Inspection Report Summary
The most recent inspection on June 9, 2023, identified deficiencies related to physical abuse during a resident transfer. Earlier inspections showed a pattern of issues involving resident care, including managing aggressive behaviors and delayed medical response, as well as a prior citation for incomplete criminal background checks for staff. Complaint investigations included substantiated findings of physical abuse and inadequate care responses, with staff termination and restrictions following the abuse case. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history indicates ongoing challenges with resident care and staff compliance, with no clear trend of improvement or worsening over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
0.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failed to keep Resident #1 free from physical abuse during transfer from bed to wheelchair.
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
Date: 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.
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.
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.
Deficiencies (2)
Failure to provide services meeting the needs of Resident #1, including managing increased physical aggression and behavioral episodes.
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.
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
Date: Feb 14, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00228642.
Complaint Details
Investigation of intake# GA00228642 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00227625.
Complaint Details
Investigation of intake GA00227625 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failure to obtain satisfactory fingerprint records check for Staff C and Staff E prior to employment.
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
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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 18, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195273.
Complaint Details
Investigation of intake #GA00195273 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: 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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