Inspection Reports for Oaks at Conyers
1352 Wellbrook Cir NE, Conyers, GA 30012, United States, GA, 30012
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 16, 2021, found no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to medication administration, staff certifications, communication with families about resident health changes, and ensuring residents’ ability to participate in transfers. Complaint investigations were mostly unsubstantiated, though some prior complaints were substantiated, including issues with timely medical attention after a fall and failure to notify the Department of serious injuries. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement over time, with the most recent inspections free of cited deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
22% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 16, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216095 and #GA216110.
Complaint Details
Investigation began 2021-08-11 and was completed 2021-08-19. 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 10, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214426.
Complaint Details
Investigation began 2021-06-04 and was completed 2021-06-10. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Apr 7, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intakes #GA00212656, #GA00213479, and #GA00213996. An onsite visit was made on 4/7/21 and the investigation was completed on 4/28/21.
Complaint Details
The visit was complaint-related, investigating intakes #GA00212656, #GA00213479, and #GA00213996. The complaint included concerns about staff certifications, staffing ratios, and medication administration.
Findings
The facility failed to ensure staff obtained required re-certifications for one staff member, lacked a written staffing pattern description including staff to resident ratios for a 24-hour cycle, and failed to ensure adequate medication administration for one resident, including missed doses of prescribed Lasix.
Deficiencies (3)
Facility failed to ensure staff obtain required re-certifications in CPR and first aid for 1 of 4 staff sampled.
Facility failed to have a written description of staffing patterns including direct care staff to resident ratios for a 24 hour cycle.
Facility failed to ensure each resident received adequate and appropriate care and services related to medication administration for 1 of 4 sampled residents.
Report Facts
Staff to resident ratio: 27
Medication doses missed: 2
Medication quantity: 10
Medication doses given: 6
Medication doses prescribed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff member who failed to renew CPR and first aid certifications. | |
| Staff B | Interviewed regarding Staff D's certification status and requested marketing materials. | |
| Staff C | Interviewed regarding Resident #1's recent emergency room visit and medication orders. | |
| Staff E | Interviewed during medication audit regarding missed medication doses for Resident #1. | |
| Staff A | Interviewed about staffing information and marketing materials. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 19, 2021
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00210905, #GA00210661, #GA00211251, #GA00211376, and #GA00211716) related to complaints against the facility.
Complaint Details
The visit was complaint-related, investigating multiple intakes. The facility was found to have failed in notifying family of Resident #14's COVID-19 positive status and oxygen saturation, failed to update medication records properly for several residents, and failed to notify representatives of adverse changes including falls. Resident #14 died after hospitalization. Medication discrepancies and billing issues were also noted.
Findings
The facility failed to notify family of a resident's positive COVID-19 status and oxygen saturation, failed to update medication administration records accurately for multiple residents, and failed to notify representatives of adverse changes including falls for a resident. Medication errors and communication lapses were documented.
Deficiencies (4)
Failure to ensure awareness of resident's normal appearance and notify family of COVID-19 positive status and low oxygen saturation for Resident #14.
Failure to update Medication Administration Record (MAR) each time medication was offered or taken for Residents #5, #6, and #7.
Failure to ensure each resident received adequate and appropriate care and services for Residents #5 and #10, including medication errors and billing issues.
Failure to notify representative and maintain record of all adverse changes and the facility's response for Resident #14, including multiple falls.
Report Facts
Sampled residents: 14
Oxygen saturation: 75
Oxygen liters: 15
Medication doses not signed: 20
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Interviewed regarding Resident #14's condition and family notification failures | |
| Staff I | Interviewed regarding Resident #14's oxygen saturation and condition | |
| Staff J | Called Staff I to assess Resident #14 and involved in communication about oxygen saturation | |
| Staff C | Interviewed about medication administration and awareness of medication issues | |
| Staff A | Interviewed about medication issues and incident reports | |
| II | Resident #10's family member interviewed about medication billing and discontinuation issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 11, 2020
Visit Reason
The purpose of this survey was to investigate intake #GA00206863, with the investigation beginning on 2020-08-03 and completing on 2020-08-11.
Complaint Details
Investigation of intake #GA00206863; no rule violations were found.
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 assessing the infection control process at the facility.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Feb 5, 2020
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 18, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195831.
Complaint Details
Investigation of intake #GA00195831 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 11, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00193213 and #GA00193205, with an onsite visit on 2019-02-20 and investigation completion on 2019-03-11.
Complaint Details
The investigation was triggered by complaints received on 2018-11-30 regarding Resident #1 falling from a wheelchair and not receiving prompt evaluation. The complaint was substantiated by findings of delayed medical attention and delayed reporting to the Department.
Findings
The facility failed to note a change in a resident's normal appearance or behavior and failed to seek timely medical attention for Resident #1 who suffered a fractured left femur after a fall. Additionally, the facility failed to report the serious injury to the Department within 24 hours as required.
Deficiencies (2)
Failed to note a change in Resident #1's normal appearance or behavior and failed to seek timely medical attention after a fall resulting in a fractured left femur.
Failed to report serious injuries requiring medical attention to the Department within 24 hours for Resident #1.
Report Facts
Dates related to incident and reporting: Nov 21, 2018
Dates related to incident and reporting: Nov 24, 2018
Dates related to incident and reporting: Nov 25, 2018
Date complaint received: Nov 30, 2018
Date incident report received by Department: Nov 29, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Interviewed regarding Resident #1's pain and skin discoloration before hospital transfer | |
| Staff B | Interviewed regarding responsibility for reporting serious incidents and delay due to internal investigation |
Inspection Report
Deficiencies: 0
Date: Nov 5, 2018
Visit Reason
The document is a statement of deficiencies and plan of correction for Morningside of Conyers, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Renewal
Deficiencies: 3
Date: Aug 9, 2018
Visit Reason
The purpose of this visit was to conduct the re-licensure inspection and to investigate complaint #GA00190183.
Complaint Details
Complaint #GA00190183 was investigated during this visit.
Findings
The facility was found deficient in ensuring all staff had a physical examination within 12 months of employment, failed to ensure residents were capable of participating in transfers, and did not properly maintain Medication Assistance Records (MAR) for multiple residents.
Deficiencies (3)
Failed to ensure all staff received a physical examination completed by a licensed provider within 12 months of employment for 1 of 5 sampled staff (Staff E).
Failed to ensure residents were able to participate in transferring from place to place for 1 of 6 residents sampled (Resident #5).
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 5 of 6 sampled residents (Resident #1, Resident #2, Resident #4).
Report Facts
Staff sampled: 5
Residents sampled: 6
Residents with MAR deficiencies: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 24, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187356 and GA00187472.
Complaint Details
Investigation of complaints #GA00187356 and GA00187472 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 9, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00181302 and GA00181892 with onsite visits made on 11/6/17 and 11/9/17.
Complaint Details
Investigation of complaint #GA00181302 and GA00181892. The investigation included onsite visits on 11/6/17 and 11/9/17 and was completed on 11/14/17.
Findings
The facility failed to ensure that the written care plan (ISP) was reviewed at least quarterly and modified as changes in the resident's needs occurred for 1 of 5 residents sampled (Resident #1), who was identified as a high fall risk but had no documented interventions in the file.
Deficiencies (1)
Failure to ensure the written care plan was reviewed at least quarterly and modified as changes in the resident's needs occurred for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 11/9/17 at 5:00 p.m. regarding interventions for Resident #1; stated no nurse was present at the time and was unsure if interventions were implemented. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 6/29/17 annual inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 8, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00177991 regarding resident care and facility compliance.
Complaint Details
Complaint #GA00177991 was investigated. Findings included failure to ensure resident transfer ability and failure to respect residents' dignity and rights.
Findings
The facility failed to ensure that residents were able to actively participate in transferring from place to place for 2 of 3 residents sampled, and failed to operate in a manner that respects the personal dignity and human rights of residents, as evidenced by inadequate bathing and transfer assistance.
Deficiencies (2)
Facility failed to ensure residents were able to participate in transferring from place to place for 2 of 3 residents sampled.
Facility failed to operate in a manner that respects the personal dignity and human rights of residents for 1 of 3 residents.
Report Facts
Residents sampled: 3
Residents with transfer issues: 2
Residents with dignity issues: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding resident transfers and care | ||
| Staff D interviewed regarding resident transfers and care | ||
| Staff C interviewed regarding resident transfers and care |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 29, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the assisted living facility.
Findings
The inspection identified multiple deficiencies related to residents' files, including missing inventories of personal items, lack of signed medical orders for end-of-life care, failure to conduct National Sex Offender Registry checks, and missing waivers of personal needs allowance for sampled residents.
Deficiencies (4)
Facility failed to include an inventory of valuable personal items brought to the assisted living community for 1 of 6 residents sampled (Resident #3).
Facility failed to have signed medical orders impacting end of life care, e.g., do not resuscitate (DNR), for 2 of 6 sampled residents (Resident #2 and Resident #3).
Facility failed to conduct a National Sex Offender Registry check for 3 of 6 residents sampled (Resident #1, Resident #2, Resident #3).
Facility failed to obtain a resident's waiver of the personal needs allowance for 1 of 6 sampled residents (Resident #2).
Report Facts
Residents sampled: 6
Residents with missing inventory of personal items: 1
Residents without signed medical orders impacting end of life care: 2
Residents without National Sex Offender Registry check: 3
Residents without waiver of personal needs allowance: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding missing paperwork and stated missing paperwork will be completed |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 28, 2017
Visit Reason
The purpose of this visit was to investigate complaint number GA00174512 with onsite visits made on 2017-05-16 and 2017-06-28.
Complaint Details
Complaint number GA00174512 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
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