Inspection Reports for The Addison of Gwinnett Park
2450 Buford Dr, Lawrenceville, GA 30043, GA, 30043
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Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 7, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005541, conducted from 2025-10-02 to 2025-10-07.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake #GA50005541 with no rule violations found.
Inspection Report
Follow-Up
Deficiencies: 4
Mar 19, 2025
Visit Reason
The inspection was conducted as a follow-up visit to the January 31, 2025 survey and to investigate complaints #GA00251499, #GA00251659, and GA00251292.
Findings
The facility failed to ensure proper implementation and enforcement of policies and procedures related to resident care, resulting in neglect of Resident #1 who developed a serious pressure ulcer requiring hospitalization. Additionally, the facility failed to administer medication as ordered for Resident #2. No rule violations were cited during the follow-up visit on March 19, 2025.
Complaint Details
The visit was complaint-related, investigating allegations concerning neglect and failure to provide appropriate care to Resident #1, including failure to monitor and document skin integrity and failure to administer medication to Resident #2. The investigation found substantiated neglect for Resident #1 and medication administration failures for Resident #2.
Severity Breakdown
D: 2
J: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Community leadership failed to ensure policies and procedures were implemented and enforced to maintain compliance. | D |
| Facility failed to maintain awareness of Resident #1's normal appearance and intervene when health was in jeopardy, resulting in untreated pressure ulcer. | J |
| Facility failed to administer medication according to physician's orders for Resident #2. | D |
| Facility failed to ensure Resident #1 was free from neglect, resulting in serious pressure ulcer and hospitalization. | J |
Report Facts
Hospitalization duration: 17
Medication doses missed: 2
Resident sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Reported observing a wound on Resident #1's hip in September 2024 and informing a med-tech but did not report further. | |
| Staff D | Unaware of Resident #1's wound until shown a picture by a relative on 9/30/24; informed relative to take Resident #1 to PCP. | |
| Staff K | Admitted to not administering prescribed insulin to Resident #2 on 9/3/24 and 9/4/24. | |
| AA | Relative of Resident #1 who observed wound, transported Resident #1 to PCP and hospital, and provided photo evidence. | |
| Staff J | Could not find medication for Resident #2 and was unaware of wound on Resident #1 until shown photo. |
Inspection Report
Original Licensing
Deficiencies: 0
Mar 7, 2025
Visit Reason
The purpose of this visit was to conduct an initial compliance inspection.
Findings
No rule violations were cited as a result of this visit.
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