Inspection Reports for Madison Heights at The Prado

GA, 31210

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Inspection Report Summary

The most recent inspection on August 8, 2024, found no deficiencies during a complaint investigation. Earlier inspections showed a pattern of complaint investigations with some deficiencies related mainly to resident abuse and medication management. Prior reports cited issues such as failure to prevent physical abuse by staff, lack of secure medication storage, and inadequate policies for managing residents at risk of elopement. No fines, immediate jeopardy findings, or license actions were listed in the available reports, and most complaint investigations were unsubstantiated except for a few substantiated cases involving staff abuse and medication loss. The facility’s recent clean inspection suggests some improvement following earlier cited issues.

Deficiencies (last 4 years)

Deficiencies (over 4 years) 1.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

73% better than Georgia average
Georgia average: 4.9 deficiencies/year

Deficiencies per year

4 3 2 1 0
2020
2021
2023
2024

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Aug 8, 2024

Visit Reason
The purpose of this visit was to investigate intake #GA00248759.

Complaint Details
Investigation of intake #GA00248759 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 18, 2024

Visit Reason
The visit was conducted to investigate intake # GA00246721 through an unannounced inspection on 6/18/2024.

Complaint Details
Investigation of intake # GA00246721 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Apr 17, 2024

Visit Reason
The visit was conducted to investigate intake #GA00245342 with an onsite visit on 4/17/2024 and the investigation completed on 4/26/2024.

Complaint Details
Investigation of intake #GA00245342 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Sep 21, 2023

Visit Reason
The purpose of this visit was to investigate intake #GA00238316.

Complaint Details
Investigation of intake #GA00238316 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Feb 21, 2023

Visit Reason
The purpose of this visit was to investigate intake# GA00228634. The investigation began on 2023-02-01 and ended on 2023-02-23.

Complaint Details
Investigation of intake# GA00228634 regarding physical abuse allegation against Staff B involving Resident #1. Staff B was suspended and later terminated due to violation of the facility's abuse policy.
Findings
Based on record review and interviews, the facility failed to ensure each resident was free from physical abuse. The investigation found that Staff B was aggressive with Resident #1, resulting in physical altercation and subsequent termination of Staff B.

Deficiencies (1)
Facility failed to ensure each resident was free from physical abuse involving Staff B and Resident #1.
Report Facts
Date of incident: Oct 6, 2022 Date of incident report: Oct 8, 2022 Date of termination letter: Oct 10, 2022

Employees mentioned
NameTitleContext
Staff BNamed in physical abuse finding and termination
Staff CWitnessed incident and intervened
AAReported the incident involving Staff B and Resident #1

Inspection Report

Complaint Investigation
Census: 40 Deficiencies: 1 Date: Jun 23, 2021

Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00214812 regarding an elopement incident involving Resident #1.

Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to provide protective care or watchful oversight, resulting in the elopement of Resident #1 on 5/29/2021. Resident #1 was found unharmed after leaving through an unsecured gate during a power outage. The facility lacked policies for gate security checks during emergencies, and staff failed to secure gates properly.
Findings
The facility failed to develop, train, and enforce policies and procedures for staff to manage residents at risk of eloping, resulting in Resident #1 eloping through an unsecured gate during a power outage. The investigation found lapses in staff oversight and gate security, especially during emergencies.

Deficiencies (1)
Failed to develop, train, and enforce policies and procedures for staff to deal with residents who may wander away, including actions to be taken if a resident elopes.
Report Facts
Census: 40 Direct care staff: 6 Certified medication aide: 1 Distance: 350 Temperature: 82

Employees mentioned
NameTitleContext
Staff BMentioned as escorting Resident #1 back to the facility and responsible for checking gates
Staff DResponsible for checking and securing gates, worked part-time
Staff FLast saw Resident #1 before elopement, stated responsibility of Staff D to check gates
Staff EReported power outage and attempted to contact Staff D, found Resident #1 in courtyard
Staff JWorked first shift on day of incident, did not see Resident #1 leaving or check gate
Staff ANotified physician about Resident #1's incident and behavioral symptoms

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Jun 2, 2021

Visit Reason
The purpose of this visit was to investigate intake #GA00210788, which began on 2021-05-11 and was completed on 2021-06-02.

Complaint Details
The investigation was initiated due to intake #GA00210788 regarding an incident on 12/27/20 where Resident #1 punched Staff C and Staff C retaliated by hitting Resident #1. Staff C was suspended and subsequently terminated for resident abuse.
Findings
The facility failed to ensure that Resident #1 was treated with dignity, kindness, and respect, and failed to protect the resident from abuse. Resident #1, diagnosed with dementia and bipolar disorder, was involved in an incident where Staff C struck the resident after being punched. Staff C was terminated for resident abuse. The resident was sent to the hospital for observation due to injuries sustained.

Deficiencies (2)
Failed to ensure each resident is treated with dignity, kindness, and consideration and respect.
Failed to ensure each resident had the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation.
Report Facts
Incident date: Dec 27, 2020 Resident admission date: Sep 10, 2020 Staff hire date: Sep 9, 2020

Employees mentioned
NameTitleContext
Staff CInvolved in resident abuse incident where Staff C struck Resident #1 after being punched
Staff DWitnessed incident and interviewed regarding Staff C's actions

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Dec 14, 2020

Visit Reason
The purpose of this visit was to investigate intake #GA00210211.

Complaint Details
Investigation of intake #GA00210211 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 processes.

Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control measures.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jan 2, 2020

Visit Reason
The purpose of this visit was to investigate intake #GA00201630, which involved a complaint regarding missing medication at the facility.

Complaint Details
The visit was complaint-related to intake #GA00201630. The complaint was substantiated by findings of missing Hydrocodone medication for Resident #1. A police report dated 12/17/2019 confirmed narcotics were reported missing from the residence with unknown perpetrator.
Findings
The facility failed to store medication securely and inventory appropriately, resulting in the loss of Hydrocodone medication for one sampled resident. Multiple staff interviews and record reviews confirmed the medication was missing since 12/14/2019 and could not be found.

Deficiencies (1)
Failed to store medication securely and inventory appropriately to prevent loss of medication for 1 of 2 sampled residents (Resident #1).
Report Facts
Date medication missing: Dec 14, 2019 Date police report: Dec 17, 2019 Medication dosage: 10 Medication dosage: 325

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