Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2023
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00237736.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted following intake #GA00237736; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 25, 2021
Visit Reason
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. |
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
Routine
Deficiencies: 4
Aug 13, 2019
Visit Reason
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. | SS= D |
Report Facts
Sampled residents: 5
Missed medication dose: 1
Incident date: Apr 17, 2019
Stitches: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding volunteer files, personal inventory list, and injury reporting | |
| Staff D | Interviewed regarding medication refill and missed dose for Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00188347.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint GA00188347 was investigated and found to have no rule violations.
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 24, 2017
Visit Reason
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: 3
E: 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: 6
Residents not ambulatory: 2
Staff sample size: 4
Staff 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 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 17, 2017
Visit Reason
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. | D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 28, 2017
Visit Reason
The purpose of this visit was to investigate complaints GA00172853 and GA00173218.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaints GA00172853 and GA00173218 resulted in no rule violations.
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