Inspection Reports for Oaks at Snellville

The purpose of this visit was to investigate complaint intake# GA50003091, which began on 2025-06-10 with an unannounced on-site visit and was completed on 2025-06-14.

The facility failed to adhere to practices and procedures that support dignity, respect, and choice in a safe environment for one sampled resident (Resident #1) who was erroneously served shellfish despite documented allergies. The resident did not ingest the shellfish and did not require hospitalization.

Complaint intake GA50003091 was reported by AA on 2025-04-20 regarding Resident #1 being served shrimp scampi despite a known shellfish allergy. The resident did not ingest the shellfish and was not hospitalized. The investigation confirmed the facility was aware of the allergy but agency staff unfamiliar with dietary restrictions served the shellfish.

The purpose of this visit was to investigate intakes GA000252437, GA00252669, and GA0000293.

No rule violations were cited as a result of this visit.

Investigation of complaint intakes GA000252437, GA00252669, and GA0000293 with no rule violations found.

The purpose of this visit was to investigate intake# GA00250448.

No rule violations were cited as a result of this visit.

Investigation of intake# GA00250448 with no rule violations cited.

The purpose of this visit was to investigate intake #GA00247876 with an on-site visit made to the facility on 7/15/2024.

The investigation was completed on 7/15/2024 and no rule violations were cited as a result of this inspection.

Investigation of intake #GA00247876; no rule violations were found.

The purpose of this visit was to investigate intakes #GA00246430.

No rule violations were cited as a result of this inspection.

Investigation of intake #GA00246430 with no rule violations found.

The purpose of this visit was to investigate intake #GA00246146 and conduct the compliance inspection.

An on-site visit was made to the facility on 5/6/24 and the investigation was completed on 5/9/24. No rule violations were cited as a result of this inspection.

Investigation of intake #GA00246146 was conducted with no rule violations cited.

The purpose of this offsite/desk review was to investigate complaint intakes #GA00243805, #GA00243817, and #GA00244324 received by the Department.

The facility failed to report allegations of abuse of a resident to law enforcement as required by the Long-Term Care Resident Abuse Reporting Act. Surveillance showed Staff B pushing Resident #1 roughly into bed causing the resident to hit his/her head on the wall. The incident was reported to law enforcement by hospice staff, but the facility did not report it, citing the family did not wish to press charges.

Investigation was complaint-related based on intakes received on 2/13/24, 2/14/24, and 2/29/24. The abuse allegation involved Staff B pushing Resident #1 causing injury. The incident was reported to law enforcement by hospice staff, but the facility did not report it to law enforcement, stating the family did not wish to press charges.

The purpose of this visit was to investigate intake #GA00238190. An on-site visit was made to the facility on 9/27/23 as part of the investigation that started on 9/25/23 and was completed on 10/02/23.

The facility failed to ensure timely refills of prescribed medications for Resident #1, resulting in missed doses of Sertraline and Eliquis. Additionally, the facility failed to provide adequate personal care services, specifically showers, as Resident #1 did not receive showers as scheduled and documentation of refusals was incomplete.

The investigation was initiated due to intake #GA00238190 concerning medication errors and inadequate personal care for Resident #1. The complaint was substantiated based on record reviews and interviews.

The purpose of this visit was to investigate intake #GA00237974. An on-site visit was made to the facility on 8/29/23. The investigation started on 8/28/23 and was completed on 8/31/23.

The facility failed to ensure proper oversight and medication management for Resident #1, resulting in administration of incorrect warfarin dosage (2.5 mg instead of 2 mg) on multiple dates in July 2023. This led to Resident #1 being hospitalized with hemothorax and warfarin toxicity. The facility also failed to properly dispose of discontinued medications and lacked nurse oversight during medication administration.

Investigation was initiated due to intake #GA00237974 regarding medication errors for Resident #1. The complaint was substantiated as Resident #1 received incorrect warfarin dosage multiple times, resulting in hospitalization for warfarin toxicity and hemothorax.

The purpose of this visit was to investigate intake #GA00237054. An on-site visit was made to the facility on 7/26/23, with the investigation starting on 7/26/23 and completed on 8/2/23.

The facility failed to ensure that a designated qualified responsible staff was present to act on the administrator's behalf and carry out duties during the administrator's absence. Staff interviews revealed confusion about who was in charge during the administrator's absence, with the designated staff unaware of their responsibilities.

Investigation was initiated based on intake #GA00237054. The complaint was investigated through on-site and telephone interviews with staff regarding the administrator's absence and delegation of responsibilities.

The purpose of this visit was to investigate intake #GA00235789. An on-site visit was made to the facility on 2023-06-29. The investigation started on 2023-06-26 and was completed on 2023-07-06.

The facility failed to ensure that Resident #1 had a physical examination dated within 30 days prior to admission and that the examination form was fully completed including tuberculosis screening. Additionally, the facility failed to have a written care plan addressing specific behaviors and interventions for Resident #1, including assistance with transfers.

Investigation of intake #GA00235789 was conducted with an on-site visit on 2023-06-29. The investigation was initiated on 2023-06-26 and completed on 2023-07-06.

The purpose of this visit was to investigate intake #GA00233733. An on-site visit was made to the facility on 4/11/23. The investigation started on 4/10/23 and was completed on 4/20/23.

The facility failed to ensure that Resident #1 received adequate and appropriate care and services, specifically related to bathing assistance. Documentation showed no confirmation that scheduled showers were completed, and interviews revealed inconsistent shower provision and documentation, with some refusals by the resident.

Investigation of intake #GA00233733 regarding failure to provide adequate bathing care to Resident #1. Resident and staff interviews indicated inconsistent shower provision and documentation. Resident sometimes refused showers, but staff did not always follow up appropriately.

The purpose of this visit was to investigate intake GA00230281 and conduct the compliance inspection at Oaks at Snellville. The onsite visit was made on 3/8/23, with the investigation starting on 3/6/23 and completed on 3/28/23.

The facility failed to ensure employees completed required training and health screenings, failed to provide well-balanced and properly prepared meals for residents, and failed to ensure residents received timely medication administration and appropriate care due to inadequate staffing.

The visit was complaint-related, investigating intake GA00230281. The investigation included review of staff training, health screenings, meal quality, and medication administration practices.

The purpose of this visit was to investigate intake #GA00225159. An on-site visit was made to the facility on 7/19/22. The investigation started on 7/18/22 and was completed on 7/21/22.

No rule violations were cited as a result of this inspection.

Investigation of intake #GA00225159 was conducted with no rule violations found.

The purpose of this visit was to investigate intake #GA00219872.

No rule violations were cited as a result of this inspection.

Investigation of intake #GA00219872 with no rule violations found.

The purpose of this visit was to investigate complaint intakes #GA00215603, #GA00215807, and #GA00215815. The investigation was opened on 2021-10-26 and completed on 2021-12-17.

The facility failed to ensure that all employees received required work-related training within the first 60 days of employment, as evidenced by Staff E's lack of training. Additionally, the facility failed to report a serious incident involving Resident #3 within 24 hours as required.

The investigation was complaint-driven based on intake numbers #GA00215603, #GA00215807, and #GA00215815. The complaint involved failure to provide required employee training and failure to report a serious incident involving Resident #3, who fell and later expired. The complaint investigation was substantiated by the findings.

The purpose of this visit was to investigate intake #GA00219637. An on-site visit was made to the facility on 12/14/21, with the investigation completed on 12/22/21.

The facility failed to ensure that personnel files for each employee were maintained either in the home or available for inspection within one hour of request and for three years following the employee's departure. Specifically, the file for Staff B was not accessible due to management changes, and requested documentation including resignation letter, criminal background check, and residents' rights and abuse training for Staff B was not provided as of 12/22/21.

Investigation was initiated due to intake #GA00219637. The complaint was substantiated by findings that personnel files were not available and required documentation for Staff B was missing.

The purpose of this visit was to investigate intake #GA00217753. An on-site visit was made to the facility on 2021-10-12. The investigation started on 2021-10-11 and was completed on 2021-11-10.

The facility failed to provide supervision consistent with the residents' needs, as evidenced by Resident #1 eloping from the facility through an unlocked kitchen exit door without staff awareness. Resident #1 was found by police and returned safely, with no injuries observed.

The investigation was initiated due to intake #GA00217753 regarding Resident #1 eloping from the facility on 2021-09-14. The resident left through an unlocked kitchen exit door without staff noticing. Staff searched for the resident, police were notified, and the resident was found and returned safely. Resident #1 was moved to memory care for safety and given a 30-day notice due to elopement.

The inspection was conducted to investigate intake #GA00214777, which began on 2021-06-14 and was completed on 2021-07-08.

The facility failed to take appropriate actions during a sudden adverse change in Resident #1's condition, including failure to notify the responsible party. Additionally, the facility did not report a serious injury to the Department within 24 hours as required.

The investigation was complaint-related, focusing on Resident #1 who was pushed by Resident #2 resulting in a fall and injury. The complaint included failure to notify the responsible party and failure to report the incident to the Department within 24 hours. The complaint was substantiated based on record reviews and staff interviews.