Inspection Reports for Oaks at Gracemont
4940 Jot Em Down Rd, Cumming, GA 30041, United States, GA, 30041
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 8, 2021, was a complaint investigation that found no deficiencies. Earlier inspections showed a mixed record with some citations related to medication procurement, cleanliness, supervision, injury reporting, and food service management. Inspectors noted issues such as failure to maintain the interior in good repair, untimely medication refills, inadequate supervision leading to resident falls, and delayed reporting of serious injuries and allegations. Complaint investigations were mostly unsubstantiated, though some substantiated cases involved food safety and delayed reporting of abuse allegations. The facility’s inspection history shows some recurring themes but also periods with no cited violations, indicating an inconsistent pattern over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 8, 2021
Visit Reason
The visit was conducted as a compliance inspection to investigate intake #GA00215210, with the investigation starting on 2021-07-06 and completing on 2021-07-23, including an onsite visit on 2021-07-08.
Complaint Details
Investigation of intake #GA00215210 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
The purpose of this visit was to investigate complaint #GA00211366, with the investigation starting on 2021-02-12 and completing on 2021-04-28.
Complaint Details
Investigation of complaint #GA00211366 was conducted from 2021-02-12 to 2021-04-28 with no rule violations 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 was to monitor COVID-19 cases and assess infection control processes.
Findings
The report focused on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 13, 2020
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00201860.
Complaint Details
Investigation of intake #GA00201860. The complaint investigation found deficiencies related to community safety precautions, medication procurement, and infection control.
Findings
The facility failed to maintain the interior in good repair, with ripped and stained carpet outside residents' rooms. The facility also failed to timely procure medications for two residents and did not ensure residents' private living spaces were cleaned adequately, posing health hazards.
Deficiencies (3)
Facility failed to keep the interior clean and in good repair; carpet outside residents' rooms was ripped, torn, and stained.
Failed to obtain ordered medications for 2 of 6 residents sampled, resulting in medication unavailability.
Failed to ensure residents' private living spaces were cleaned as needed, including stained carpet, stained bathroom sink, and sticky bathroom floor.
Report Facts
Residents sample: 6
Residents with medication issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Interviewed regarding carpet replacement and cleaning responsibilities | |
| Staff G | Interviewed regarding medication administration and procurement |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 6, 2019
Visit Reason
The visit was conducted as a follow-up inspection to the 10/10/18 compliance inspection and to investigate complaint GA00191667.
Complaint Details
Complaint GA00191667 was investigated during this follow-up inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 10, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint Intake GA00191667.
Complaint Details
Complaint Intake GA00191667 was investigated. The complaint involved Resident #1 who had multiple falls and injuries, including a fractured face, and the facility's failure to report these serious injuries to the Department.
Findings
The facility failed to provide supervision consistent with residents' needs for 1 of 34 residents sampled, resulting in multiple falls and injuries including a fractured face. Additionally, the facility failed to report serious injuries requiring medical attention to the Department as required.
Deficiencies (2)
Failed to provide supervision consistent with residents' needs for Resident #1, who had multiple falls resulting in injuries including a fractured face.
Failed to report serious injuries requiring medical attention to the Department for Resident #1.
Report Facts
Residents sampled: 34
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1's falls and failure to report injury to Department | |
| Staff B | Interviewed regarding Resident #1's fall risk and injuries | |
| Staff C | Interviewed regarding Resident #1's fall risk and injuries |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 26, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of Gracemont Assisted Living and Memory Care, with onsite visits made on 7/25/17 and 7/26/17.
Findings
The facility was found deficient in several areas including failure to obtain a satisfactory fingerprint records check for the Executive Director prior to employment, failure to conduct fire drills monthly and on rotating shifts as required, failure to update Medication Assistance Records (MAR) timely for residents, and failure to obtain timely refills of prescribed as needed medications for residents.
Deficiencies (4)
Failed to obtain a satisfactory fingerprint records check determination for the Executive Director prior to serving in that role.
Failed to ensure fire drills were conducted monthly and on rotating shifts as required by fire safety regulations.
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 5 residents sampled.
Failed to obtain timely refills of prescribed as needed (PRN) medications to ensure availability for 2 of 5 residents sampled.
Report Facts
Residents sampled: 5
Residents with MAR deficiencies: 2
Residents with medication procurement deficiencies: 2
Dates missing fire drill documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in deficiency for failure to obtain fingerprint records check and involved in interviews regarding fire drills and medication issues |
| Staff B | Mentioned as new staff working with Staff A to improve MAR and medication procurement processes |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 6, 2017
Visit Reason
The purpose of this visit was to investigate facility reported complaint #GA001705258.
Complaint Details
The complaint investigation was substantiated by findings that the facility did not complete required NSOR searches and delayed reporting of sexual molestation allegations for Resident #1. The report of the incident was faxed to the Department one month after the event.
Findings
The facility failed to conduct a complete National Sex Offender Registry search for one sampled resident and failed to report allegations of sexual molestation within 24 hours to the Department as required by the Long Term Care Resident Abuse Reporting Act.
Deficiencies (2)
Failed to conduct a complete National Sex Offender Registry search for 1 of 1 sampled resident.
Failed to report allegations of sexual molestation within 24 hours to the Department.
Report Facts
Dates related to Resident #1: Jun 6, 2017
Resident admission date: Jun 28, 2016
Incident date: Apr 20, 2017
Incident report fax date: May 19, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed but no full name provided | ||
| Staff B mentioned in incident report but no full name provided |
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 8, 2017
Visit Reason
The purpose of this visit was to conduct the follow-up inspection to the 2/27/17 complaint investigation.
Complaint Details
Follow-up inspection to the 2/27/17 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 27, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00171243 and GA00171162, with the investigation starting on 2017-02-14 and completing on 2017-02-27.
Complaint Details
The visit was complaint-related, investigating complaints #GA00171243 and GA00171162. The investigation was substantiated by findings of deficiencies in food service management and menu posting.
Findings
The facility failed to ensure safe food handling practices were enforced by the designated Food Service Manager, as evidenced by unsatisfactory Food Service Establishment Inspection scores and staff interviews. Additionally, the facility did not have a current menu posted showing meals planned at least one week in advance, as required.
Deficiencies (2)
Failure to ensure the Food Service Manager enforced safe food handling practices addressing food safety, hygiene, cross contamination, time and temperature requirements, and sanitation.
Failure to post a current menu showing meals at least one week in advance.
Report Facts
Food Service Establishment Inspection score: 63
Food Service Establishment Inspection score: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed as new Food Services Director, second day on the job, in process of making kitchen improvements |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 11, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00170213.
Complaint Details
Complaint #GA00170213 was investigated and found to have no violations.
Findings
No violations were cited as a result of this investigation.
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