Inspection Reports for Oaks at Pooler
125 Southern Jct Blvd #800, Pooler, GA 31322, United States, GA, 31322
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 8, 2025, found no deficiencies. Earlier inspections showed a mix of issues primarily related to resident safety, staff training and credentialing, and food handling practices. Complaint investigations substantiated concerns such as inadequate supervision leading to residents leaving the facility unsupervised, improper food handling, and missing staff background checks and training documentation. There were no fines, immediate jeopardy findings, or license actions listed in the available reports, though law enforcement was notified in one substantiated case involving theft by a staff member. The facility’s inspection history shows some recurring themes but also periods of no deficiencies, indicating a variable compliance pattern over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
4.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
65 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 8, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50006244.
Complaint Details
Investigation started and completed on 2025-10-08 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 15, 2025
Visit Reason
The visit was conducted to investigate complaint intakes #GA50004646 and GA50004645 with an onsite visit made on 2025-08-14 and the investigation completed on 2025-08-15.
Complaint Details
Investigation of complaint intakes #GA50004646 and GA50004645 found no rule violations.
Findings
No rule violations were cited as a result of the investigations.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 24, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50003574 with an onsite visit made on 6/24/2025.
Complaint Details
Investigation was initiated based on intake #GA50003574. The complaint involved improper food handling and failure to provide dessert to a resident. The investigation included observations and interviews confirming these issues.
Findings
The facility failed to ensure proper food handling practices as staff transferred grated cheese without hairnet and gloves, and failed to provide dessert to Resident #3 while serving other residents, indicating inadequate care and service.
Deficiencies (2)
Facility failed to ensure all foods were protected from spoilage and contamination; staff transferred grated cheese without wearing hairnet and disposable gloves.
Facility failed to provide adequate and appropriate care by not offering dessert to Resident #3 while serving other residents.
Report Facts
Sampled residents: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Observed transferring grated cheese without hairnet and gloves | |
| Staff E | Interviewed regarding food handling practices and dessert service | |
| Staff A | Interviewed regarding food handling practices | |
| Staff G | Interviewed regarding food handling practices |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The visit was conducted to investigate intake #GA50002938, which involved a complaint regarding a resident eloping from the facility. The investigation started on 2025-04-28 and was completed on 2025-05-01, with an onsite visit on 2025-04-30.
Complaint Details
The investigation was initiated due to intake #GA50002938 concerning Resident #1 eloping from the memory care unit through a defective emergency exit door alarm on 2025-04-13. The resident was found by bystanders and returned safely. Staff interviews revealed unawareness of the defective locking mechanism and alarm system failure.
Findings
The facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping, as evidenced by a defective alarm system on an emergency exit door that allowed Resident #1 to elope unnoticed. Resident #1 was found offsite and returned safely, but the door's locking mechanism was defective and did not trigger an alarm.
Deficiencies (1)
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping; defective alarm system on emergency exit door in memory care unit.
Report Facts
Resident census: 65
Residents at risk sampled: 4
Resident elopement incident date: Apr 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed staff who was unaware of defective locking system and alarm failure on emergency exit door | |
| Staff C | Interviewed staff who recognized Resident #1 at gas station after elopement | |
| AB | Emergency Medical Technician | Provided information about defective locking mechanism and alarm system on emergency exit door |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 12, 2025
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 6
Date: Jan 16, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50000830, which started on 2025-01-16 and was completed on 2025-01-28. The investigation was triggered by allegations including failure to provide a safe environment and issues with staff credentialing and training.
Complaint Details
The complaint investigation was initiated due to allegations that the facility failed to provide a safe environment after homeless men entered and stayed overnight without staff knowledge. Additional complaints included employing certified medication aides not verified on the registry and missing required staff training documentation.
Findings
The facility failed to obtain satisfactory fingerprint background checks for some staff, lacked required training documentation for multiple employees, did not have an operational automated alert system for unauthorized entry, and employed certified medication aides not verified on the Georgia Certified Medication Aide Registry. Additionally, the facility failed to complete annual competency reviews for some medication aides.
Deficiencies (6)
Failed to obtain satisfactory fingerprint records check determination for 2 of 11 sampled staff (Staff C and Staff F).
Failed to include evidence of trainings, skills competency determinations, and recertifications in personnel files for 9 of 11 sampled staff.
Failed to activate an automated alert system when the front door was unattended, allowing unauthorized entry by homeless individuals.
Failed to verify that medication aides employed were listed in good standing on the Georgia Certified Medication Aide Registry for 3 of 11 sampled staff.
Failed to complete annual comprehensive clinical skills competency reviews for 4 of 11 sampled certified medication aides.
Permitted a certified medication aide (Staff C) to administer medications independently without verification of good standing on the Georgia Certified Medication Aide Registry.
Report Facts
Census: 48
Census: 12
Sampled Staff: 11
Deficient Staff: 2
Deficient Staff: 9
Deficient Staff: 3
Deficient Staff: 4
Certified Medication Aides Employed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Failed fingerprint background check, missing training documentation, not verified on medication aide registry, permitted to administer medications independently without verification | |
| Staff F | Failed fingerprint background check, missing training documentation, missing annual competency review | |
| Staff E | Missing training documentation, not verified on medication aide registry, missing annual competency review | |
| Staff D | Missing training documentation, not verified on medication aide registry | |
| Staff G | Missing training documentation | |
| Staff I | Missing training documentation, missing annual competency review | |
| Staff J | Missing training documentation | |
| Staff K | Missing training documentation | |
| Staff B | Missing training documentation | |
| Staff A | Interviewed staff assisting with organizing files and training documentation | |
| Staff O | Housekeeper | Discovered homeless individuals sleeping in facility |
| Staff N | Reported incident to law enforcement and conducted patrols | |
| Staff L | Interviewed regarding security and staffing after hours | |
| Staff M | Reported local law enforcement patrolling community |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 26, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00252433 and #GA00252907. The investigation started and was completed on 12/26/2024 with an onsite visit.
Complaint Details
Investigation of intakes #GA00252433 and #GA00252907 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA00251298, #GA00251192, and #GA00251181, with the investigation starting on 2024-10-28 and completing on 2024-10-31.
Complaint Details
Investigation of complaint intakes #GA00251298, #GA00251192, and #GA00251181 was completed with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Date: Sep 3, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249426, which involved concerns about grab bars in resident toilets and the locking mechanisms on exterior doors of resident rooms.
Complaint Details
The investigation was initiated due to intake #GA00249426, which included an allegation that a safe environment was not provided after a complainant found that Resident #8's apartment door could not be locked from the outside. Resident #8 was removed from the facility on 7/24/2024.
Findings
The facility failed to equip resident toilets with grab bars that meet accessibility needs for 6 of 7 sampled residents and failed to ensure that exterior doors of resident rooms were equipped with locks for 2 of 7 sampled residents. Several doors lacked proper locking mechanisms, and only a few apartments had external key locks.
Deficiencies (2)
Failed to equip resident toilets with grab bars that meet accessibility needs for 6 of 7 sampled residents.
Failed to ensure exterior doors of resident rooms were equipped with locks for 2 of 7 sampled residents.
Report Facts
Residents sampled: 7
Residents without grab bars: 6
Residents with door lock issues: 2
Total residents in AL section: 39
Total apartments in AL section: 54
Apartments with external key locks: 3
Apartments with privacy lock levers: 51
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The visit was conducted to investigate intake #GA00247407 regarding allegations of misappropriation of funds involving Resident #1.
Complaint Details
The complaint investigation was substantiated based on video evidence and staff admission. The family reported the theft, and law enforcement was notified. The complainant chose not to press charges as the facility terminated the responsible staff member.
Findings
The facility failed to safeguard Resident #1's personal property, as Staff C admitted to stealing approximately $500 over a three-month period. Staff C was terminated for misconduct, and law enforcement was notified.
Deficiencies (1)
Failure to ensure the right of each resident to safeguard his/her private property and possessions, evidenced by theft of money from Resident #1 by Staff C.
Report Facts
Amount stolen: 500
Date of staff termination: Jun 4, 2024
Staff hire date: Apr 11, 2023
Resident admission date: Jan 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Admitted to stealing money from Resident #1 and was terminated for misconduct | |
| Staff A | Reported theft to management and law enforcement, interviewed Staff C | |
| AB | Family member of Resident #1 who reported theft, installed hidden camera, and provided video evidence |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00244800, #GA00244781, and #GA00244737.
Complaint Details
Investigation of three intakes (#GA00244800, #GA00244781, and #GA00244737) with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 27, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00243625 and GA00243919.
Complaint Details
The visit was complaint-related, investigating intake #GA00243625 and GA00243919. Resident #1 was found outside the building unsupervised on 1/29/24, and staff interviews confirmed the resident was missing for up to 10 minutes before being returned safely.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care and services in compliance with state law and regulations. Resident #1 was found outside the facility unsupervised, posing a safety risk, and was redirected back inside by staff with no injuries noted.
Deficiencies (1)
Failure to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations, evidenced by Resident #1 leaving the facility unsupervised.
Report Facts
Date of incident: Jan 29, 2024
Duration resident missing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding Resident #1 leaving the facility | |
| Staff C | Interviewed regarding Resident #1 leaving the facility | |
| Staff E | Redirected Resident #1 back to the facility after finding him/her outside |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 6, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00243221, #GA00242995, #GA00243307, and #GA00243583. The investigation started on 2024-02-05 and was completed on 2024-02-08, with an onsite visit on 2024-02-06.
Complaint Details
The investigation was complaint-related, triggered by multiple intakes. Resident #1 alleged that Staff B inappropriately touched him/her. Staff A and Staff B provided conflicting accounts regarding the accusation. Staff C and Staff G stated that Resident #1 was not assessed due to being taken out by family and not being in memory care.
Findings
The facility failed to include specific behaviors to be addressed with interventions in the care plan for Resident #1, despite allegations of inappropriate touching by Staff B. Interviews revealed conflicting statements about the accusation and the assessment process was incomplete due to the resident being taken out by family.
Deficiencies (1)
Facility failed to include in each resident's care plan the specific behaviors to be addressed with interventions to be used, for 1 of the 2 sampled residents (Resident #1).
Report Facts
Complaint intakes: 4
Sampled residents: 2
Residents with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided statements regarding Resident #1's behavior and care plan assessment | |
| Staff B | Accused by Resident #1 of inappropriate touching; denied accusation | |
| Staff C | Did not assess Resident #1 due to family removal | |
| Staff G | Stated hospital would normally do assessment in such situations |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 29, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00241373 and #GA00241272, with the investigation starting on 2023-11-28 and completed on 2023-11-29, including an onsite visit on 2023-11-29.
Complaint Details
The investigation was complaint-related, triggered by allegations of physical and sexual abuse of Resident #1 by a staff member (Staff C). Law enforcement was notified and is investigating. Incident reports and a police report document the events, including a staff member searching the resident's adult brief without permission and the resident's subsequent upset. No arrest order was issued, but the investigation is ongoing.
Findings
The facility failed to obtain a satisfactory fingerprint record check for one staff member and failed to ensure a resident's care plan addressed specific behavioral issues. Additionally, the facility did not operate in a manner respecting the personal dignity and human rights of a resident, involving an incident where a staff member searched the resident's adult brief without permission, leading to allegations of physical and sexual abuse. Law enforcement was notified and is investigating the incident.
Deficiencies (3)
Failed to obtain a satisfactory fingerprint record check determination for 1 of 8 sampled staff (Staff C).
Failed to ensure the resident's care plan included specific behaviors to be addressed with interventions for 1 of 4 sampled residents (Resident #1).
Failed to operate in a manner that respects the personal dignity and human rights of residents, specifically regarding an incident involving Resident #1 and Staff C.
Report Facts
Sampled staff: 8
Sampled residents: 4
Incident reports: 2
Admission date: Jun 29, 2021
Staff C hire date: Oct 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiency for failure to obtain fingerprint clearance and involved in resident search incident | |
| Staff A | Interviewed regarding fingerprint clearance and investigation of resident search incident | |
| Staff B | Interviewed regarding resident care plan and incident reporting | |
| Staff D | Mentioned as having key for medication cart during incident investigation | |
| AB | Interviewed by phone regarding resident behavior |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239628.
Complaint Details
Investigation of intake #GA00239628 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237627 and #GA00237353.
Complaint Details
The visit was complaint-related to investigate intake #GA00237627 and #GA00237353. The incident involved Staff B pushing Resident #1 after being hit and bitten by the resident. The incident was not reported to the Department as required.
Findings
The facility failed to report within 24 hours a serious incident involving a resident (Resident #1) where Staff B pushed the resident after being hit and bitten. The incident was not reported to the Department as required.
Deficiencies (1)
Facility failed to report within 24 hours a serious incident involving a resident.
Report Facts
Incident report submission date: Jul 19, 2023
Incident date: Jul 9, 2023
Interview date: Aug 17, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236397.
Complaint Details
Investigation of intake #GA00236397 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 27, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00234009 and #GA00234044 regarding the facility's care and services.
Complaint Details
The visit was complaint-related, investigating allegations that residents were not being fed, Resident #1 was not assisted with hygiene or transfers, the environment was unsanitary, and care plans were not updated. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to have a full-time administrator, maintain personnel files, provide sufficient staff assistance with eating, hygiene, and transfers, maintain a clean and safe environment, update care plans to reflect residents' changing needs, and provide adequate care and services to Resident #1. Significant delays in emergency call responses and poor resident care were documented.
Deficiencies (8)
Facility failed to have a full-time administrator to provide day-to-day leadership.
Facility failed to maintain personnel file and make it available for inspection for Staff B.
Facility failed to provide sufficient staff time to ensure prompt, unhurried assistance with eating for Resident #1.
Facility failed to ensure assistance with daily hygiene including baths and oral care for Resident #1.
Facility failed to ensure sufficient staff time to assist with transfers for Resident #1.
Facility failed to maintain the interior environment clean, in good repair, and free of unsanitary or unsafe conditions posing health or safety risks.
Facility failed to update the care plan when the needs of Resident #1 changed substantially.
Facility failed to provide adequate, appropriate care and services in compliance with state laws for Resident #1, including monitoring weight and wound care.
Report Facts
Emergency call response time: 1715
Resident weight: 131
Resident weight: 114.8
Fall incidents: 2
Care plan review dates: Jan 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Corporate Nurse / LPN acting as Wellness Director | Observed performing administrative tasks and interviewed regarding facility leadership and personnel files. |
| Staff B | Licensed Practical Nurse, Wellness Director | Hired 4/10/2023, interviewed about staffing, emergency call response, care plan updates, and facility deficiencies. |
| Staff C | Observed delivering food to Resident #1 but did not assist with feeding or respond to emergency alarms. | |
| Staff D | Interviewed about response to Resident #1's pendant alarm and refusal of assistance by Resident #1. | |
| AB | Friend of Resident #1 who reported concerns about care and cleanliness. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 11, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232019.
Complaint Details
The visit was complaint-related, investigating intake #GA00232019.
Findings
The facility failed to ensure personnel files included evidence of satisfactory fingerprint record checks, training and skills competency determinations, and that medication aides were listed in good standing on the Georgia Certified Medication Aide Registry for sampled staff.
Deficiencies (3)
Personnel files lacked evidence of a satisfactory fingerprint record check determination for 1 of 6 sampled staff (Staff D).
Personnel files lacked evidence of training and skills competency determinations for 3 of 6 sampled staff (Staff D, Staff E, and Staff F).
Medication aides employed were not listed in good standing on the Georgia Certified Medication Aide Registry for 1 of 6 sampled staff (Staff F).
Report Facts
Sampled staff: 6
Staff with fingerprint check deficiency: 1
Staff with training and skills competency deficiency: 3
Staff with registry listing deficiency: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 1, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224356.
Complaint Details
Investigation of intake GA00224356 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 18, 2022
Visit Reason
The purpose of this visit was to investigate intakes #GA0022035 and GA00220875 and conduct the compliance inspection.
Complaint Details
Investigation was triggered by intakes #GA0022035 and GA00220875. The complaint was substantiated by findings that the facility did not have signed DNR orders in the resident's file despite hospital documentation and family instructions.
Findings
The facility failed to include signed medical orders impacting end of life care, such as Do Not Resuscitate (DNR) orders, in the resident's file for 1 of 6 sampled residents (Resident #6). Resident #6 was found unresponsive and deceased with no documented DNR in the file despite hospital documentation and discussions with the resident's family.
Deficiencies (1)
Facility failed to include signed medical orders impacting end of life care, e.g. do not resuscitate, physician's orders for life sustaining treatment, etc. for Resident #6.
Report Facts
Intakes investigated: 2
Sampled residents: 6
Resident #6 hospital admission dates: Admitted 12/26/21 to 1/8/22
Resident #6 admission date to facility: Admitted 12/22/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Completed facility incident report dated 1/17/22 regarding Resident #6 | |
| Staff H | Interviewed on 1/21/22; reviewed hospital discharge paperwork and attempted to obtain DNR authorization |
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: Jul 29, 2019
Visit Reason
The purpose of this visit was to investigate complaints #GA00198202 and GA00198295.
Complaint Details
Investigation was conducted following complaints #GA00198202 and GA00198295; no violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00197492.
Complaint Details
Investigation of complaint #GA00197492 resulted in no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 3, 2019
Visit Reason
The purpose of this visit was to investigate complaint numbers GA00196912, GA00197107, and GA00197120.
Complaint Details
Investigation of complaints GA00196912, GA00197107, and GA00197120 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 3, 2019
Visit Reason
The purpose of this survey was to conduct a paperwork follow-up to the 1/23/19 inspection.
Findings
Based on a review of documentation submitted by the facility, the violation cited on the previous inspection has been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 23, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint GA00194037.
Complaint Details
Investigation of complaint GA00194037 regarding emergency preparedness and fire drill evacuation times.
Findings
The facility failed to comply with emergency preparedness requirements, specifically related to fire drills. Fire drills conducted between 1/1/18 and 1/19/19 took longer than the allowed 13 minutes to evacuate residents, with some drills taking up to 26 minutes due to evacuating residents needing more assistance.
Deficiencies (1)
Failure to comply with emergency preparedness requirements including fire drills exceeding the allowed evacuation time of 13 minutes.
Report Facts
Fire drill evacuation time: 26
Fire drill evacuation time: 15
Allowed evacuation time: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding fire drill evacuation times and resident assistance. | |
| State Fire Marshall representative | Interviewed regarding evacuation time requirements during fire drills. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 6, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00192377.
Complaint Details
Investigation was begun on 2018-11-05, an on-site visit was made on 2018-11-06, and the investigation was completed on 2018-11-07. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 12, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/22/18 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 21, 2018
Visit Reason
The purpose of this visit was to investigate intake #GA #00190543, involving an incident where Resident #1 was injured during transport in the facility van on 7/31/18.
Complaint Details
Investigation of intake #GA #00190543 regarding Resident #1's injury during transport on 7/31/18. The complaint was substantiated as the facility failed to document the incident, provide medical intervention, and notify the family timely.
Findings
The facility failed to provide adequate and appropriate care and services for Resident #1 after an incident where the resident's wheelchair tipped backward in the van causing a head injury. The incident was not properly documented, medical intervention was lacking, and the resident's family was not notified in a timely manner.
Deficiencies (1)
Failure to provide adequate care and services to Resident #1 after a head injury during transport, including lack of documentation and failure to notify family.
Report Facts
Incident date: Jul 31, 2018
Investigation start date: Aug 21, 2018
Investigation completion date: Sep 17, 2018
Hospital stay duration: 20
Dismissal date of Staff F: Aug 31, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Transported Resident #1 during incident; failed to report injury; dismissed from work | |
| Staff A | Reported that Staff F did not report incident and family was not notified | |
| Staff D | Called Resident #1's power of attorney and sent Resident #1 to hospital after condition change | |
| Staff B | Took vital signs of Resident #1 after incident | |
| GG | Family member not notified timely of incident; reported hospital stay and diagnoses |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 21, 2018
Visit Reason
The purpose of this visit was to investigate self reported incident # GA00188463.
Complaint Details
Investigation of self reported incident # GA00188463 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 17, 2018
Visit Reason
The purpose of this visit was to investigate complaint # GA00187436 regarding alleged abuse.
Complaint Details
Complaint investigation of abuse allegations involving Staff B. Resident #1 reported verbal and physical abuse, supported by witness interviews. The complaint was substantiated as the facility failed to prevent abuse.
Findings
The facility failed to ensure that residents were free from mental, verbal, and physical abuse. Specifically, Resident #1 reported verbal and physical abuse by Staff B, which was corroborated by witness statements.
Deficiencies (1)
Facility failed to provide for each resident the right to be free from mental, verbal and physical abuse for 1 of 2 sampled residents (#1).
Report Facts
Date of facility incident report: Apr 1, 2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2018
Visit Reason
The purpose of this visit was to investigate a self-reported incident GA00186598.
Complaint Details
Investigation of self-reported incident GA00186598 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 22, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00186079 with on-site visits made on 2018-03-13 and 2018-03-21, and the investigation completed on 2018-03-22.
Complaint Details
The investigation was initiated due to complaint #GA00186079. The complaint involved inadequate staff training on resident transfers, resulting in Resident #1 sustaining a spiral tibia fracture and fibular fracture on 2017-12-22, and a subsequent open tibial fracture with displacement and laceration on 2018-02-14. The responsible party stated they never received an explanation of how the injuries occurred and that transfer procedures were not addressed in the care plan.
Findings
The facility failed to ensure staff received hands-on training within the first 60 days of employment on transferring residents using gait belts and draw sheets, and failed to review and update the written care plan for Resident #1 regarding transfers. Resident #1 suffered two fractures and a laceration related to improper transfers, with inadequate documentation and explanation provided to the responsible party.
Deficiencies (3)
Facility failed to ensure staff hired to provide hands-on personal services received training within the first 60 days on assisting residents with transfers using gait belts and draw sheets.
Facility failed to ensure the written care plan was reviewed at least quarterly and modified as changes in the resident's needs occurred for Resident #1, specifically regarding transfer procedures.
Facility failed to provide each resident with care and services which were adequate, appropriate, and in compliance with state law and regulations, resulting in Resident #1 sustaining fractures and laceration during transfers.
Report Facts
Number of sampled staff lacking training: 7
Dates of on-site visits: 2018-03-13 and 2018-03-21
Dates of Resident #1 care plans reviewed: 2017-11-13 and 2017-12-28
Dates of Resident #1 injuries: 2017-12-22 and 2018-02-14
Units of blood required: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA 00184328.
Complaint Details
Complaint GA 00184328 was investigated and found to have no rule violations.
Findings
No rule violations were cited during the investigation.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 31, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
The facility failed to ensure fire evacuation drills were rehearsed in compliance with fire safety standards, as evidenced by incomplete fire drill records and staff interview indicating a shortage of fire drills.
Deficiencies (1)
Facility failed to ensure fire evacuation drills were rehearsed in compliance with fire safety standards.
Report Facts
Fire drills performed: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 14, 2017
Visit Reason
The visits on 07-11-2017 and 08-14-2017 were conducted to investigate complaint #GA00178370.
Complaint Details
Complaint #GA00178370 was investigated during visits on 07-11-2017 and 08-14-2017. The complaint was substantiated by findings of prohibited proxy caregiver services.
Findings
The facility was found to be providing nursing services that are prohibited proxy caregiver services, specifically an unlicensed staff member administered morphine to a resident.
Deficiencies (1)
Provision of nursing services by unlicensed staff, including administration of morphine to a resident.
Report Facts
Date of complaint investigation visits: Visits conducted on 07-11-2017 and 08-14-2017
Dose of morphine administered: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Unlicensed staff who administered morphine to Resident #3 | |
| Staff B | Confirmed administration of morphine by Staff E on 7-29-2017 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 4, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00173043.
Complaint Details
Complaint #GA00173043 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 19, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00170353.
Complaint Details
Complaint #GA00170353 was investigated and substantiated based on the finding that the resident was able to leave the facility unsupervised.
Findings
The facility failed to provide protective care and watchful oversight for one sampled resident who was able to exit the facility through an open window and walk approximately 1,500 feet down the street before staff located the resident.
Deficiencies (1)
Failed to provide protective care and watchful oversight for 1 of 1 sampled resident who exited the facility through an open window and walked down the street.
Report Facts
Distance resident walked: 1500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C and Staff D interviewed regarding the incident; no full names provided. |
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