Inspection Reports for
Sunrise of Decatur

The investigation was complaint-driven based on intakes #GA00216787 and #GA00216614. Resident #3 received an accidental overdose of Methadone on 2021-08-05, was hospitalized, and later died from COVID-19. Staff interviews revealed the overdose was due to a medication administration error by Staff C, who measured 10 ml instead of 1 ml of Methadone. The facility failed to provide adequate monitoring and care following the error.

The facility failed to provide medication administration services in accordance with physicians' orders and resident needs, resulting in a medication error where Resident #3 was given an overdose of Methadone causing hospitalization and subsequent death. The facility also failed to ensure adequate and appropriate care and services for Resident #3 in compliance with state law and regulations.

The investigation was initiated due to a complaint regarding theft of narcotics. The complaint was substantiated by findings of missing narcotics and procedural failures in narcotic handling and reporting.

The facility failed to provide necessary oversight to prevent narcotic diversion, including improper narcotic reconciliation, failure to report termination of a medication aide to the registry, and failure to properly inventory controlled substances. A sleeve of 30 Oxycodone pills was missing, and staff did not follow required counting procedures.

Investigation was conducted based on intake GA00200573. The complaint was substantiated as the facility failed to ensure required staff training for emergency first aid and CPR for one staff member.

The facility failed to ensure that staff hired to provide hands-on personal services to residents received required training within the first 60 days of employment. Specifically, one of nine sampled staff (Staff F) did not have current certification in emergency first aid or cardiopulmonary resuscitation (CPR).

The investigation was triggered by intake #GA00200068 concerning failure to honor a DNR order and inadequate staff training related to hospice care. The complaint was substantiated based on record review and staff interviews.

The facility failed to ensure all staff received required training on medical and social needs of the resident population, specifically hospice care. Additionally, the facility failed to honor a signed Do Not Resuscitate (DNR) order for Resident #1 during a choking incident, resulting in inappropriate resuscitation efforts.

The investigation was complaint-driven based on concerns reported in an incident report dated 2/8/19 about residents not receiving prescribed medications, receiving discontinued medications, and medication changes not being updated timely.

The facility failed to maintain updated medication administration records (MAR) for residents, specifically Resident #8, where medication changes were not timely updated or documented. Additionally, the facility failed to obtain new prescriptions within 48 hours for Resident #2, resulting in medication not being available and administered as ordered.

Investigation was conducted based on complaint intakes #GA00191524, #GA00191964, #GA00192684, and #GA00192977. The complaint was substantiated as the facility failed to notify Resident #1's family of a pressure ulcer and failed to take immediate appropriate action.

The facility failed to immediately take appropriate actions in response to a sudden adverse change in condition for Resident #1, specifically failing to notify the resident's family/representative of an open sacral wound. The nurse responsible was terminated for failure to report the pressure ulcer.

The visit was complaint-related, investigating self-reported incidents #GA00191524 and #GA00191964. The complaint was substantiated as the facility failed to notify the legal representative about the resident's wound.

The facility failed to inform the legal representative of a change in the resident's condition for 1 of 75 residents (Resident #2), specifically regarding a wound on the resident's buttock area. Staff attempted to obtain a doctor's order for home health care but did not receive a response.

Investigation was conducted related to self-reported incident #GA00190291.

The facility failed to ensure that hot water temperatures in 5 of 6 sampled bathroom sinks did not exceed 120 degrees Fahrenheit, with recorded temperatures ranging from 124 to 128 degrees Fahrenheit.