Inspection Reports for River Place at Forsyth
3492 Johnstonville Rd, Forsyth, GA 31029, United States, GA, 31029
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 19, 2022, found no deficiencies. Earlier inspections showed a mixed record, with some citations related to medication management, staff certification, and documentation from a complaint investigation in March 2021. Prior reports also noted substantiated findings of staff mental abuse and lack of dementia training in late 2020, which led to staff termination and law enforcement notification. Complaint investigations were mostly unsubstantiated except for the mental abuse case. The facility’s inspection history shows improvement with no deficiencies noted in the latest report after previous issues.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Original Licensing
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
The purpose of this visit was to conduct an initial inspection.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 22, 2021
Visit Reason
The purpose of this inspection was to investigate intake #GA00211210, with the investigation starting on 2021-01-26 and completed on 2021-03-22.
Complaint Details
The inspection was complaint-related, investigating intake #GA00211210. The investigation started on 2021-01-26 and was completed on 2021-03-22.
Findings
The facility failed to ensure proper oversight and compliance with regulations for medication management, staff certification, physical examination documentation, and medication administration records for sampled residents. Specific deficiencies included lack of documentation for medication omissions and refusals, failure to obtain current emergency first aid certification for staff, incomplete physical examination reports, and failure to timely obtain medication refills leading to interruptions in medication dosing.
Deficiencies (6)
Failed to ensure staff provided oversight necessary for compliance with applicable rules for 2 of 4 sampled residents.
Failed to document medication omissions, refusals, ordering and receiving medications, resulting in no interruption documentation.
Failed to obtain evidence of current certification in emergency first aid for 2 of 3 sampled staff.
Failed to obtain updated physical examination report using the Department's required form for 1 of 4 sampled residents.
Failed to ensure the Medication Administration Record (MAR) included initials, time, and date when medications were taken, refused, or errors identified for 2 of 4 sampled residents.
Failed to obtain medication refills timely to prevent interruption in routine dosing for 2 of 4 sampled residents.
Report Facts
Deficiencies cited: 6
Dates of medication omissions: Dec 16, 2020
Dates of medication omissions: Jan 20, 2021
Dates of medication omissions: Dec 22, 2020
Dates of medication omissions: Jan 10, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed and provided email correspondence regarding medication documentation and certification deficiencies. | |
| Staff A | Spoke with Resident #4 family about medication orders and refills. | |
| Staff C | Sampled staff lacking current emergency first aid certification. | |
| Staff D | Sampled staff lacking current emergency first aid certification and interviewed about medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
The purpose of this inspection was to investigate intake GA00209729.
Complaint Details
Investigation began on 2020-12-08 and was completed on 2021-01-14. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 17, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208405, which started on 2020-10-14 and was completed on 2020-11-17.
Complaint Details
The investigation was complaint-driven based on intake #GA00208405. The complaint involved allegations of staff to resident mental abuse, including posting videos of residents on social media and tormenting residents in the memory care unit. The complaint was substantiated with multiple staff interviews and review of video evidence. Staff B was terminated and law enforcement was notified.
Findings
The facility failed to ensure staff received required dementia training and failed to respect the personal dignity and human rights of residents. Staff B was found to have mentally abused residents by mocking, laughing at, and ridiculing them, including recording videos of residents without consent and tormenting them. Multiple staff witnessed the abuse but failed to report it immediately. Staff B was terminated and law enforcement was notified.
Deficiencies (3)
Failure to ensure staff assigned to the unit received required dementia training within the first six months of employment.
Failure to operate in a manner that respects the personal dignity and human rights of residents, including mental abuse by Staff B.
Failure to ensure residents were free from mental, verbal, sexual and physical abuse, neglect and exploitation, including Staff B's actions of tormenting residents and recording videos without consent.
Report Facts
Sampled staff: 18
Sampled residents: 5
Staff B employment period: 397
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in multiple findings related to mental abuse, tormenting residents, recording videos, and termination. | |
| Staff A | Interviewed regarding Staff B's misconduct and termination. | |
| Staff G | Received harassing text messages from Staff B and had video evidence. |
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
Routine
Deficiencies: 0
Date: Aug 14, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Jun 27, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to have a secured outdoor space with wheelchair accessible walkways for the memory care unit, as confirmed by observation and staff interview.
Deficiencies (1)
Facility failed to have a secured outdoor space with wheelchair accessible walkways for the memory care unit.
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