Inspection Reports for The Phoenix at Lake Lanier

The purpose of this visit was to investigate intake #GA00248703.

No violations were cited as a result of this survey.

Investigation of intake #GA00248703 with no violations cited.

The purpose of this survey was to investigate complaint #GA00246280.

No rule violations were cited during the onsite visit.

Investigation of complaint #GA00246280 with no rule violations found.

The purpose of this survey was to investigate complaint #GA00246280.

No rule violations were cited during the onsite visit.

Investigation of complaint #GA00246280 with no rule violations found.

The purpose of this survey was to investigate complaint #GA00246280 with an onsite visit conducted on 5/23/24.

No rule violations were cited during the investigation.

Investigation of complaint #GA00246280; no violations found.

The purpose of this survey was to investigate complaint #GA00246280.

The onsite visit found no rule violations were cited.

Investigation of complaint #GA00246280 with no rule violations cited.

The visit was conducted to investigate intake #GA00244882 with an onsite visit on 2024-04-03 and the investigation completed on 2024-04-04.

No rule violations were cited as a result of this investigation.

Investigation of intake #GA00244882 found no rule violations.

The purpose of this offsite/desk review was to investigate intake #GA00243762.

No rule violations were cited as a result of this review.

Investigation of intake #GA00243762 with no rule violations cited.

The purpose of this survey was to investigate complaints #GA00235403, GA00236179, and GA00236166, with the onsite visit conducted on 7/26/2023 and investigation completed on 8/16/2023.

The facility failed to ensure that two of three sampled residents were treated with dignity and respect, as Staff B was observed grabbing residents roughly by the arm and wrist, resulting in discoloration and subsequent termination of Staff B.

Investigation was complaint-related based on complaints #GA00235403, GA00236179, and GA00236166. Staff B was terminated due to rough handling of residents. The complaint was substantiated by interviews and record review.

The purpose of this survey was to investigate complaint #GA00230113 during an onsite visit on 3/1/2023.

No rule violations were cited as a result of this investigation.

Investigation of complaint #GA00230113 found no rule violations.

The purpose of this visit was to investigate intake #GA00226864.

No rule violations were cited as a result of this investigation.

Investigation began on 2022-11-03, an onsite visit was made on 2022-11-08, and the investigation was completed on 2022-11-09. No rule violations were found.

The purpose of this visit was to investigate intake #GA00216720.

No rule violations were cited as a result of this investigation.

Investigation of intake #GA00216720 with no rule violations found.

The purpose of this visit was to investigate intake #GA00215509, which began on 2021-07-13 with an onsite visit on 2021-07-20 and completed on 2021-09-02.

The facility failed to immediately take appropriate action and notify the representative or legal surrogate in response to an accident or sudden adverse change in condition for one resident. Resident #1 sustained multiple bruises and a displaced comminuted right proximal femoral fracture with no documented fall or explanation, and staff interviews revealed lack of knowledge about the incident.

Investigation of intake #GA00215509 regarding unexplained bruising and injury to Resident #1. The complaint was substantiated as the facility failed to properly respond to the resident's adverse condition and document appropriately.

The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00214047, #GA00214004, #GA00213968, and #GA00213832 with onsite visits on 5/25/21, 7/20/21, and completion on 7/26/21.

The facility failed to ensure required criminal background checks for direct access employees, adequate ongoing staff training, sufficient staffing to provide prescribed services and medications to residents, and initial staff training on dementia care topics. Multiple residents did not receive medications due to staffing shortages, and some staff lacked required training hours and dementia-specific education.

The inspection was conducted in response to complaint intakes #GA00214047, #GA00214004, #GA00213968, and #GA00213832. Findings included substantiated issues with staffing shortages leading to missed medications and inadequate care, lack of required staff training, and failure to complete criminal background checks.

The purpose of this visit was to investigate intake #GA00212172, with the investigation starting on 2021-03-01 and completing on 2021-03-08.

The facility failed to keep an updated inventory of valuable personal items for 3 of 6 sampled residents (Residents #2, #3, and #4). Resident files lacked documentation of personal belongings inventories, and staff acknowledged the deficiency.

Investigation of intake #GA00212172 was conducted from 3/1/21 to 3/8/21 regarding missing inventories of personal belongings for residents #2, #3, and #4.

The purpose of this inspection was to investigate complaint intakes #GA00209362 and GA00209483, opened on 2020-11-17 and completed on 2020-12-15.

The facility failed to ensure timely refills of prescribed medications for one resident, resulting in missed doses of Trazodone on three consecutive days. Additionally, the facility failed to ensure that a resident and their representative were provided access to inspect the resident's records upon request.

The inspection was complaint-related, investigating two intakes (#GA00209362 and GA00209483). The medication refill issue involved Resident #1 missing doses due to delayed pharmacy delivery and lack of follow-up by medication aides. The record access issue involved Resident #2's family requesting incident reports multiple times without receiving them, due to failure of staff to submit the request properly.

The purpose of this visit was to investigate intake #GA00207034, which involved allegations of staff to resident abuse at the facility.

The investigation found that Staff B threw water on Resident #1 and grabbed the resident's shirt collar to escort him/her forcefully to his/her room after an altercation. Staff B was terminated for violating the resident abuse policy. The facility also failed to ensure staff completed required memory care training within six months of employment.

The complaint investigation was initiated due to allegations of staff to resident abuse involving Staff B and Resident #1. The investigation confirmed that Staff B threw water on Resident #1 and grabbed the resident's shirt collar to escort him/her forcefully to his/her room. Staff B was terminated and the incident was reported to law enforcement.

The purpose of this review was to monitor COVID 19 cases and assess infection control processes.

The report focused on monitoring COVID-19 cases and evaluating the facility's infection control procedures.

The purpose of this visit was to conduct a follow-up inspection to the 7/15/19 investigation.

An onsite visit was made on 1/9/20 and the inspection was completed on 1/10/20. No rule violations were cited as a result of this inspection.

The purpose of this visit was to conduct a compliance inspection and to investigate complaint #GA00199656 with onsite visits on 9/30/19 and 10/7/19, completed on 11/1/19.

The facility was found deficient in multiple areas including failure to ensure staff health screenings, inadequate staffing levels to meet resident needs, insufficient staff time to keep residents comfortable and clean, failure to comply with fire safety drill requirements, medication administration and procurement issues, and failure to maintain clean resident living spaces.

The inspection was conducted to investigate complaint #GA00199656. The complaint investigation revealed multiple deficiencies including staffing shortages, medication errors, and inadequate resident care.

The purpose of this visit was to investigate complaint #GA00197168, with an on-site visit made on 2019-06-17 and the investigation completed on 2019-07-15.

The facility failed to maintain awareness of a resident's normal appearance and intervene appropriately, resulting in Resident #1 eloping twice, sustaining injuries including a fractured wrist and ribs, and being hospitalized multiple times. The facility also failed to utilize effective safety devices such as door alarms to prevent elopement and did not provide adequate care and services in compliance with state regulations for Resident #1.

The investigation was complaint-driven based on complaint #GA00197168. Resident #1 was found missing after elopement, was located by law enforcement, and had multiple health issues including confusion, UTI, hyponatremia, and injuries from falls. The complaint was substantiated by findings of inadequate supervision, lack of safety devices, and insufficient care.

The purpose of this visit was to investigate intake # GA00193349 and to conduct a follow-up to the 5/30/19 investigation related to the same intake.

The facility failed to ensure that Resident #3 was treated with dignity, kindness, consideration, and respect. Staff C was observed pushing Resident #3 in a wheelchair against the resident's will, violating residents' rights.

The visit was complaint-related, investigating intake # GA00193349. Violations cited related to this intake were listed in the report.

The purpose of this visit was to conduct a follow-up to the 5/30/18 inspection and to investigate intake #GA00193349.

No violations were cited as a result of the 5/30/18 follow-up inspection.

Investigation of intake #GA00193349 was conducted during this visit.

The purpose of this visit was to investigate complaint #GA00190131 regarding the care and safety of Resident #1 at the facility.

The facility failed to update the care plan annually or more frequently for Resident #1 despite substantial changes in needs, and failed to ensure adequate care and safety, as Resident #1 eloped from the facility and was found outside without injury. Multiple staff failed to perform required safety rounds.

The complaint investigation was substantiated by findings that Resident #1 eloped from the facility on 7/17/18, was found outside in the woods, and that staff failed to perform required safety rounds. Corrective action plans were documented for multiple staff members who failed to check Resident #1 as required.

The purpose of this visit was to investigate complaint #GA00188425, which began on 2018-05-14 and ended on 2018-05-30.

The facility failed to maintain adequate staffing ratios to meet residents' health and safety needs, resulting in delayed responses to call lights and insufficient medication administration. Additionally, the facility failed to notify residents' representatives of changes in condition and did not provide medication administration according to physician orders for several residents.

The complaint #GA00188425 was investigated from 2018-05-14 to 2018-05-30. The complaint involved staffing shortages, delayed response to resident calls, medication administration errors, and failure to notify family members of changes in residents' conditions.

The purpose of this visit was to conduct an initial inspection and to investigate complaint numbers GA00186710, GA00187064, GA00187063, and GA00187430, with on-site visits on 4/3/18, 4/4/18, and 4/19/18, completed on 4/26/18.

The facility failed to provide medication administration services according to physician's orders for 3 of 13 sampled residents, failed to maintain accurate medication assistance records for 2 residents, failed to take appropriate action for a resident's sudden adverse condition, and failed to report a serious injury to the Department within 24 hours for 1 resident.

The inspection included investigation of complaints GA00186710, GA00187064, GA00187063, and GA00187430. Findings included medication errors, record-keeping deficiencies, failure to respond appropriately to a resident's adverse condition, and failure to report a serious injury.