Inspection Reports for Oaks at Braselton
5373 Thompson Mill Rd, Hoschton, GA 30548, United States, GA, 30548
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Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2024
Visit Reason
The purpose of this survey was to investigate complaint numbers #GA00248633 and #GA00248096.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaints #GA00248633 and #GA00248096 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 21, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246337 regarding concerns about protective care and watchful oversight for residents.
Findings
The facility failed to ensure protective care and watchful oversight for 3 of 7 residents, resulting in multiple falls outside in the garden area. Safety hazards were observed in the outdoor garden area including uneven sidewalks, exposed drain pipes, sharp sticks, and loose bricks, which contributed to unsafe conditions for residents.
Complaint Details
The investigation was triggered by intake #GA00246337. The complaint was substantiated based on observations, record reviews, and interviews showing multiple falls and unsafe outdoor conditions.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide protective care and watchful oversight for residents leading to multiple falls. | Level D |
| Memory care center failed to include secured outdoor spaces and walkways that are wheelchair accessible and safe, with hazards such as drop offs, exposed pipes, sharp sticks, and loose bricks. | Level D |
Report Facts
Falls: 6
Falls: 10
Residents involved: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Interviewed staff member who reported Resident #1's falls and outdoor safety hazards. | |
| BB | Visitor who assisted Resident #2 and Resident #3 outside and provided information about mobility assistance. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 18, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241265. An onsite visit was made to the facility on 12/18/23, with the investigation completed on 12/21/23.
Findings
The facility failed to maintain the interior in good repair and clean condition, with food-like stains on carpet and damaged walls in Resident #1's apartment. The facility also failed to ensure Resident #1's privacy and dignity, as Staff A entered the resident's apartment unannounced multiple times while the resident was undressed and receiving shower assistance, yelling and threatening the resident's private caregiver.
Complaint Details
The investigation was initiated due to intake #GA00241265. Resident #1 reported Staff A entered the apartment unannounced while undressed and receiving shower assistance, causing distress. Staff A also yelled and threatened the resident's private caregiver to sign an agreement and leave the premises. The caregiver reported feeling physically threatened and fearful for their life.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to keep the interior clean and in good repair, with food-like stains on carpet and damaged walls in Resident #1's apartment. | SS= D |
| Facility failed to ensure each resident enjoys privacy in his/her room; Staff A entered Resident #1's apartment unannounced without knocking. | SS= D |
| Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect; Staff A yelled and threatened Resident #1's private caregiver and demanded the caregiver leave. | SS= D |
Report Facts
Dates of investigation: Investigation started on 2023-12-18 and completed on 2023-12-21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to privacy violation and threatening behavior toward Resident #1 and private caregiver | |
| BB | Private caregiver for Resident #1, reported being threatened by Staff A | |
| AA | Interviewed regarding facility conditions and Resident #1's apartment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 26, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00234097 with an onsite visit on 4/26/2023.
Findings
The investigation was completed on 5/19/2023 with no rule violations cited as a result of this survey.
Complaint Details
Investigation of complaint #GA00234097 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 8, 2022
Visit Reason
The visit was conducted to investigate intake numbers GA00228963, GA00229002, and GA00229643.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was complaint-related, initiated by intake numbers GA00228963, GA00229002, and GA00229643. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 20, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00228007, GA00228080, and GA00228533, with an onsite visit made on 10/20/22 and the investigation completed on 11/17/22.
Findings
The facility failed to ensure new prescriptions were obtained within 48 hours of receipt for 1 of 7 residents (Resident #1), and failed to provide adequate care and services in compliance with state law for Resident #1. Specifically, there was a delay in medication Linzess being filled and administered, and unauthorized rectal stimulation was performed by a staff member without training or proper authorization.
Complaint Details
The investigation was complaint-related, triggered by intakes GA00228007, GA00228080, and GA00228533. The complaint involved Resident #1 not receiving prescribed medication timely and unauthorized rectal stimulation by staff. The complaint was substantiated based on record review and interviews.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure new prescriptions were obtained within 48 hours of receipt of notice for Resident #1. | SS= D |
| Failed to provide adequate and appropriate care and services in compliance with state law for Resident #1, including unauthorized rectal stimulation by staff. | SS= D |
Report Facts
Sampled residents: 7
Prescription order date: Oct 3, 2022
Medication administration dates documented as given: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff member who performed unauthorized rectal stimulation on Resident #1 and documented medication administration in error | |
| Staff A | Staff member who stated that medication documentation was in error and who educated Staff D and other staff about rectal stimulation | |
| BB | Person who communicated about Resident #1's pain and medication delay, and who was unaware of rectal stimulation until informed | |
| AA | Staff member who reported witnessing Staff D perform rectal stimulation on Resident #1 | |
| DD | Person who stated medication Linzess was not filled until 10/24/22 inquiry and explained monthly ordering process |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 12, 2022
Visit Reason
The visit was conducted to investigate intake #GA00223158 and to perform a compliance inspection.
Findings
The facility failed to ensure compliance with applicable fire and safety rules as published by the Office of the Safety Fire Commissioner. A review of fire drills for 2021 showed limited drills conducted, and staff could not locate additional fire drills.
Complaint Details
Investigation was initiated based on intake #GA00223158. The visit included an onsite inspection on 5/12/22 and was completed on 6/1/22.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure compliance with applicable fire and safety rules published by the Office of the Safety Fire Commissioner. | SS= D |
Report Facts
Fire drills conducted: 3
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 30, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00214558 and #GA00214248, with onsite visits on 2021-05-25 and 2021-06-23, and survey completion on 2021-07-30.
Findings
The facility was found deficient in multiple areas including failure to ensure required continuing education for staff, lack of required health screenings, inadequate supervision of residents leading to neglect, insufficient initial and ongoing memory care training, and failure to verify certification status of medication aides. Several staff were found to have incomplete training or missing health documentation, and there were reports and observations of staff sleeping during night shifts and residents being left unattended or soiled.
Complaint Details
The visit was complaint-related, investigating intake #GA00214558 and #GA00214248. Findings included substantiated issues with staff training, health screenings, supervision of residents, and medication aide certification verification.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure staff with second year of employment had minimum sixteen hours of job-related continuing education. | SS= D |
| Failure to ensure each employee received tuberculosis screening and physical examination within twelve months prior to providing care. | SS= D |
| Failure to supervise residents consistent with their needs, resulting in residents being left soiled and unattended, and staff sleeping on duty. | SS= D |
| Failure to provide required initial staff training on Alzheimer's disease and dementia care topics within first six months of employment. | SS= D |
| Failure to check the Georgia Certified Medication Aide Registry to ensure medication aides were in good standing before permitting medication administration. | SS= D |
Report Facts
Staff with deficient continuing education: 1
Staff missing health screening: 1
Residents inadequately supervised: 5
Staff missing initial dementia care training: 2
Staff with unchecked medication aide registry status: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Failed to complete required continuing education hours. | |
| Staff G | Missing tuberculosis screening and physical exam; lacked required memory care training. | |
| Staff F | Certified Medication Aide | No evidence of registry check; reported sleeping on night shift and later terminated. |
| Staff A | Interviewed multiple times regarding deficiencies and staff issues. | |
| BB | Reported residents left soiled and staff sleeping on night shift. | |
| CC | Reported some staff previously slept on night shift but no longer employed. | |
| DD | Observed residents left unattended and soiled; reported toileting issues. | |
| EE | Observed residents left soaked and staff sleeping on multiple occasions. | |
| FF | Reported staff failing to do required checks and rounds; observed staff sleeping on night shift. | |
| Staff B | Reported being told some staff slept on night shift but no names given. | |
| Staff L | Reported on resident care timing and changes during shifts. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 10, 2020
Visit Reason
The purpose of this investigation was to investigate intake #GA00207501, which started on 2020-09-21 and ended on 2020-10-01.
Findings
The facility failed to ensure that residents had reasonable safeguards for the protection and security of their personal property, specifically narcotic medications were missing for two residents. An investigation revealed medication errors and the termination of a staff member for failure to follow company policy related to drug handling.
Complaint Details
Investigation was initiated due to intake #GA00207501. The complaint involved missing narcotic medications for Resident #1 and Resident #2. Staff K was terminated for failure to follow drug policy after an investigation. Interviews confirmed missing narcotics and medication cart was unlocked during Staff K's shift.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure reasonable safeguards for protection and security of residents' personal property, evidenced by missing narcotic medications for 2 of 7 residents sampled. | SS= D |
Report Facts
Missing narcotic pills: 48
Residents sampled: 7
Residents with missing narcotics: 2
Staff K employment period: From 2/4/20 to 8/3/20 (termination date 8/4/20)
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Terminated for failure to follow drug policy related to missing narcotics | |
| Staff A | Conducted investigation and provided statements regarding missing narcotics | |
| Staff I | Provided interview about medication counts and missing narcotics on 7/27/20 | |
| Staff J | Counted narcotics on medication cart on 7/27/20 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2020
Visit Reason
The visit was conducted to investigate intake #GA00205766.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2020-06-15 and was completed on 2020-07-30. No rule violations were found.
Inspection Report
Monitoring
Deficiencies: 0
Apr 7, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control processes.
Findings
No specific findings or deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 26, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00200696 regarding staff training compliance.
Findings
The facility failed to ensure that staff received required training within the first 60 days of employment on Residents' Rights and the Long-Term Care Facility Resident Abuse Reporting Act for 2 of 7 sampled staff. Additionally, the facility failed to ensure staff hired to provide hands-on personal services received cardiopulmonary resuscitation (CPR) training with return demonstration of competency for 2 of 6 sampled staff.
Complaint Details
Investigation of complaint #GA00200696 regarding staff training compliance.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff received training within the first 60 days of employment on Residents' Rights and Long-Term Care Facility Resident Abuse Reporting Act for 2 of 7 sampled staff (Staff B and Staff F). | SS= D |
| Failure to ensure staff hired to provide hands-on personal services received CPR training with return demonstration of competency for 2 of 6 sampled staff (Staff C, Staff E, and Staff F). | SS= D |
Report Facts
Sampled staff for Residents' Rights training: 7
Staff not trained on Residents' Rights: 2
Sampled staff for CPR training: 6
Staff not trained on CPR with return demonstration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed staff who provided information about training documentation | |
| Staff F | Staff member lacking documentation of Residents' Rights and CPR training | |
| Staff G | Staff member mentioned in relation to training documentation | |
| Staff C | Staff member lacking CPR training documentation | |
| Staff E | Staff member lacking CPR training documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 4, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00196868.
Findings
The facility failed to obtain criminal history background checks in compliance with Georgia law for 2 of 10 sampled staff and failed to properly dispose of unused medications for 1 of 7 sampled residents.
Complaint Details
Investigation of complaint #GA00196868 regarding compliance with employee background checks and medication disposal.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to obtain a criminal records check determination in compliance with O.C.G.A 31-7-250-et seq. for 2 of 10 sampled staff (Staff C, Staff D). | D |
| Failed to properly dispose of unused medications for 1 of 7 sampled residents (Resident #5). | D |
Report Facts
Sampled staff: 10
Staff with deficient background checks: 2
Sampled residents: 7
Residents with medication disposal deficiency: 1
Date of discontinued medication order: May 2, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiency for failure to obtain proper criminal background check | |
| Staff D | Named in deficiency for failure to obtain proper criminal background check | |
| Staff B | Interviewed regarding use of third party agency for background checks | |
| Staff A | Interviewed regarding use of third party agency for background checks | |
| Staff J | Interviewed regarding medication disposal deficiency for Resident #5 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00188955. The investigation was started on 2018-06-12 and completed on 2018-06-15.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00188955 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 27, 2018
Visit Reason
The purpose of this visit was to investigate complaints GA00187274 and GA00187464.
Findings
The investigation began on 2018-04-13 and ended on 2018-04-27. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaints GA00187274 and GA00187464 resulted in no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 2, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00186608. The investigation began on 2018-03-27 and ended on 2018-04-02.
Findings
The facility failed to ensure that all residents were treated with dignity, kindness, consideration, and respect for 2 sampled residents in the memory care unit. Staff C was found to have mistreated residents, including yelling, pinching, and improper handling, leading to Staff C's termination.
Complaint Details
Complaint GA00186608 was investigated from 2018-03-27 to 2018-04-02. The complaint involved mistreatment of residents by Staff C, who was terminated on 2018-03-15 due to disregard of residents and violation of policy.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were treated with dignity, kindness, consideration, and respect, including incidents of yelling, pinching, and improper handling of residents in the memory care unit. | E |
Report Facts
Date of incident: Mar 14, 2018
Date of Staff C termination: Mar 15, 2018
Staff C hire date: Feb 19, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in multiple findings related to resident mistreatment and terminated for disregard of residents and violation of policy | |
| Staff B | Provided statements regarding mistreatment of Resident #1 and observations of Staff C | |
| Staff D | Provided statements and interviews regarding mistreatment incidents involving Resident #1 and Staff C | |
| Staff F | Provided statements regarding mistreatment of Resident #2 and Staff C's behavior |
Inspection Report
Annual Inspection
Deficiencies: 1
Nov 16, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate self-reported complaint #GA00181476. The investigation began on 2017-11-07 and ended on 2017-11-16.
Findings
The facility failed to ensure that all residents were treated with dignity, kindness, consideration, and respect for 3 of 7 residents. Staff B was found to have used improper techniques, rough handling, and neglectful behavior towards residents, leading to termination. Multiple complaints and disciplinary actions against Staff B were documented.
Complaint Details
Investigation of self-reported complaint #GA00181476 regarding rough and improper care by Staff B, including rough handling, refusal to assist residents, and inappropriate behavior such as throwing ice cream at a resident. Complaint substantiated by interviews and documentation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were treated with dignity, kindness, consideration, and respect, including improper toileting assistance and rough handling by Staff B. | SS= D |
Report Facts
Residents affected: 3
Residents reviewed: 7
Dates of disciplinary actions: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Employee terminated for improper technique, rough handling, and failure to follow care plans. | |
| Staff A | Interviewed and stated Staff B was terminated due to improper technique and not following care plan. | |
| Staff GG | Reported Staff B's rough handling and refusal to assist residents. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 19, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00174006, with the investigation beginning on 2017-05-03 and completed on 2017-06-19.
Findings
No violations were cited as a result of the complaint investigation.
Complaint Details
Complaint #GA00174006 was investigated and found to have no violations.
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