Inspection Reports for Rising Star Personal Care Home
5018 E Ponce de Leon Ave, Stone Mountain, GA 30083, GA, 30083
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Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00229277 with an onsite visit made on 12/8/22.
Findings
The investigation was completed on 12/8/22 and no rule violations were cited.
Complaint Details
Investigation of intake #GA00229277 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2022
Visit Reason
The visit was conducted to investigate complaint intakes GA00224998 and GA0022420, and to perform a compliance inspection.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00224998 and GA0022420 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 2, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217661 with an on-site visit made to the facility on 11/2/21.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00217661; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 27, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00213731, which was opened on 2021-05-11 and completed on 2021-07-27.
Findings
The facility was found to have multiple deficiencies including a rolled-up rug posing a trip hazard, ceiling stains and damage, and windows in resident bedrooms that could not be opened to provide a secondary exit for emergencies.
Complaint Details
The visit was complaint-related, investigating intake GA00213731. The intake was opened on 2021-05-11 and completed on 2021-07-27.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Floor covering was not intact and securely fastened, with a rug rolled up on the edges under and outside of bed for Resident #4 posing a trip hazard. | D |
| Ceiling was not kept clean and in good repair, evidenced by a large brown stain in the conference room and a ceiling vent hanging with cracked paint near the dining room. | D |
| Windows in resident bedrooms (#302 and #304) did not allow for a secondary exit as they were painted shut and could not be opened. | E |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 8, 2021
Visit Reason
The purpose of this inspection was to investigate intake GA00211872 and conduct the compliance inspection.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00211872 was conducted with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 5
Dec 9, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00209085 and #GA00208968, focusing on allegations of physical abuse and neglect of Resident #1.
Findings
The facility failed to ensure Resident #1 was free from physical abuse and neglect. Resident #1 sustained serious injuries including a brain bleed requiring emergency surgery after an alleged assault by Staff B. The facility also failed to report the incident to the Department within 24 hours and did not notify the responsible party timely. Staff oversight and care were inadequate, and the resident's adverse condition changes were not properly addressed.
Complaint Details
The investigation was initiated due to complaints alleging physical abuse of Resident #1 by Staff B on 10/12/2020. The resident sustained serious injuries including a subdural hematoma requiring emergency brain surgery. The facility failed to report the abuse timely and did not notify the responsible party. Law enforcement listed Staff B as the offender and Resident #1 as the victim.
Severity Breakdown
J: 3
D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure staff provided oversight to prevent abuse of Resident #1. | J |
| Failure to provide adequate care and services in compliance with laws and regulations for Resident #1. | J |
| Failure to ensure Resident #1 was free from mental, verbal, sexual, and physical abuse, neglect, and exploitation. | J |
| Failure to take appropriate actions during sudden adverse change in Resident #1's condition, including notifying responsible party. | D |
| Failure to report serious injury requiring medical treatment to the Department within 24 hours for Resident #1. | D |
Report Facts
Incident dates: Oct 12, 2020
Incident report dates: Oct 14, 2020
Incident report dates: Oct 19, 2020
Hospital admission date: Oct 20, 2020
Emergency surgery date: Oct 21, 2020
Resident temperature: 101
Staff B shift hours: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Facility staff who acknowledged responsibility but did not provide physical oversight or report abuse | |
| Staff B | Caregiver alleged to have physically abused Resident #1 | |
| Staff C | Staff who completed Resident #1's assessment and was involved in incident reporting | |
| Staff D | Staff who observed Resident #1's injuries and reported abuse | |
| BB | Visitor who witnessed Resident #1's condition and reported abuse | |
| CC | Visitor who observed Resident #1 crying and injuries | |
| DD | Medical professional who evaluated Resident #1 and confirmed abuse and need for emergency surgery | |
| AA | Responsible party who was not timely notified of hospital admission |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 24, 2020
Visit Reason
The purpose of this visit was to investigate intake # GA00202058 with an on-site visit made on 2020-01-24 and investigation completed on 2020-01-27.
Findings
The facility failed to keep the floors in good repair as evidenced by worn and stained carpets in the halls observed during the tour. Staff B confirmed that the owner was informed about the carpet issue. This deficiency was previously cited on 2019-05-30.
Complaint Details
Investigation was conducted based on intake # GA00202058.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to keep the floors in good repair; carpets in the halls were worn and stained. | E |
Inspection Report
Complaint Investigation
Deficiencies: 15
May 30, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00196846.
Findings
The facility was found deficient in multiple areas including workforce qualifications and training, physical plant health and safety standards, admission procedures, resident care, and proxy caregiver services. Specific issues included lack of current emergency first aid and CPR certification for staff, inadequate training hours, missing work performance reviews, fire safety noncompliance, unclean and unsafe physical conditions, failure to admit only residents whose care needs could be met, missing admission interviews and physical exams, lack of written admission agreements, inadequate resident care documentation, and missing plans of care and competency checklists for proxy caregivers.
Complaint Details
The inspection was conducted to investigate intake #GA00196846.
Severity Breakdown
SS= D: 13
SS= J: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 6 sampled staff had current certification in emergency first aid within first 60 days of employment. | SS= D |
| Failed to ensure 1 of 6 sampled staff had current certification in CPR with return demonstration of competency. | SS= D |
| Failed to ensure all staff involved with personal services received at least 16 hours of training per year for 4 of 6 sampled staff. | SS= D |
| Failed to have work performance reviews including skills competency checklists for 1 of 6 unlicensed staff performing medication administration. | SS= D |
| Failed to ensure compliance with fire and safety rules; sprinkler system last serviced 7/27/2017 and fire drills varied in duration. | SS= D |
| Failed to keep floors and walls clean and in good repair; carpet torn, worn, stained; walls stained and marred. | SS= D |
| Failed to sanitize bathrooms daily; urine odor and sticky yellowish stains found in resident bathrooms. | SS= D |
| Hot water temperature exceeded 120 degrees F; measured 134.1 degrees F in resident bathroom. | SS= J |
| Failed to ensure furnishings and housekeeping standards presented a clean and orderly appearance; strong urine odor and stains in resident rooms. | SS= D |
| Failed to admit or retain only residents whose care needs could be met; Resident #3 had pressure injuries requiring wound care and therapies. | SS= D |
| Failed to conduct admission interview and obtain physical examination report within 30 days prior to admission for Resident #3. | SS= D |
| Failed to enter into a written admission agreement between governing body and Resident #3. | SS= D |
| Failed to ensure Resident #2 received adequate care and services; no documentation of weights, care plan interventions, or consistent progress notes. | SS= D |
| Failed to ensure written plan of care developed by licensed healthcare professional for proxy caregivers for 4 of 6 sampled residents. | SS= D |
| Failed to use skills competency checklist form for specific health maintenance activities for 2 of 6 sampled staff. | SS= D |
Report Facts
Staff sampled: 6
Residents sampled: 9
Fire drill durations: 15
Hot water temperature: 134.1
Pressure injury size: 7.8
Pressure injury size: 6.5
Training hours required: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed multiple times regarding staff training, facility conditions, resident care, and deficiencies | |
| Staff C | Medication Technician | Performed medication administration without completed proxy caregivers training |
| Staff D | Sampled staff lacking current emergency first aid and CPR certification and skills competency checklist | |
| Staff E | Sampled staff lacking required training hours and skills competency checklist | |
| Staff F | Sampled staff lacking required training hours | |
| AA | Interviewed regarding Resident #2's weight and care documentation | |
| Staff A | Witnessed thermometer calibration and hot water temperature measurement |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 22, 2018
Visit Reason
The purpose of this visit was to conduct follow-up inspections related to the 10/25/17 annual inspection and the 12/12/17 complaint investigation.
Findings
The facility failed to display the most recent inspection report and plan of correction from the 12/12/17 inspection in a location routinely used to communicate information to residents and visitors. The facility had seven different inspections since 2/2/16, but only an older report from 2/2/16 was displayed.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have a copy of the most recent inspection report and plan of correction displayed in the home in a location routinely used to communicate information to residents and visitors. | SS= D |
Report Facts
Number of inspections since 2/2/16: 7
Inspection dates: Inspection dates include 2/2/16, 6/1/16, 9/14/16, 11/3/16, 12/20/16, 10/25/17, and 12/12/17.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 22, 2018
Visit Reason
The visit was conducted as a follow up to the 12/12/17 complaint investigation and a follow up to the 10/25/17 annual inspection.
Findings
No rule violations were cited as a result of the follow up to the 12/12/17 complaint investigation.
Complaint Details
Follow up to the 12/12/17 complaint investigation with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 12, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00182459.
Findings
The facility failed to ensure it retained only ambulatory residents capable of self-preservation with minimal assistance, as evidenced by Resident #2 who required physical and oral assistance and was not ambulatory. Staff reported Resident #2's condition had declined and a 30-day discharge notice was planned.
Complaint Details
Complaint #GA00182459 was investigated and substantiated by findings related to admission and retention of non-ambulatory residents.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The home admitted and retained a non-ambulatory resident requiring physical and oral assistance, contrary to admission requirements. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding Resident #2's condition and facility plans for discharge notice. |
Inspection Report
Annual Inspection
Deficiencies: 14
Oct 25, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of Rising Star Personal Care Home.
Findings
The inspection identified multiple deficiencies including failure to ensure staff had current emergency first aid and CPR certifications, inadequate fire drills, improper locking mechanisms on exterior doors, unclean furnishings, admission of non-ambulatory residents without proper waivers, missing physical examinations for residents, ineffective safety devices for residents at risk of eloping, incomplete medication administration records, medications not kept in original containers, failure to provide well-balanced meals, storage of expired and improperly stored food, and failure to document changes in resident conditions.
Severity Breakdown
F: 2
E: 2
D: 9
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to ensure staff had current certification in emergency first aid. | F |
| Facility failed to ensure employees demonstrated evidence of current CPR certification. | F |
| Facility failed to conduct six required fire drills annually, including two during sleeping hours. | D |
| Exterior doors had locks requiring keys to open from the inside. | D |
| Facility failed to maintain a clean and orderly appearance; fan with dust found in kitchen. | D |
| Facility admitted non-ambulatory resident without proper waiver. | D |
| Facility failed to obtain physical examinations within 30 days prior to admission for 3 of 5 sampled residents. | E |
| Facility failed to maintain appropriate safety devices that activate alarms for residents at risk of eloping. | D |
| Facility failed to maintain daily Medication Assistance Records for 2 of 5 sampled residents. | D |
| Medications were not kept in original containers with original labels intact for 1 of 7 sampled residents. | D |
| Facility failed to provide well-balanced meals seven days a week. | E |
| Facility failed to maintain food free from spoilage and adulteration; expired and unlabeled foods found. | D |
| Facility failed to store perishable foods properly; refrigerator temperature was 54°F and door could not close completely. | D |
| Facility failed to retain a record of sudden adverse change in a resident's physical condition or emotional adjustment. | D |
Report Facts
Fire drills conducted: 5
Fire drills during sleeping hours: 1
Expired cakes: 11
Bundles of butter: 7
Gallons of mayonnaise: 3
Refrigerator temperature: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings related to lack of emergency first aid and CPR certification and inability to provide details on resident condition change. | |
| Staff A | Interviewed regarding fire drills, meal provision, and resident condition change documentation. | |
| Staff B | Interviewed regarding cleanliness, physical examination documentation, medication records, food storage, and safety devices. | |
| KK | Interviewed regarding resident admission and meal options. |
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