Inspection Reports for Oaks at Gracemont
4940 JOT EM DOWN ROAD, CUMMING, GA, 30041
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 7, 2025, found deficiencies related to resident care, staffing, and medication disposal, including a failure to prevent elopement and improper medication administration. Earlier inspections showed similar issues with staffing levels, care adequacy, and medication handling, as well as past deficiencies involving resident dignity and safety training. Complaint investigations were mostly unsubstantiated except for a substantiated case in 2022 involving failure to treat a resident with dignity and timely incident reporting. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern of deficiencies has persisted over time without clear improvement.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 7, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to verify correction of previous deficiencies related to resident care, staffing, and medication disposal.
Findings
The facility failed to implement adequate policies and staffing to ensure the safety and dignity of residents, specifically failing to prevent elopement of Resident #1 who was found off-site unharmed but required hospitalization. Additionally, the facility improperly disposed of medications by administering dropped medications. No rule violations were cited as a result of this follow-up inspection.
Deficiencies (4)
Failure to implement policies, procedures, and practices supporting dignity, respect, choice, independence, and privacy for Resident #1, resulting in elopement.
Failure to maintain adequate staffing above minimum ratios to meet Resident #1's health, safety, and care needs.
Failure to properly dispose of unused medications according to FDA or EPA guidelines; medications dropped on the floor were administered to Resident #5.
Failure to provide adequate, appropriate care and services in compliance with state law for Resident #1.
Report Facts
Date of resident elopement incident: Nov 17, 2024
Hospital stay duration: 8
Staffing ratio requirement: 15
Staffing ratio requirement: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided email and interview statements regarding elopement risk and staffing. | |
| Staff B | Interviewed regarding Resident #1's dementia diagnosis and condition prior to elopement. | |
| Staff C | Interviewed about medication disposal incident and Resident #1's wandering and hallucinations. | |
| Staff D | Reported Resident #1 missing, called 911, and stayed with Resident #1 until emergency responders arrived. | |
| Staff E | Found Resident #1 in vacant car and described video evidence of Resident #1's distress. | |
| Staff G | Third shift staff who interacted with Resident #1 the night before elopement. | |
| AA | Family member | Provided detailed interview about Resident #1's condition, elopement, and concerns about facility care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
The purpose of this visit was to investigate allegation intake GA50001404.
Complaint Details
Investigation of allegation intake GA50001404 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 5, 2025
Visit Reason
The purpose of this visit was to investigate intake complaints GA00252875, GA50000056, GA50000979, and GA50000635, with an onsite visit made on 2/5/2025 and investigation completed on 2/27/2025.
Complaint Details
The investigation was initiated due to multiple intakes alleging failure to provide adequate care and supervision, resulting in Resident #1 eloping from the facility on 11/17/2024. The resident was found unharmed but required hospitalization for dehydration and other complications. The facility failed to provide appropriate watchful oversight and staffing to prevent the elopement. The resident had dementia and other health issues and was relocated after discharge from the hospital.
Findings
The facility failed to provide adequate protective care and watchful oversight for a resident at risk of elopement, resulting in Resident #1 eloping from the facility and being found unharmed in a vacant car across the street. The facility also failed to maintain adequate staffing to meet residents' needs, properly dispose of unused medications, and ensure care and services were adequate and appropriate for Resident #1. Resident #1 was hospitalized due to complications following the elopement and subsequently relocated to another long-term care facility.
Deficiencies (4)
Failure to implement policies, procedures, and practices supporting dignity, respect, choice, independence, and privacy for Resident #1, resulting in elopement.
Failure to maintain adequate staffing above minimum ratios to meet Resident #1's health, safety, and care needs.
Failure to properly dispose of unused medications according to FDA or EPA guidelines; medications dropped on the floor were administered to Resident #5.
Failure to provide adequate, appropriate care and services in compliance with state law and regulations for Resident #1.
Report Facts
Date of elopement: Nov 17, 2024
Hospital stay duration: 8
Staffing ratio requirement: 15
Staffing ratio requirement: 20
Temperature range: 40-52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided email and interview statements regarding elopement risk and staffing. | |
| Staff C | Interviewed about medication incident and resident behaviors. | |
| Staff D | Notified about missing resident, involved in search and found Resident #1. | |
| Staff E | Conducted search and found Resident #1 at private residence. | |
| Staff G | Third shift staff who interacted with Resident #1 prior to elopement. | |
| AA | Family member | Family member of Resident #1 who provided statements about resident's condition and concerns. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240292 with an onsite visit made on 11/2/23 and inspection completed on 11/3/23.
Complaint Details
Investigation of intake #GA00240292; no rule violations found.
Findings
No rule violations were cited during this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00225934.
Complaint Details
Investigation of intake GA00225934 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 9, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224279 and GA00224867. An onsite visit was made to the facility on 6/9/22, with the investigation starting on 6/6/22 and completed on 6/29/22.
Complaint Details
The investigation was complaint-related, triggered by allegations that Staff E slapped Resident #2's hand during breakfast and stopped the resident from eating until medications were taken. Resident #2 reported feeling disrespected and bullied. Staff E denied slapping but admitted placing hand over Resident #2's hand. The facility did not complete an incident report, notify family, or report the incident to the Department, classifying it as a violation of resident rights rather than abuse.
Findings
The facility failed to comply with fire and safety training requirements for staff, maintain personal inventory and signed Resident's Rights forms in resident files, ensure residents were treated with dignity and respect, notify next of kin/legal representatives of adverse incidents, and report serious incidents to the Department within 24 hours. Specifically, Staff E slapped Resident #2's hand during breakfast, violating the resident's rights, and the facility failed to document or report this incident appropriately.
Deficiencies (6)
Facility failed to be in compliance with fire and safety rules for 1 of 4 sampled staff due to missing fire safety certification for evacuation procedures.
Facility failed to maintain and keep updated an inventory of all personal items brought into the facility for 1 of 4 residents.
Facility failed to ensure each resident file contained a signed copy of the Resident's Rights form for 4 of 4 sampled residents.
Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect for 1 of 4 sampled residents (Resident #2) involving Staff E slapping Resident #2's hand.
Facility failed to notify the resident's next of kin/legal representative and retain a record of an adverse change or accident for 1 of 4 sampled residents (Resident #2).
Facility failed to report a serious incident involving a resident to the Department within 24 hours after the incident for 1 of 4 sampled residents (Resident #2).
Report Facts
Sampled residents: 4
Sampled staff: 4
Incident date: May 18, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in incident involving slapping Resident #2's hand and violation of resident rights | |
| Staff A | Interviewed regarding missing fire safety training and incident involving Resident #2 | |
| Staff B | Reported Resident #2's complaint about Staff E and involved in investigation |
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