Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 9, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00234701 regarding alleged physical abuse of Resident #1 during a transfer from bed to wheelchair.
Findings
The facility failed to keep Resident #1 free from physical abuse as staff were observed on video slapping Resident #1's hand to force release of the wheelchair during a transfer. Staff C was terminated and Staff D, agency staff, was not allowed to return. Resident #1 showed cognitive and verbal impairments and expressed no recollection of the event. No injuries were found and Resident #1 was not hospitalized.
Complaint Details
Investigation of complaint intake# GA00234701 regarding physical abuse of Resident #1. Substantiated by video evidence showing staff slapping Resident #1's hand during transfer. Staff C terminated and Staff D barred from facility.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to keep Resident #1 free from physical abuse during transfer from bed to wheelchair. | D |
Report Facts
Date of incident: Apr 21, 2023
Date of incident report: Apr 24, 2023
Admission date: Nov 1, 2022
Date of staff termination: Apr 26, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed witness who reviewed video and described incident | |
| Staff B | Interviewed witness who reviewed video and described incident | |
| Staff C | Staff involved in abuse, terminated 4/26/23 | |
| Staff D | Agency staff involved in abuse, barred from facility | |
| AA | Person who placed camera in Resident #1's room and shared video |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 1, 2023
Visit Reason
The purpose of this survey was to investigate complaints #GA00231369 and #GA00235463. The onsite visit was conducted on 6/1/2023 and the survey was completed on 6/8/2023.
Findings
The facility failed to provide adequate services to meet the needs of residents, including failure to manage aggressive behaviors of Resident #1 and failure to take immediate action after an accident involving Resident #2, resulting in delayed medical attention for a swollen and bruised elbow.
Complaint Details
The investigation was triggered by complaints #GA00231369 and #GA00235463. The findings included substantiated issues with Resident #1's aggressive behavior and inadequate response to Resident #2's injury and condition changes.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide services meeting the needs of Resident #1, including managing increased physical aggression and behavioral episodes. | Level D |
| Failure to ensure immediate action was taken after an accident or sudden adverse change in Resident #2's condition, resulting in delayed medical intervention for a swollen and bruised elbow. | Level D |
Report Facts
Dates of incidents: May 31, 2023
Incident date: May 18, 2023
Admission date Resident #1: Dec 19, 2021
Admission date Resident #2: Mar 18, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 14, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00228642.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00228642 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 16, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00227625.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00227625 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 21, 2021
Visit Reason
An onsite visit was made to the facility on 10/21/21 to conduct a compliance inspection and investigate intake #GA 00218017.
Findings
The facility failed to ensure that prior to serving as a direct access employee, a satisfactory fingerprint records check was obtained for 2 of 7 sampled staff (Staff C and Staff E), as required by the Rules and Regulations for Criminal Background Checks.
Complaint Details
Investigation was conducted related to intake #GA 00218017. The complaint was substantiated based on failure to obtain required criminal background checks for two staff members.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain satisfactory fingerprint records check for Staff C and Staff E prior to employment. | D |
Report Facts
Number of sampled staff: 7
Number of staff without satisfactory background check: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and stated he/she would provide documentation of satisfactory criminal background check for Staff C and Staff E. | |
| Staff C | Hired 8/24/18, lacked documentation of satisfactory criminal background check. | |
| Staff E | Hired 8/16/21 and terminated 10/1/21, lacked documentation of satisfactory criminal background check. |
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: 0
Mar 18, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195273.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00195273 with no rule violations cited.
Inspection Report
Original Licensing
Deficiencies: 0
Sep 4, 2018
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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