Inspection Reports for Jonesboro Assisted Living Center
2620 HIGHWAY 138, JONESBORO, GA, 30236.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 20, 2024, found no deficiencies. Earlier inspections showed a pattern of occasional deficiencies primarily related to medication management and staff background checks, including a May 24, 2024, investigation that cited missing controlled substances and incomplete criminal background checks for new staff. Prior reports also noted issues with medication administration accuracy, timely medication procurement, and documentation, as well as one substantiated complaint involving medication errors and failure to report a serious incident. Most complaint investigations were unsubstantiated, with the exception of a few substantiated cases involving medication and resident care concerns. The facility’s recent clean inspection suggests some improvement compared to earlier findings.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248561, which began on 2024-07-15 and was completed on 2024-08-20.
Complaint Details
Investigation of intake #GA00248561 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246547. The investigation started on 2024-05-21 and was completed on 2024-05-24.
Complaint Details
The investigation was initiated due to intake #GA00246547. The complaint involved missing controlled substances (ten hydrocodone tablets) from Resident #1. The facility did not call law enforcement as directed by corporate office initially but later a police report was filed. The family of Resident #1 was notified and the medication was to be replaced. The consultant pharmacist was contacted. The facility failed to determine which staff took the narcotics.
Findings
The facility failed to ensure direct care staff hired after October 1, 2019 had the required criminal background checks prior to employment for 5 of 6 sampled staff. Additionally, the facility failed to have an adequate system to inventory controlled substances to prevent loss and failed to follow their policy, resulting in a discrepancy of ten missing hydrocodone tablets for a resident.
Deficiencies (2)
Failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement for 5 of 6 sampled staff.
Failed to have an adequate system to inventory controlled substances to prevent loss and failed to follow policy, resulting in missing narcotics.
Report Facts
Missing tablets: 10
Sampled staff without background check: 5
Date of incident report: May 8, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 23, 2024
Visit Reason
The purpose of this visit was to investigate complaint #GA00241768.
Complaint Details
Investigation of complaint #GA00241768 with no rule violations found.
Findings
No rule violation was cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241323.
Complaint Details
Investigation of intake #GA00241323 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 30, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240914.
Complaint Details
Investigation of intake #GA00240914 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA0023669.
Complaint Details
Investigation of intake #GA0023669 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 9, 2023
Visit Reason
The purpose of this visit was to investigate intakes GA00235215 and GA00235088.
Complaint Details
Investigation of intakes GA00235215 and GA00235088 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
The purpose of this visit was to investigate intakes# GA 00233957 and GA002333754.
Complaint Details
Investigation of intakes# GA 00233957 and GA002333754 with no rule violations cited.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00230412, starting on 2023-02-16 and completed on 2023-02-17.
Complaint Details
Investigation of intake GA00230412 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 7, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00214361.
Complaint Details
Investigation of intake #GA00214361 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00211986 and GA00211958.
Complaint Details
Investigation began 2021-02-19 and was completed 2021-02-24. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204934, which began on 2020-05-21 and was completed on 2020-06-02.
Complaint Details
Investigation of intake #GA00204934 found no rule violations.
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 evaluating the infection control process at the facility.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 23, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 5/10/19 compliance inspection.
Findings
The facility failed to ensure that each resident received adequate and appropriate care in compliance with state law, as evidenced by falsification of medication administration records for Resident #1, where blood sugar checks were not performed and false blood pressure readings were documented.
Deficiencies (1)
Failure to ensure adequate and appropriate care for Resident #1, including falsification of medication administration records by documenting blood pressure instead of blood sugar readings and not performing the required blood sugar checks.
Report Facts
Dates with missing blood sugar documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Admitted to falsifying medication administration records by documenting false blood pressure readings instead of blood sugar checks for Resident #1 |
Inspection Report
Routine
Deficiencies: 1
Date: May 10, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection of the assisted living facility.
Findings
The facility failed to obtain ordered medications for one of six sampled residents (Resident #5), specifically Diphenhydramine and Prednisone prescribed on 5/3/19 were not available at the facility. Staff interviews confirmed the medications were not delivered to the pharmacy and were discontinued on 5/8/19.
Deficiencies (1)
Failed to obtain ordered medications for Resident #5, including Diphenhydramine and Prednisone.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 14, 2018
Visit Reason
The purpose of this visit was to investigate intake #GA00192533 with an onsite visit made on 11/14/18 and the investigation completed on 11/16/18.
Complaint Details
The visit was complaint-related to intake #GA00192533. The complaint was substantiated by findings of medication errors for Resident #1 and failure to report a serious incident involving Resident #3.
Findings
The facility failed to ensure adequate and appropriate care for Resident #1 by administering the incorrect dosage of furosemide medication. Additionally, the facility failed to notify the Department of a serious change in condition for Resident #3 following a fall and surgery.
Deficiencies (2)
Failed to ensure Resident #1 received the correct dosage of furosemide medication; furosemide 20 mg was administered instead of the ordered 80 mg twice daily.
Failed to notify the Department of a serious change in condition for Resident #3 after a fall resulting in a dislocated left hip and subsequent surgery.
Report Facts
Medication quantity: 24
Residents sampled: 3
Inspection Report
Follow-Up
Deficiencies: 5
Date: Aug 15, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/28/18 compliance inspection and investigation.
Findings
The facility failed to comply with regulations regarding prohibited proxy caregiver services, certified medication aide requirements, maintaining medication assistance records, timely management of medication procurement, and supporting residents' rights. Specific deficiencies included unauthorized administration of liquid morphine by a CMA, improper medication packaging, incomplete medication administration records, failure to timely obtain medication refills, and failure to provide adequate care and services as required by state law for multiple sampled residents.
Deficiencies (5)
Facility failed to ensure medical and nursing services required on a periodic basis or for short-term illness were not provided as services of the assisted living community for 1 of 8 sampled residents (Resident #2).
Certified Medication Aides administered medications not limited to unit or multidose packaging for 2 of 8 sampled residents (Resident #8 and Resident #14).
Failed to maintain daily Medication Assistance Record (MAR) with staff initials for medications offered or taken for 5 of 8 sampled residents (Residents #8, #9, #10, #11, #13).
Failed to obtain refills of prescribed medications timely for 4 of 8 sampled residents (Residents #8, #9, #10, #12), resulting in medication unavailability.
Failed to provide adequate care and services in compliance with state law for 3 of 8 sampled residents (Residents #8, #11, #12), including lack of documentation of blood pressure and blood sugar checks as required.
Report Facts
Sampled residents: 8
Residents with MAR deficiencies: 5
Residents with medication procurement issues: 4
Residents with inadequate care: 3
Morphine dose: 10
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Mar 7, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate complaint #GA00185817. Onsite visits were made on 3/7/18 and 3/8/18 and the investigation was completed on 4/12/18.
Complaint Details
Complaint #GA00185817 was investigated related to failure to monitor a resident after a fall and intervene appropriately. The complaint was substantiated based on record review and interviews.
Findings
The facility was found deficient in multiple areas including failure to monitor a resident after a fall and intervene appropriately, failure to maintain documentation of quarterly medication aide observations, medication aides performing duties outside their scope of practice, and failure to securely store and inventory narcotic medications to prevent loss and unauthorized use.
Deficiencies (4)
Failure to monitor a resident after a fall and intervene appropriately when the resident's state of health appeared to be in jeopardy.
Failure to maintain documentation that a licensed registered professional nurse or pharmacist conducted quarterly random medication administration observations for certified medication aides.
Certified medication aides performing duties outside their scope of practice by assisting with medications that were not unit or multi-dose packaged.
Failure to store medications securely and inventory appropriately to prevent loss and unauthorized use of narcotic medications.
Report Facts
Date of fall incident: Dec 8, 2017
Medication counts discrepancy: 2
Number of sampled residents with monitoring failure: 1
Number of sampled certified medication aides without documentation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Completed quarterly observations of CMAs and assessed Resident #1 after fall. |
| Staff A | Interviewed regarding quarterly observations and narcotic diversion incident. | |
| Staff C | Certified Medication Aide | One of the CMAs lacking documentation of quarterly observation. |
| Staff D | Certified Medication Aide | One of the CMAs lacking documentation of quarterly observation. |
| Staff I | Could not explain narcotic count discrepancy. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 8, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA 00181452.
Complaint Details
The visit was complaint-related to investigate complaint GA 00181452 regarding a resident eloping from the facility and sustaining injury.
Findings
The facility failed to provide protective care and watchful oversight for one sampled resident who eloped from the facility causing injury. Staff interviews and records confirmed the resident was missing and later found and treated at a local hospital.
Deficiencies (1)
Failed to provide protective care and watchful oversight for 1 of 1 sampled resident who eloped causing injury.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff B were interviewed regarding the resident elopement incident; no full names provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00180012 and GA00179891.
Complaint Details
Investigation of complaints #GA00180012 and GA00179891 resulted in no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Apr 25, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate complaints #GA00173954 and #GA00173822.
Complaint Details
The inspection included investigation of complaints #GA00173954 and #GA00173822.
Findings
The facility failed to obtain ordered medications for 1 of 4 residents sampled. Specifically, Resident #1 was given another resident's medications due to zero refills on their prescriptions, which is not in compliance with medication order requirements.
Deficiencies (1)
Facility failed to obtain ordered medications for Resident #1, resulting in administration of another resident's medications.
Report Facts
Residents sampled: 4
Residents with medication issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed staff who admitted giving Resident #1 another resident's medications |
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