The most recent inspection on August 31, 2023, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed record, with some deficiencies related to safety devices on exit doors, resident care documentation, and staff competency evaluations. Prior reports also noted issues with medication management, failure to report a serious injury, and one substantiated complaint of verbal abuse that led to staff termination. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean inspection suggests some improvement compared to earlier findings.
Deficiencies (last 6 years)
Deficiencies (over 6 years)1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00216532, with an on-site visit made on 8/25/21 and the investigation completed on 9/2/21.
Findings
The home did not have operable safety devices on six exterior exit doors to protect residents at risk of eloping. A review of Resident #3's file showed a diagnosis of memory loss, and staff were unaware that the safety devices were not operable but stated they would be repaired immediately.
Complaint Details
Investigation was conducted based on intake #GA00216532.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
The home did not have operable safety devices on six exterior exit doors to protect residents at risk of eloping.
SS= D
Report Facts
Number of exterior doors without operable safety devices: 6
Employees Mentioned
Name
Title
Context
Staff A
Interviewed and stated unawareness of non-operable safety devices and commitment to immediate repair.
The purpose of this visit was to conduct the compliance inspection.
Findings
The facility failed to implement policies supporting resident dignity and safety, including lack of volunteer files and TB screening. Medication refills were not timely for one resident, resulting in missed doses. Resident files lacked inventories of personal items, and a serious injury to a resident requiring medical treatment was not reported to the Department.
Severity Breakdown
SS= D: 4
Deficiencies (4)
Description
Severity
Governing body failed to implement policies ensuring volunteer files and TB screening.
SS= D
Refills of prescribed medications were not obtained timely, causing interruption in routine dosing for one resident.
SS= D
Resident file lacked documentation of an inventory of personal items brought to the facility.
SS= D
Facility failed to report a serious injury to a resident that required medical treatment.
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The facility failed to maintain compliance with Life Safety Code fire regulations, did not retain only ambulatory residents capable of self-preservation, lacked operable safety devices on exit doors for residents at risk of eloping, and failed to provide evidence of routine evaluations of staff skills competencies.
Severity Breakdown
D: 3E: 1
Deficiencies (4)
Description
Severity
Failed to maintain compliance with Life Safety Code fire regulations requiring six fire drills per year with two during sleeping hours; residents were not evacuated out of the building during drills.
D
Facility admitted and retained two residents who were not ambulatory or capable of self-preservation with minimal assistance.
E
Failed to have operable safety devices on exit doors to protect residents at risk of eloping.
D
Failed to provide evidence of routine evaluations of continued skills competencies by a licensed healthcare professional for 1 of 4 staff.
D
Report Facts
Fire drills required: 6Residents not ambulatory: 2Staff sample size: 4Staff without recent competency evaluation: 1
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding fire drills and resident self-preservation capability
Staff B
Interviewed regarding exit door alarms and staff competency evaluations
Staff D
Staff member lacking recent skills competency evaluation
The purpose of this visit was to investigate complaints GA00173683 and GA00173617 regarding alleged verbal abuse of a resident.
Findings
No rule violations were cited as a result of this inspection, although the facility failed to ensure all residents were free from abuse for 1 of 2 sampled residents. An internal investigation was conducted and the staff involved was terminated.
Complaint Details
The visit was complaint-related to investigate allegations of verbal abuse by a staff member towards Resident #1 on 4/6/17. The complaint was substantiated by documentation and staff interviews. The staff involved was terminated on 4/11/17.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure that all residents were free from abuse, neglect and/or exploitation for 1 of 2 sample residents (#1) based on verbal abuse allegations.