resident #1, Resident #3, Resident #6). | D |
Report Facts
Sampled staff: 7
Sampled residents: 6
Residents affected: 3
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings for lack of current first aid/CPR recertification and missing work performance reviews | |
| Staff C | Named in findings for missing work performance reviews | |
| Staff F | Interviewed staff providing information about missing documents and recertifications | |
| AA | Interviewed staff providing information about Resident #1's care needs |
Inspection Report
Follow-Up
Deficiencies: 3
Dec 21, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 5/4/17 complaint investigation with intake numbers GA00172656 and GA00173253.
Findings
The facility failed to ensure that the physical examination form was completed in its entirety for one resident, failed to arrange for special therapeutic diets as prescribed for one resident, and failed to obtain all health appraisals for one resident. These violations were previously cited on 5/4/17.
Complaint Details
This was a follow-up visit to a complaint investigation initiated on 5/4/17 with intake numbers GA00172656 and GA00173253.
Severity Breakdown
E: 2
K: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Physical examination form was incomplete for Resident #6, missing the physician's address. | E |
| Failed to arrange for special therapeutic diets as prescribed for Resident #2, who was on a pureed diet but was observed eating regular food without physician's order to change diet. | K |
| Failed to obtain all health appraisals for Resident #7, missing home health agency appraisals including physical therapy. | E |
Report Facts
Sampled residents with deficiencies: 3
Previous citation date: May 4, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding completion of physical examination forms and diet orders. | |
| BB | Interviewed regarding Resident #2's diet preferences and changes. | |
| CC | Interviewed about Resident #2's lunch and diet. | |
| DD | Confirmed Resident #2 was eating a regular diet. |
Inspection Report
Follow-Up
Deficiencies: 0
May 9, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the annual inspection conducted on 2017-02-08.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 5
May 2, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00174035 and #GA00174609.
Findings
The facility failed to ensure that retained residents were capable of self-preservation with minimal assistance for 2 sampled residents. The facility also failed to report a serious injury to a resident within 24 hours, failed to ensure the registered nurse developing proxy plans of care was licensed under Georgia law, failed to disclose qualifications of licensed healthcare professionals developing plans of care, and failed to ensure proxy caregivers achieved required literacy testing for medication assistance.
Complaint Details
The visit was conducted to investigate complaints #GA00174035 and #GA00174609. The facility was found noncompliant in multiple areas including resident self-preservation capability, injury reporting, licensing of nursing staff, disclosure of healthcare professional qualifications, and proxy caregiver literacy testing.
Severity Breakdown
D: 4
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure retained residents were capable of self-preservation with minimal assistance for 2 of 2 sampled residents (#2, #3). | D |
| Failed to report within 24 hours a serious injury to a resident that required medical treatment for 1 of 1 sampled residents (#1). | E |
| Failed to ensure the registered nurse used to develop the proxy plan of care was licensed and authorized under Georgia law. | D |
| Failed to disclose the qualifications of licensed healthcare professionals who develop written plans of care for clients and provide training for 2 of 2 sampled residents. | D |
| Failed to ensure proxy caregivers for resident medication assistance achieved at least a minimum score of 75 on the Test of Functional Health Literacy for Adults for 5 of 5 staff. | D |
Report Facts
Resident sample size: 3
Staff proxy caregivers: 5
Incident report date: Apr 30, 2017
Inspection Report
Complaint Investigation
Deficiencies: 5
Mar 28, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00172656 and #GA00173253. An on-site visit was made on 3/28/17 and the investigation was completed on 5/4/17.
Findings
The facility failed to ensure that residents had complete physical examinations within 30 days prior to admission, failed to follow physician's medication orders, failed to arrange special therapeutic diets as prescribed, failed to maintain complete resident health appraisals, and failed to ensure adequate care and services for one sampled resident, resulting in serious adverse outcomes including hospitalization and death.
Complaint Details
The visit was complaint-related, investigating complaints #GA00172656 and #GA00173253. The investigation included review of resident records and staff interviews, confirming multiple deficiencies related to resident care and compliance.
Severity Breakdown
D: 3
J: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents had a physical examination by a licensed provider dated within 30 days prior to admission and completed in its entirety. | D |
| Failed to follow physician's orders and to have physician's orders for medication changes for one resident. | D |
| Failed to arrange for special therapeutic diets as prescribed by the resident's physician. | J |
| Failed to obtain all health appraisals for one resident, including physical therapy, occupational therapy, nursing, and nursing aide services. | D |
| Failed to ensure each resident received adequate, appropriate care and services in compliance with applicable laws, resulting in Coumadin toxicity and hospitalization. | J |
Report Facts
Medication dosage: 4.5
Date of admission: Jan 26, 2017
Date of physical examination: Jan 25, 2017
Date of incident: Mar 27, 2017
Date of hospital admission: Feb 13, 2017
Inspection Report
Annual Inspection
Deficiencies: 2
Feb 8, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The inspection found deficiencies related to the governing body's failure to implement policies for resident fall monitoring and documentation, and failure to ensure medications were stored securely under lock and key for one resident.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The governing body failed to follow facility policies concerning resident falls and documentation of resident accidents, including lack of fall risk evaluation, incident report, post-fall assessment, and revised service plan for Resident #1. | SS= D |
| The facility failed to ensure medications were stored under lock and key for 1 of 4 residents (#1), with Gas X and Vitamin D pills observed in an unlocked bedroom. | SS= D |
Report Facts
Residents with medication storage deficiency: 1
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