Inspection Reports for Greenwood Place AL
1901 W Elm St, Wrightsville, GA 31096, USA, GA, 31096
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 2025
Visit Reason
The onsite unannounced visit was conducted to investigate intake #GA50001566 and to complete a compliance inspection.
Findings
No rule violations were cited as a result of this investigation/inspection.
Complaint Details
Investigation was related to intake #GA50001566; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2024
Visit Reason
The purpose of this investigation was to investigate intake # GA00249875 through an on-site investigation.
Findings
No rule violations were cited as a result of this investigation/inspection.
Complaint Details
Investigation was complaint-related for intake # GA00249875; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 23, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00239640, with an onsite visit made on 10/23/2023 and the investigation completed on 11/6/2023.
Findings
No rule violations were cited as a result of the inspection; however, the facility failed to have a registered professional nurse or licensed practical nurse on-site to support care and oversight of the residents, as evidenced by lack of documentation and staff interview.
Complaint Details
Investigation was complaint-related intake GA00239640. The facility was found to be without a nurse for a month as stated by Staff A during interview.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to have a registered professional nurse or licensed practical nurse on-site to support care and oversight of the residents. | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 22, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207024 and #GA00207573. The investigation was started on 2020-08-11 and completed on 2020-09-22.
Findings
The facility failed to maintain an insect, rodent, or pest control program which continually protected the health of residents, resulting in Resident #1 being bitten by ants on multiple occasions. Resident #1 was found with live ants on his/her body, bleeding from scratching, and was in extreme pain. Pest control treatments were only applied outside the facility and not inside until after the ant infestation was reported. Resident #1 was transferred to hospice care and expired a week later.
Complaint Details
The visit was complaint-related, investigating intake #GA00207024 and #GA00207573. Resident #1 was bitten by ants on 7/11/2020, with multiple staff interviews and incident reports confirming the presence of ants and inadequate care. The complaint was substantiated by findings of ant infestation and failure to provide adequate care.
Deficiencies (2)
| Description |
|---|
| Failure to maintain an insect, rodent or pest control program which continually protected the health of residents, resulting in ant bites and infestation affecting Resident #1. |
| Failure to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations, as evidenced by Resident #1 being bitten by ants and not properly monitored or cared for. |
Report Facts
Dates of pest control treatments: Outside pest control treatments on 3/28/2020 and 6/23/2020; ant treatments on 7/12/2020 and 7/19/2020.
Resident #1 admission date: Resident #1 admitted on 4/18/2018.
Inspection Report
Monitoring
Deficiencies: 0
Apr 7, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 2, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 6/18/19 compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 2
Oct 1, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 6/18/19 compliance inspection and complaint investigation.
Findings
The facility failed to obtain satisfactory criminal history background checks for two sampled staff members prior to employment and failed to allow one resident to communicate freely and privately without staff censorship, including restricting telephone use and limiting communication to only two family members.
Complaint Details
This visit was a follow-up to a complaint investigation conducted on 6/18/19. The violations cited were previously identified on 6/18/19.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory criminal records check prior to offering employment for 2 of 2 sampled staff (Staff B and Staff C). | E |
| Failed to allow a resident to associate and communicate freely and privately without being censored by staff, including restricting telephone use and limiting communication to only two family members. | E |
Report Facts
Number of sampled staff with deficient criminal background checks: 2
Dates Staff C scheduled to work third shift: 4
Resident admission date: Resident #1 admitted on 5/25/18.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 1, 2019
Visit Reason
The visit was conducted to investigate complaints #GA00199643 and #GA00199777 and to perform a follow-up to the 6/18/19 compliance inspection.
Findings
The facility failed to ensure that residents could interact freely with community members both inside and outside the assisted living community, restricting visitors to family only. Additionally, the facility did not provide residents with access to a working telephone placed in an area ensuring privacy and accessibility.
Complaint Details
The investigation was based on complaints #GA00199643 and #GA00199777. The findings substantiated that residents' rights were restricted regarding visitation and telephone access.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The community failed to ensure that each resident is able to interact with members of the community both inside and outside the assisted living community, restricting visitors to family only. | D |
| The community failed to provide access to a telephone placed in an area to ensure privacy without denying accessibility; the designated telephone was not working or connected. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding visitor restrictions and telephone access for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 18, 2019
Visit Reason
The purpose of this visit was to complete the compliance inspection and to investigate complaints #GA00197275.
Findings
The facility failed to obtain satisfactory criminal history background checks for 2 of 4 sampled staff prior to employment and failed to allow 1 of 4 sampled residents to associate and communicate freely and privately without staff censorship, as instructed by the resident's family despite the resident being deemed competent.
Complaint Details
Complaint #GA00197275 was investigated. The complaint involved failure to obtain criminal background checks for staff and restricting a resident's right to communication despite the resident being competent.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to obtain satisfactory criminal history background checks for 2 of 4 sampled staff prior to employment. | D |
| Failed to allow 1 of 4 sampled residents to associate and communicate freely and privately without staff censorship. | D |
Report Facts
Number of sampled staff with unsatisfactory background checks: 2
Number of sampled residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiency for unsatisfactory criminal history background check | |
| Staff E | Named in deficiency for unsatisfactory criminal history background check | |
| Staff F | Interviewed regarding criminal background checks and resident communication restrictions | |
| Staff A | Interviewed regarding resident communication restrictions |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 28, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 8/29/18 compliance inspection and complaint investigation #GA00190770.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up to complaint investigation #GA00190770; no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 29, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint #GA00190770.
Findings
The facility failed to ensure that staff received tuberculosis screenings within 12 months prior to providing care for 1 of 3 staff sampled, and failed to ensure that all Certified Medication Aides were listed on the CMA registry as active and in good standing, with one CMA's registration expired.
Complaint Details
Complaint #GA00190770 was investigated during this visit.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff received a tuberculosis screening within 12 months prior to providing care for 1 of 3 staff sampled. | SS= D |
| Failed to ensure that all Certified Medication Aides were listed on the CMA registry as active and in good standing; 1 CMA's registration expired. | SS= D |
Report Facts
Staff sampled for TB screening: 3
Certified Medication Aides sampled: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Staff member whose tuberculosis screening documentation was missing | |
| Staff D | Certified Medication Aide | Staff member whose CMA registration had expired |
| Staff A | Interviewed staff who acknowledged missing TB screening documentation and expired CMA registration |
Inspection Report
Monitoring
Deficiencies: 0
May 29, 2018
Visit Reason
The purpose of the 5/29/18 visit was to monitor ongoing compliance with the rules and regulations.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 7, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA #00188165 with an on-site visit made on 5/07/18 and the complaint investigation completed on 5/24/18.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint GA #00188165 was investigated and found to have no rule violations.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 10, 2018
Visit Reason
The purpose of this visit was to conduct the follow-up inspection to the 8/31/17 re-licensure inspection and to investigate complaint #GA00186642.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Complaint #GA00186642 was investigated during this visit.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 10, 2018
Visit Reason
The visit was conducted as a follow-up inspection to the 8/31/17 re-licensure inspection and to investigate complaint #GA00186642.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Complaint #GA00186642 was investigated during this visit; no violations were found.
Inspection Report
Annual Inspection
Deficiencies: 10
Aug 24, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of Greenwood Place Retirement Community.
Findings
The inspection identified multiple deficiencies including failure to ensure staff had required continuing education and competency training, inadequate emergency preparedness drills, improper handling and storage of food, insufficient emergency food supply, incomplete admission agreements, failure to utilize effective safety devices for residents at risk of eloping, and multiple medication and treatment errors for sampled residents.
Severity Breakdown
D: 8
E: 1
J: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to ensure staff had a minimum sixteen (16) hours of job-related continuing education for 2 of 4 sampled staff. | D |
| Facility failed to ensure staff had required skills competency determinations and recertifications for administering gastrostomy tube feedings and care for 3 of 3 staff reviewed. | D |
| Facility failed to obtain supporting documentation reflecting basic qualifications for 1 of 4 sampled staff. | D |
| Facility failed to ensure fire and disaster drills were rehearsed in compliance with fire safety standards; no documented full house fire drill evacuations and only one severe weather drill in 2016. | E |
| Admission agreement failed to include description of how the community responds to formal complaints for 1 of 4 sampled residents. | D |
| Admission agreement failed to disclose how and by what level of staff medications are handled and the required packaging system for 1 of 4 sampled residents. | D |
| Facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping; door chimes not working due to dead batteries. | D |
| Facility failed to ensure all foods were protected from spoilage and contamination; observed open, unsealed food packages. | D |
| Facility failed to maintain a 3-day supply of non-perishable emergency food and water sufficient for usual resident census. | D |
| Facility failed to provide adequate and appropriate care and services for 3 sampled residents, including multiple medication and treatment errors such as missed medication doses, missed blood sugar checks, missed tube feedings, and lack of documentation. | J |
Report Facts
Missed blood sugar checks: 32
Missed blood sugar checks: 51
Missed blood sugar checks: 32
Missed blood sugar checks: 33
Missed blood sugar checks: 38
Missed blood sugar checks: 41
Missed tube feeding opportunities: 7
Missed tube feeding opportunities: 17
Resident census for emergency food supply: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding training documentation, fire drills, medication handling, and safety devices | |
| Staff B | Administered gastrostomy tube feedings and interviewed about tube feeding frequency | |
| Staff C | Interviewed regarding medication administration and resident care; involved in medication errors | |
| Staff D | Staff file reviewed for training and competency documentation |
Inspection Report
Follow-Up
Census: 28
Deficiencies: 6
Mar 13, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 7/19/16 annual inspection and complaint.
Findings
The facility failed to meet several regulatory requirements including criminal background checks for employees, maintaining minimum staffing ratios during non-waking hours, having specialized certified medication aides on duty, documenting quarterly medication administration observations, ensuring medication skills competency for unlicensed staff, and maintaining clean residents' private living spaces.
Severity Breakdown
D: 3
E: 1
F: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to obtain a criminal records check determination for 1 of 5 sampled staff. | D |
| Failed to maintain minimum on-site staff to resident ratio during non-waking hours. | D |
| Failed to have specialized staff for medication administration on duty during the 7:00 a.m. to 3:00 p.m. shift. | E |
| Failed to maintain documentation of quarterly observations of random medication administration for 1 of 5 sampled certified medication aides. | F |
| Failed to ensure unlicensed staff demonstrated medication skills competency by completing skills competency checklists. | D |
| Failed to ensure residents' private living spaces were cleaned as needed to prevent health hazards. | F |
Report Facts
Census: 28
Staff working night shift: 1
Certified medication aides: 3
Certified medication aides in training: 2
Medication administration frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Failed to have a criminal record check documented | |
| Staff A | Provided medications without documented competency checklist; gave medications on 3/13/17 | |
| Staff B | Observed providing care on 3/13/17 without certified medication training documentation | |
| Staff E | Certified medication aide lacking quarterly observation documentation | |
| Staff F | Interviewed regarding staffing and medication administration; family member of Staff D | |
| Staff G | Last day worked was 3/7/17, affecting night shift staffing |
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