Inspection Reports for Governor’s Glen Mem Care & Assisted Living Comm
5000 GOVERNOR'S DRIVE, FOREST PARK, GA, 30297.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 19, 2024, found no deficiencies. Earlier inspections showed a mixed pattern with some citations related to staff training and documentation, as well as resident care issues such as inadequate wound care and supervision lapses leading to resident elopement. Prior substantiated complaints included failures in ensuring adequate care, updating service plans, and preventing abuse, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaint investigations were unsubstantiated, with the exception of a few substantiated cases involving resident safety and care plan deficiencies. The facility appears to have addressed some earlier issues, as the most recent inspections have been free of cited violations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 19, 2024
Visit Reason
The purpose of this visit was to investigate intake GA 00247237.
Complaint Details
Investigation began on 2024-06-13 and ended on 2024-06-19. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 8, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00244650 with an onsite visit made on 2024-05-08 and the investigation completed on 2024-05-22.
Complaint Details
Investigation of intake # GA00244650 with findings of failure to meet staff training requirements, incomplete staff files, and failure to update resident care plans.
Findings
The facility failed to ensure staff received required annual training hours, lacked documentation for certain staff files including training and medical screenings, and failed to update individual resident service plans quarterly or when needs changed.
Deficiencies (3)
Facility failed to ensure any person working in the home received at least 24 hours of training per year.
Facility failed to have a file for every staff including training on evacuation procedures, resident rights, abuse reporting act, infection control, physical examination, and tuberculosis screening.
Facility failed to update the resident's service plan at least quarterly or when the resident's needs changed for 1 of 5 sampled residents.
Report Facts
Training hours required: 24
Sampled residents: 5
Resident #1 admission date: Aug 4, 2021
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243645.
Complaint Details
Investigation of intake #GA00243645 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243165.
Complaint Details
Investigation of intake #GA00243165 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 19, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242628 and GA00242542.
Complaint Details
Investigation of intake #GA00242628 and GA00242542 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00229842.
Complaint Details
Investigation of intake #GA00229842 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA 002229825, GA00229782, and GA002291773.
Complaint Details
Investigation of complaint intakes #GA 002229825, GA00229782, and GA002291773 revealed substantiated deficiencies related to inadequate wound care for Resident #1.
Findings
The facility failed to ensure adequate and appropriate care for Resident #1, who developed a pressure ulcer that worsened from stage 1 to stage 2 due to inadequate wound care by facility staff.
Deficiencies (1)
Facility failed to provide adequate pressure ulcer wound care for Resident #1, resulting in worsening of the pressure ulcer from stage 1 to stage 2.
Report Facts
Number of dressing changes per day: 3
Date of Physician Medical Evaluation: Jul 16, 2021
Date home health staff began wound care: Apr 13, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 21, 2022
Visit Reason
The purpose of this visit was to investigate intakes GA00228952 and GA00228946.
Complaint Details
Investigation of intakes GA00228952 and GA00228946 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00226611.
Complaint Details
Investigation of intake GA00226611 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225178 regarding a missing resident incident.
Complaint Details
The investigation was triggered by intake #GA00225178 concerning Resident #1 who went missing on 6/16/22. The resident was located walking on highway 85 by law enforcement after eloping from the facility. Staff and family interviews were conducted, and a police report was reviewed.
Findings
Resident #1, diagnosed with Dementia, eloped from the secured memory care courtyard using a ladder left in the area, climbed onto the roof, and left the facility. The resident was found unharmed by law enforcement after several hours. Staff interviews and documentation revealed failures in ensuring resident safety and supervision.
Deficiencies (1)
Facility failed to ensure each resident received adequate and appropriate care and services in compliance with state law for Resident #1 who eloped from the facility.
Report Facts
Date of resident admission: Jun 6, 2022
Date of elopement incident: Jun 16, 2022
Time resident went missing: 1120
Time resident located: 1240
Staff B hire date: Apr 28, 2022
Staff C hire date: Nov 29, 2021
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 20, 2022
Visit Reason
The purpose of this visit was to investigate self report intake GA 0023112.
Complaint Details
Investigation of self report intake GA 0023112; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 22, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA 00219807 and #GA 00219844 related to allegations of abuse involving Resident #1.
Complaint Details
The investigation was initiated due to complaints intake #GA 00219807 and #GA 00219844. The complaint involved allegations that Staff A assaulted Resident #1, who sustained multiple injuries including rib fractures and pericardial effusion. The criminal investigation is ongoing.
Findings
Based on observation, record review, and interviews, the facility failed to ensure Resident #1 was free from mental, verbal, sexual, and physical abuse, neglect, and exploitation. Resident #1 sustained multiple rib fractures and other injuries following an altercation with Staff A, who reportedly hit the resident during the incident. The criminal investigation is ongoing.
Deficiencies (1)
Failure to ensure each resident was free from mental, verbal, sexual and physical abuse, neglect and exploitation for Resident #1.
Report Facts
Date of incident report: Dec 7, 2021
Date of facility incident report: Dec 4, 2021
Date of police report: Dec 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in abuse incident involving Resident #1; involved in physical altercation | |
| Staff B | Witnessed and attempted to intervene in altercation between Resident #1 and Staff A |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212472.
Complaint Details
Investigation began 2021-03-08 and was completed 2021-03-15 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00209088. This complaint was previously investigated in intake GA00208294.
Complaint Details
Investigation of complaint intake #GA00209088, which was previously investigated in intake GA00208294.
Findings
The report does not provide specific findings or deficiencies beyond the statement that the visit was to investigate a complaint intake.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 29, 2020
Visit Reason
The visit was conducted to investigate complaint intakes #GA00208294 and #GA00208057, with the investigation beginning on 2020-09-23 and completed on 2020-09-29.
Complaint Details
The investigation was complaint-related, triggered by intakes #GA00208294 and #GA00208057. Resident #1 was reported missing after eloping from the facility, with substantiation indicated by the documented incident and police reports.
Findings
The facility failed to ensure adequate and appropriate care and services in compliance with state law. Resident #1 eloped from the facility on 2020-09-04, was missing for over a day, and was later found unharmed near a highway. The facility lacked cameras on the property, and staff responses and notifications were documented.
Deficiencies (1)
Failure to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations, evidenced by Resident #1 eloping from the facility and being missing for over a day.
Report Facts
Date Resident #1 went missing: Sep 4, 2020
Date Resident #1 was found: Sep 5, 2020
Investigation start date: Sep 23, 2020
Investigation completion date: Sep 29, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Worked 11:00 p.m. - 7:00 a.m. shift, discovered Resident #1 missing around 6:00 a.m., made statement to police | |
| Staff B | Notified by Staff A about Resident #1 missing, initiated code orange alert, completed incident report, contacted Resident #1's family |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206857.
Complaint Details
Investigation began on 2020-08-07 and was completed on 2020-08-10. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: 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: 1
Date: Jan 6, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00201749.
Complaint Details
Investigation of intake #GA00201749 regarding aggressive behavior of Resident #1 toward other residents, including pushing and hitting.
Findings
The community failed to ensure each resident received adequate and appropriate care and services in compliance with state law for 1 of 2 residents. Resident #1 exhibited aggressive behaviors toward others, including pushing and hitting other residents.
Deficiencies (1)
Failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulations for Resident #1 exhibiting aggressive behaviors toward others.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 30, 2019
Visit Reason
The purpose of this visit was to conduct the annual inspection and investigate intake #GA00199746, #GA00199715 and GA00199716.
Findings
The facility failed to ensure that each resident was treated with dignity, kindness, consideration and respect, as evidenced by verbal abuse toward Resident #2 by Staff J, who was terminated on 9/10/19.
Deficiencies (1)
Facility failed to ensure that each resident was treated with dignity, kindness, consideration and respect, including an incident of verbal abuse by Staff J toward Resident #2.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 1, 2019
Visit Reason
The purpose of this visit was to investigate self reported incident # GA0019556.
Complaint Details
Investigation of self reported incident # GA0019556 with no violations found.
Findings
No violations of the rules and regulations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 17, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00193276. Onsite visits were made on 2019-01-14 and 2019-01-17 and the investigation was completed on 2019-01-17.
Complaint Details
The investigation was complaint-driven based on complaint GA00193276. The complaint involved concerns about use of restraints and failure to report injuries and incidents involving residents.
Findings
The facility failed to ensure that residents did not require physical restraints for behavioral control, failed to initiate immediate investigation and reporting of accidents or injuries for sampled residents, and failed to report serious injuries requiring medical attention to the Department.
Deficiencies (3)
Facility failed to ensure that all residents did not require physical restraints for behavioral control for 1 of 1 sampled resident (Resident #3) who was observed with a seat belt restraint despite documentation indicating no restraints were required.
Facility failed to ensure immediate investigation and reporting of the cause of an accident, injury, or death involving residents (Resident #1 and Resident #2), including failure to document incidents and notify representatives or legal surrogates.
Facility failed to report serious injuries requiring medical attention to the Department for 1 of 1 resident (Resident #1) who had a fractured hip after a fall.
Report Facts
Number of sampled residents with deficiencies: 3
Date of physical evaluation: Jan 16, 2018
Date of hospital admission: Jan 5, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Interviewed regarding Resident #3's inability to remove seat belt restraint. | |
| Staff B | Interviewed regarding Resident #3's admission with wheelchair seat belt and lack of knowledge about bruising on Resident #2. | |
| Staff A | Interviewed regarding lack of knowledge about restraint use and injury reporting requirements. | |
| NN | Interviewed and stated he/she was not notified about Resident #1's black eye. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 11, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00191282.
Complaint Details
Complaint #GA00191282 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint #GA00190886.
Complaint Details
Investigation of complaint #GA00190886 with no violations cited.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 21, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA0018598.
Complaint Details
Complaint #GA0018598 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 19, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00177684 and GA0017732.
Complaint Details
The visit was complaint-related, investigating complaints #GA00177684 and GA0017732.
Findings
The facility failed to ensure that Resident #1 had a physical examination completed prior to admission, did not have an admission agreement with a current statement of fees, and did not develop an individual written care plan within 14 days of admission as required.
Deficiencies (3)
Failed to ensure that all residents admitted had a physical examination completed on a form provided by the Department.
Failed to have an admission agreement inclusive of a current statement of all fees and charges for Resident #1.
Failed to develop an individual written care plan within 14 days of admission for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed and stated the facility did not obtain a physical examination, did not ask for an admission agreement signature, and did not develop a written care plan for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00182762 and #GA00180762.
Complaint Details
Investigation of complaints #GA00182762 and #GA00180762 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jul 6, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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