Inspection Reports for Heartis Suwanee
4055 Suwanee Dam Rd NW, Suwanee, GA 30024, United States, GA, 30024
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 13, 2025, found no deficiencies. Prior inspections showed a mix of results, with some substantiated complaints related mainly to staff training, medication administration, and documentation issues. Earlier reports cited deficiencies such as failure to ensure staff had required emergency certifications and background checks, medication errors including failure to notify physicians, and falsified training documentation for medication aides. Several complaint investigations were unsubstantiated, though some substantiated cases involved medication errors and staff training lapses; no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some recurring issues with staff training and medication management, but recent inspections indicate improvement in compliance.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50000853.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA50000853 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 4, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001285. An onsite visit was made on 3/4/2025 and the investigation was completed on 3/7/2025.
Findings
The facility failed to ensure that staff hired to provide hands-on personal services to residents received required training within the first 60 days of employment, including current certification in emergency first aid and cardiopulmonary resuscitation, and failed to obtain a satisfactory fingerprint record check determination for one of four sampled staff (Staff D).
Complaint Details
Investigation was triggered by intake #GA50001285. The complaint was substantiated as deficiencies were found related to staff training and background checks.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure staff hired to provide hands-on personal services received current certification in emergency first aid within the first 60 days of employment for 1 of 4 sampled staff (Staff D). | D |
| Failed to ensure staff hired to provide hands-on personal services received current certification in cardiopulmonary resuscitation within the first 60 days of employment for 1 of 4 sampled staff (Staff D). | D |
| Failed to obtain a satisfactory fingerprint record check determination for 1 of 4 sampled staff (Staff D). | D |
Report Facts
Sampled staff: 4
Deficiencies found: 3
Staff D hire date: Aug 7, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiencies for lack of required certifications and fingerprint check | |
| Staff A | Interviewed staff who confirmed lack of documentation for Staff D |
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 24, 2025
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00250567 and GA00251079.
Findings
The facility failed to implement required policies, procedures, and practices related to medication administration. Specifically, a medication error involving Resident #3 was identified where the wrong dosage of Methotrexate was administered and the prescribing physician was not notified as required.
Complaint Details
The visit was complaint-related, investigating medication errors involving Resident #3, including failure to notify the physician and incorrect medication dosage administration.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement policies, procedures, and practices in the community as required by owner governance. | D |
| Failure to notify the prescribing physician of a medication error involving Resident #3. | D |
| Failure to provide medication administration services in accordance with physicians' orders and residents' needs for Resident #3. | D |
Report Facts
Resident sample size: 3
Medication dosage: 4
Incident report date: Sep 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E involved in medication error and failure to notify physician | ||
| Staff G created incident report and reported to Staff H | ||
| Staff H acknowledged medication error and lack of physician notification | ||
| AA | Interviewed regarding medication administration error causing resident pain |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00246437.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00246437 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 1, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244340. An onsite visit was made to the facility on 4/1/24.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation started on 4/1/24 and completed on 4/4/24. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2024
Visit Reason
The purpose of this survey was to investigate intake #GA00243571 with an onsite visit to the facility.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00243571 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 31, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242757 with an onsite visit made to the facility on 1/31/24.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00242757 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00238320 and GA00238005.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes #GA00238320 and GA00238005 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00235597 during an onsite visit on 7/5/2023.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00235597 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 7
Mar 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00231229. The investigation started on 2023-02-13, included an onsite visit on 2023-02-14, and was completed on 2023-03-01.
Findings
The facility knowingly submitted falsified and/or altered written documents related to Medication Administration Clinical Skills checklists for certified medication aides. The facility failed to have evidence of training, skills competency determinations, and required documentation for multiple staff. Additionally, the facility did not conduct required quarterly observations or ensure annual clinical skills competency reviews for several staff members.
Complaint Details
Investigation of intake #GA00231229 initiated on 2023-02-13, onsite visit on 2023-02-14, completed on 2023-03-01.
Severity Breakdown
SS= D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility knowingly submitted falsified and/or altered Medication Administration Clinical Skills checklists for 7 of 14 sampled staff. | SS= D |
| Failed to have evidence of training and skills competency determinations for 3 of 14 sampled staff. | SS= D |
| Failed to have written evidence of initial satisfactory completion of skills competency checklists for 2 of 14 sampled staff. | SS= D |
| Failed to ensure direct care staff completed minimum eight hours of specialized dementia care training annually for 1 of 14 sampled staff. | SS= D |
| Failed to maintain documentation on training records reflecting course content, agenda, instructor qualifications, and attendance roster for trainings for 5 of 14 sampled staff. | SS= D |
| Failed to use a licensed registered nurse or pharmacist to conduct quarterly observations of certified medication aides for 4 of 6 sampled staff. | SS= D |
| Failed to do an annual clinical skills competency review for 3 of 5 sampled staff. | SS= D |
Report Facts
Sampled staff count: 14
Staff with falsified documents: 7
Staff lacking training evidence: 3
Staff lacking initial skills competency checklist: 2
Hours of specialized dementia care training required: 8
Staff lacking quarterly observations: 4
Staff lacking annual clinical skills competency review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding falsified documents, training, and competency checklist issues | |
| Staff B | Named in falsified documents and training deficiencies; provided interviews about checklist and observations | |
| Staff D | Named in falsified documents and training deficiencies | |
| Staff E | Named in falsified documents and training deficiencies | |
| Staff F | Named in falsified documents and training deficiencies | |
| Staff J | Named in training and competency checklist deficiencies | |
| Staff K | Named in training and competency checklist deficiencies | |
| Staff L | Named in falsified documents | |
| Staff M | Named in falsified documents | |
| Staff N | Named in falsified documents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 19, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00226136 with an onsite visit on 8/19/2022.
Findings
The investigation was completed on 8/23/2022 with no rule violations cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00226136 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 16, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00221951. An onsite visit was made to the facility on 03/16/22, with the investigation started on 03/14/22 and completed on 04/05/22.
Findings
The facility failed to display the memory care certificate in a conspicuous place visible to residents and visitors. During the tour on 03/16/22, the certificate could not be found, and staff stated the former executive director did not apply for the certificate, so the facility did not have it.
Complaint Details
Investigation was initiated due to intake GA00221951. The complaint was substantiated by the finding that the facility did not have the required memory care certificate.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to display the memory care certificate in a conspicuous place visible to residents and visitors. | D |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 18, 2021
Visit Reason
The purpose of this survey was to investigate complaint #GA00217404, with the investigation starting on 2021-10-15 and completing on 2021-10-18.
Findings
The facility failed to protect residents' rights to make choices about aspects of their lives, as evidenced by Staff B verbally scolding Resident #2 for locking the apartment door and using a condescending tone. Staff B received a counseling/disciplinary notice for failing to maintain acceptable standards of respect for residents.
Complaint Details
Investigation of complaint #GA00217404 found substantiated issues with Staff B verbally mistreating Resident #2 and Resident #1, including a condescending tone and scolding for locking the door.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to protect residents' rights to make choices about aspects of their life, specifically Resident #2 being verbally scolded by Staff B for locking the door. | D |
Report Facts
Date of incident: Sep 5, 2021
Date of disciplinary notice: Sep 10, 2021
Staff B hire date: Jul 1, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to verbal mistreatment and disciplinary action | |
| Staff A | Acknowledged findings during interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 28, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00215195.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00215195 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2020
Visit Reason
This inspection was conducted to investigate a complaint identified as #GA00203522.
Findings
The report references a complaint investigation but does not provide specific findings or deficiencies within the document.
Complaint Details
Complaint investigation referenced as #GA00203522; no substantiation status provided.
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Deficiencies: 4
Mar 30, 2020
Visit Reason
The investigation was conducted to investigate intake #GA00203533, opened on 2020-03-26 and completed on 2020-03-30, regarding a resident fall and related care concerns.
Findings
The facility failed to implement policies and procedures supporting residents' dignity, respect, and safety, particularly regarding a resident's fall on 2020-03-05. The resident was not properly assessed or monitored post-fall, family notification was delayed, and required incident reports were not completed. The resident sustained serious injuries including a fractured femur and other fractures. Staff interviews and record reviews confirmed failures in protective care, oversight, and timely response to the resident's change in condition.
Complaint Details
The investigation was complaint-driven based on intake #GA00203533. The complaint involved a resident fall on 3/5/20 with delayed family notification, inadequate assessment and monitoring, and failure to complete required incident reports. The complaint was substantiated by record review and staff interviews.
Severity Breakdown
SS= D: 1
SS= J: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to implement policies supporting dignity, respect, choice, independence, and privacy of residents in a safe environment. | SS= D |
| Failure to provide protective care and watchful oversight to meet the needs of the resident. | SS= J |
| Failure to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations. | SS= J |
| Failure to immediately take appropriate actions and notify representative in case of sudden adverse change in resident's condition. | SS= J |
Report Facts
Date of resident fall: Mar 5, 2020
Incident report time: 556
Time delay in assessment: 6
Hospital discharge date: Mar 19, 2020
Inspection Report
Original Licensing
Deficiencies: 0
Apr 18, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection.
Findings
No rule violations were cited as a result of this inspection.
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