Inspection Report
Annual Inspection
Deficiencies: 0
Nov 3, 2021
Visit Reason
The purpose of this visit was to conduct the Annual inspection of the facility.
Findings
No rule violations were cited as a result of the visit.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 18, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214956. An unannounced visit was made to the facility on 6/18/21, with the investigation started on 6/14/21 and completed on 7/23/21.
Findings
The facility failed to update the Medication Administration Record (MAR) each time medication was offered or taken for 3 of 6 sampled residents. Specific instances of missing documentation for multiple medications across several dates were identified for Residents #1, #2, and #3.
Complaint Details
Investigation was initiated based on intake #GA00214956. The complaint involved failure to properly document medication administration, including staff leaving medication in resident's bedroom without observation and residents needing to remind staff for medication assistance.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to update the Medication Administration Record (MAR) each time medication was offered or taken for 3 of 6 sampled residents. | SS= D |
Report Facts
Residents with MAR documentation issues: 3
Sampled residents: 6
Inspection Report
Monitoring
Deficiencies: 0
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
Complaint Investigation
Deficiencies: 1
Jan 15, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate self-reported complaint #GA00193791.
Findings
The facility failed to ensure that all Certified Medication Aides (CMAs) working in the facility were listed on the CMA registry as active and in good standing for 3 of 5 sampled CMAs. Specifically, Staff B's registry expired in 10/2018, and Staff E and Staff F had not paid the required fee for their registries.
Complaint Details
Investigation of self-reported complaint #GA00193791. The complaint was substantiated by findings related to Certified Medication Aide registry status.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure that all Certified Medication Aides were listed on the CMA registry as active and in good standing for 3 of 5 sampled CMAs (Staff B, E, F). | SS= D |
Report Facts
Number of sampled CMAs not in good standing: 3
Number of sampled CMAs reviewed: 5
Registry expiration date: 201810
Registry fee: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Medication Aide whose registry expired and was not active in the CMA registry. | |
| Staff E | Certified Medication Aide who had not paid the $25 fee for registry renewal. | |
| Staff F | Certified Medication Aide who had not paid the $25 fee for registry renewal. | |
| Staff A | Interviewed staff who provided information about CMA registry status. |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 19, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/30/18 compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 14, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00190433.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00190433 was investigated and found to have no rule violations.
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 30, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility on 3/30/2018.
Findings
The facility failed to ensure that fire drills were conducted in compliance with fire safety regulations, specifically that fire drills were not conducted on rotating shifts so that each shift rehearsed a fire drill once per quarter.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Fire drills were not conducted on rotating shifts so that each shift rehearsed a fire drill once per quarter. | SS= D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D acknowledged the fire drills documentation provided an accurate account of the drills conducted. |
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 29, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
The facility failed to report a serious injury requiring medical attention to the Department as required. Specifically, a resident who sustained a subdural hematoma after a fall was not reported because staff believed only deaths needed to be reported.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure that all serious injuries requiring medical attention were reported to the Department for 1 of 1 residents. | D |
Report Facts
Resident involved: 1
Incident date: Aug 27, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding failure to report injury to Department |
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