Inspection Report
Complaint Investigation
Deficiencies: 1
May 28, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00245559, with an onsite visit made on 5/28/24 and the investigation completed on 6/14/24.
Findings
The facility failed to ensure that residents received adequate and appropriate care and services in compliance with state law, specifically related to the emergency call light system not being properly answered or reset, affecting 2 of 5 sampled residents. Issues included call lights not being answered timely, system outages, and reliance on staff personal phones due to equipment backorders.
Complaint Details
Investigation was complaint-related for intake # GA00245559. Substantiation status is not explicitly stated.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate and appropriate care and services in compliance with state law, evidenced by call lights not being answered timely and residents left without assistance. | Level D |
Report Facts
Sampled residents: 5
Residents affected: 2
Dates of onsite visit and investigation completion: Onsite visit on 2024-05-28 and investigation completed on 2024-06-14
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244839.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00244839 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2024
Visit Reason
The purpose of this visit was to investigate complaint #GA00244363.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted onsite on 2024-03-12 and completed on 2024-03-14. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240851.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00240851; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 8, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237290 with an onsite visit made to the facility on 09/08/2023.
Findings
The investigation was completed on 09/08/2023 and no violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00237290; no violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00234571.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00234571; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00229491.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00229491 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2022
Visit Reason
The visit was conducted to investigate intake #GA00219002, with the onsite visit occurring on 2022-03-21 and the investigation completed on 2022-04-18.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation intake #GA00219002 was initiated on 2022-02-04, with an onsite visit on 2022-03-21 and completed on 2022-04-18. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 6, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA0022049.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2022-04-06, onsite visit made on 2022-04-06, and investigation completed on 2022-04-08.
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 8, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00221797 and #GA00221774, with an onsite visit made on 3/8/22 and investigation completed on 3/29/22.
Findings
The facility failed to provide medication administration services in accordance with physician's orders and the needs of Resident #5, including failure to maintain medication supply and failure to notify the physician or obtain timely refills, resulting in interruption of prescribed medication. The resident experienced pain due to lack of Morphine Sulfate 15 mg extended release tablets and the facility did not call hospice for a refill as required.
Complaint Details
The investigation was triggered by complaint intakes #GA00221797 and #GA00221774. The complaint was substantiated based on observations, record reviews, and interviews indicating medication administration failures and lack of timely medication refills for Resident #5.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide medication administration services in accordance with physician's orders and resident needs for Resident #5. | D |
| Failed to notify physician of unavailability of prescription, request direction, and ensure timely refills to avoid interruption in routine dosing for Resident #5. | E |
Report Facts
Dates of medication administration irregularities: 8
Previous citation date: Jul 7, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding medication orders and MAR notation explanations. | |
| Staff G | Interviewed regarding failure to fax refill request to hospice and medication unavailability. | |
| GG | Interviewed regarding medication supply, nurse visits, and refill procedures. | |
| FF | Interviewed regarding medication refills done by facility and hospice. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 4, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00221405, with an onsite visit made on 2022-02-23 and inspection completed on 2022-03-04.
Findings
The facility failed to have a licensed administrator as required by the State Board of Long-Term Care Facility Administrators and failed to ensure cardiopulmonary resuscitation (CPR) was initiated when a resident became unresponsive, resulting in the resident's death without CPR being performed.
Complaint Details
Investigation of intake #GA00221405 regarding failure to initiate CPR for Resident #1 who was found non-responsive and later pronounced deceased. Resident #1 was full code status but CPR was not administered by staff.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to have an administrator licensed by the State Board of Long-Term Care Facility Administrators. | D |
| Facility failed to ensure cardiopulmonary resuscitation was initiated when a resident became unresponsive. | D |
Report Facts
Number of sampled residents: 3
Resident admission date: Jan 24, 2021
Staff hire date: May 9, 2018
CPR/First aid certification expiration year: 2023
Response time by EMS: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Observed as administrator without valid license |
| Staff E | Discovered Resident #1 non-responsive, did not perform CPR | |
| Staff B | Reported Staff E wheeled Resident #1 back to room and called EMS | |
| Staff F | Witnessed discovery of Resident #1 expired, did not witness CPR | |
| AA | Stated Resident #1 was full code status and discussed code status at admission |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220689.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00220689 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 7, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00205367.
Findings
The facility failed to ensure timely refills of prescribed medications for Resident #4, resulting in interruptions in routine dosing. Three medications were missing from the medication cart despite being listed on the Medication Assistance Record, with some medications unavailable since June and July 2021.
Complaint Details
The visit was complaint-related, investigating intake #GA00205367. Staff reported difficulty contacting the responsible party (AB) who had a stroke, and issues with contacting the resident's physician and insurance. No documentation was available regarding communication attempts.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure refills of prescribed medications in a timely manner so that there is no interruption in the routine dosing for Resident #4. | SS= D |
Report Facts
Medications missing: 3
Medication unavailability duration: 6
Medication unavailability duration: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Reported attempts to contact responsible party and physician regarding medication procurement. | |
| Staff E | Stated they would ensure medications are obtained. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 16, 2020
Visit Reason
The purpose of this inspection is to investigate intake #GA0020537. The inspection was started on 2020-06-04 and completed on 2020-06-16.
Findings
No specific findings or deficiencies are detailed in the provided report excerpt.
Complaint Details
Inspection was conducted to investigate complaint intake #GA0020537.
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 measures.
Inspection Report
Original Licensing
Deficiencies: 0
Feb 25, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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