Inspection Report Summary
The most recent inspection on April 23, 2024, found deficiencies related to staff infection control training, physical examinations prior to employment, and completion of required fire drills. Earlier inspections showed a mix of results, with some investigations finding no violations and others citing issues in medication management, resident care, staffing, safety reporting, and food storage. The main themes of deficiencies involved staff training and compliance with safety procedures, as well as medication and resident supervision concerns in prior years. Several complaint investigations were unsubstantiated, but substantiated complaints included failure to timely report resident elopements and inadequate medication assistance. The inspection history shows some recurring issues with staff training and safety compliance, though recent findings focus more narrowly on infection control and emergency preparedness.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
22 residents
Based on a March 2020 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 23, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00245422. An unannounced onsite visit was made on 4/23/2024 and the investigation was completed on 4/25/2024.
Complaint Details
Investigation was initiated based on intake #GA00245422. The complaint was substantiated by findings of missing infection control training, missing physical examinations for staff, and failure to conduct required fire drills.
Findings
The facility failed to ensure staff received required infection control training and physical examinations prior to employment. Additionally, the facility did not complete required fire drills since 9/20/2023.
Deficiencies (3)
Facility failed to ensure staff had training on general infection control principles including hand hygiene for 1 of 4 sampled staff (Staff C).
Facility failed to ensure each employee received a physical examination by a licensed provider within 12 months prior to employment for 3 of 4 sampled staff (Staff B, Staff C, Staff D).
Facility failed to complete required fire drills; last documented drill was on 9/20/2023 with no current drills completed.
Report Facts
Number of sampled staff missing infection control training: 1
Number of sampled staff missing physical examinations: 3
Date of last completed fire drill: Sep 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Missing infection control training and physical examination | |
| Staff B | Missing physical examination | |
| Staff D | Missing physical examination | |
| Staff A | Interviewed staff providing information on deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 21, 2024
Visit Reason
The purpose of this visit was to investigate intake GA00243314.
Complaint Details
Investigation of intake GA00243314; no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00237541.
Complaint Details
Investigation of intake #GA00237541 with no rule violations found.
Findings
No rule violation was cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236595 and #GA00237446.
Complaint Details
Investigation of intake #GA00236595 and #GA00237446 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00233894.
Complaint Details
Investigation of intake #GA00233894 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00227922.
Complaint Details
Investigation of intake #GA00227922 completed with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 25, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220815. An on-site visit was made on 1/25/22 and the investigation was completed on 1/26/22.
Complaint Details
Visit was complaint-related to intake #GA00220815. Investigation included observations and interviews regarding medication assistance and food storage practices.
Findings
The facility failed to provide medication assistance following the Five Rights, failed to update the Medication Assistance Record (MAR) each time medication was given or offered, and failed to store food in airtight containers as required.
Deficiencies (3)
Facility failed to provide assistance that followed the Five Rights of medication assistance, including medication cups left on a shelf and lack of documentation.
Facility staff failed to update the Medication Assistance Record (MAR) each time medication was given or offered, with no staff signatures from 1/11/22 to present and no current MARs available.
Facility failed to store food in airtight containers; observed multiple items in the pantry not properly sealed including a large open bag of sugar.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 2, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00218184. The investigation started on 2021-10-18, included an unannounced visit on 2021-10-27, and was completed on 2021-11-02.
Complaint Details
Investigation was initiated due to intake GA00218184. The complaint involved concerns about resident care needs and medication management.
Findings
The facility failed to ensure sufficient smoke detectors with audible alarms in sleeping rooms, failed to admit or retain a resident requiring specialist memory care, and failed to have an effective medication management system to prevent unauthorized access to medications.
Deficiencies (3)
Facility failed to ensure sufficient smoke detectors powered by house electrical service with battery back-up that initiate an audible alarm in sleeping rooms.
Facility failed to admit or retain a resident who needs care beyond which the home is permitted to provide, specifically a resident requiring placement in a specialist memory care unit.
Facility failed to have an effective system to manage medications including storing medications under lock and key or other secure system to prevent unauthorized access at all times.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding smoke detector battery replacement, resident re-evaluation, and medication storage. | |
| Staff E | Interviewed regarding medications left in resident's bedroom. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 4, 2021
Visit Reason
The purpose of this survey was to investigate intake #GA00214429.
Complaint Details
Investigation began on 2021-06-01 and was completed on 2021-06-04. No violations were found.
Findings
No violations were cited as a result of the investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess the infection control process.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 8
Date: Mar 12, 2020
Visit Reason
The purpose of this visit was to investigate intakes #GA00203439 and #GA00203304 with an onsite visit made on 3/12/20 and the investigation completed on 3/20/20.
Complaint Details
The visit was complaint-related to investigate intakes #GA00203439 and #GA00203304. The investigation included observations, record reviews, and interviews related to staffing inadequacies and resident care concerns.
Findings
The facility failed to maintain adequate staffing ratios to meet residents' ongoing health, safety, and care needs, resulting in insufficient assistance for incontinent residents and inadequate supervision. Additional deficiencies included failure to prevent pressure ulcers, poor physical plant cleanliness, admission of residents not capable of self-preservation without proper waivers, incomplete admission agreements, insufficient resident activities, improper medication storage, and failure to follow posted meal menus.
Deficiencies (8)
Failed to staff the home above minimum on-site staff ratios to meet residents' ongoing health, safety, and care needs for 4 of 9 sampled residents.
Failed to provide sufficient staff time to prevent pressure ulcers and contractures for 1 of 9 sampled residents.
Failed to keep floors clean and in good repair; dining room floor and hallways were sticky.
Admitted and retained residents not capable of self-preservation with minimal assistance for 2 of 9 sampled residents without proper waivers.
Admission agreement did not contain a current statement of all fees and charges; included falsified family signatures and disputed balances for 1 of 9 sampled residents.
Failed to provide sufficient activities to promote physical, mental, and social well-being of residents; no activity schedule posted.
Medications were not kept in original containers with original labels intact; pill organizer found in unlocked bedroom and loose pills in medication closet.
Failed to follow posted menu; observed meals did not match posted menu.
Report Facts
Facility census: 22
Residents sampled: 9
Residents with staffing issues: 4
Residents not capable of self-preservation: 2
Balance due: 9000
Admission date: Sep 24, 2019
Admission date: Jul 26, 2012
Inspection Report
Routine
Deficiencies: 0
Date: Sep 25, 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
Complaint Investigation
Deficiencies: 0
Date: May 30, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00188723.
Complaint Details
Complaint GA00188723 was investigated and no rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 16, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 8/11/17 investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 21, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to a 4/10/17 complaint investigation.
Complaint Details
This visit was a follow-up to a complaint investigation from 4/10/17. The complaint involved failure to timely report a resident elopement. The Department received notification of the elopement and Mattie's call on 8/3/17. The issue was previously cited on 8/11/17 by another Surveyor.
Findings
The facility failed to call the local police department to report the elopement of a resident within 30 minutes of staff receiving actual knowledge, violating the Mattie's Call Act requirements. The incident involved Resident #1 who was missing on 7/29/17, with police notified late and inconsistencies found between reported times and video evidence.
Deficiencies (1)
Failure to call the local police department to report the elopement of a resident within 30 minutes as required by the Mattie's Call Act.
Report Facts
Date of incident: Jul 29, 2017
Time police dispatched: 1950
Time resident last seen by staff: 1915
Time police notified by staff: 1945
Time staff signed in: 1800
Time staff searching resident: 1820
Date Department received notification: Aug 3, 2017
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 11, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00177948 and #GA00178110 with on-site visits made on 2017-08-09 and 2017-08-10, and the investigation completed on 2017-08-11.
Complaint Details
The investigation was complaint-driven based on complaints #GA00177948 and #GA00178110. Resident #1 was found missing for approximately 6 hours after eloping from the facility. The complaint was substantiated by findings of inadequate safety measures and delayed reporting to authorities.
Findings
The facility failed to ensure appropriate and effective safety devices were used to protect residents at risk of eloping, specifically Resident #1 who eloped and was missing for several hours. The facility also failed to report the elopement to local police within 30 minutes as required by the Mattie's Call Act and failed to report the initiation and discontinuation of the call to the Department within required timeframes.
Deficiencies (2)
Failed to utilize appropriate and effective safety devices to protect residents at risk of eloping from the premises for 1 of 5 sampled residents (Resident #1).
Failed to call local police within 30 minutes of staff receiving knowledge that Resident #1 was missing and failed to report initiation and discontinuation of Mattie's call to the Department within 30 minutes.
Report Facts
Visual checks missing: No visual checks documented for Resident #1 between 5:33 p.m. and 10:00 p.m. on 7/28/17 and after 5:10 p.m. on 7/29/17.
Time missing: 6
Incident report date: Jul 29, 2017
Police notification time delay: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Reported Resident #1 missing and last seen at 7:15 p.m. and searched for resident before calling 911. | |
| Staff A | Completed needs assessment for Resident #1 and placed resident on every 30 minutes visual checks. | |
| Staff C | Facility Nurse | Arrived shortly after Resident #1 was reported missing and assisted in search. |
| JJ | Reviewed facility video footage and reported inconsistencies in staff search times. | |
| MM | Interviewed and confirmed Resident #1 eloped and was missing for 6 hours. | |
| KK | Reported prior elopement history of Resident #1 and was informed facility was secured. |
Inspection Report
Annual Inspection
Census: 12
Deficiencies: 2
Date: Apr 10, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and investigate complaints #GA00173566 and #GA00173122.
Complaint Details
The inspection included investigation of complaints #GA00173566 and #GA00173122 related to resident elopements and reporting failures.
Findings
The facility failed to provide supervision consistent with the needs of one resident who eloped from the facility, and failed to report the initiation and discontinuation of a Mattie's call to the Department within the required timeframe.
Deficiencies (2)
Facility failed to provide supervision consistent with the resident needs for 1 of 12 residents, evidenced by Resident #2 eloping from the facility.
Facility failed to report the initiation and discontinuation of a Mattie's call to the Department within 30 minutes as required.
Report Facts
Residents present: 12
Staff on duty: 2
Time to contact 911: 8
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