Inspection Reports for The Phoenix at Lake Lanier
2601 Thompson Bridge Rd, Gainesville, GA 30501, United States, GA, 30501
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 13, 2024, found no deficiencies. Earlier inspections showed a mixed history with some substantiated complaints related mainly to resident care and staffing issues, including concerns about dignity and respect, medication administration, and adequate staffing levels. Notable events included substantiated findings of rough handling of residents leading to staff termination and several instances of missed medications and insufficient staff training. Complaint investigations were mostly unsubstantiated in recent years, with one substantiated case in 2023 involving resident mistreatment. The trend suggests improvement in compliance, as recent inspections and complaint investigations have not identified new deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
92 residents
Based on a July 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248703.
Complaint Details
Investigation of intake #GA00248703 with no violations cited.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246280.
Complaint Details
Investigation of complaint #GA00246280 with no rule violations found.
Findings
No rule violations were cited during the onsite visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246280.
Complaint Details
Investigation of complaint #GA00246280 with no rule violations found.
Findings
No rule violations were cited during the onsite visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246280 with an onsite visit conducted on 5/23/24.
Complaint Details
Investigation of complaint #GA00246280; no violations found.
Findings
No rule violations were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246280.
Complaint Details
Investigation of complaint #GA00246280 with no rule violations cited.
Findings
The onsite visit found no rule violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
The visit was conducted to investigate intake #GA00244882 with an onsite visit on 2024-04-03 and the investigation completed on 2024-04-04.
Complaint Details
Investigation of intake #GA00244882 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
The purpose of this offsite/desk review was to investigate intake #GA00243762.
Complaint Details
Investigation of intake #GA00243762 with no rule violations cited.
Findings
No rule violations were cited as a result of this review.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to ensure residents were treated with dignity and respect; Staff B grabbed Resident #2 and Resident #3 roughly by the arm and wrist causing discoloration.
Report Facts
Complaint identifiers: 3
Incident date: Jun 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings for rough handling and termination | |
| Staff A | Interviewed and informed of findings | |
| Staff C | Observed Staff B grabbing residents during rounds |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00230113 during an onsite visit on 3/1/2023.
Complaint Details
Investigation of complaint #GA00230113 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00226864.
Complaint Details
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.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 3, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216720.
Complaint Details
Investigation of intake #GA00216720 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 2, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to immediately take action and notify representative or legal surrogate in case of accident or sudden adverse change in resident's condition for Resident #1.
Report Facts
Dates of investigation: 3
Incident date: Jun 21, 2021
Physical exam date: Jan 25, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Noticed bruises and pain in Resident #1 during morning care | |
| Staff H | Documented bruising of Resident #1 on 6/18/21 | |
| Staff G | Noted bruises on Resident #1 during personal care | |
| Staff J | Reported mobile x-ray for Resident #1 | |
| Staff K | Notified hospice case manager and contacted medical director regarding Resident #1 | |
| Staff A | Acknowledged the finding during interview on 9/2/21 | |
| Staff B | Interviewed regarding lack of knowledge about Resident #1's injury | |
| AA | Interviewed about Resident #1's condition and staff awareness | |
| BB | Interviewed expressing concern about Resident #1's injury | |
| CC | Interviewed about Resident #1's bruising and fall |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Date: Jul 26, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to ensure direct access employees had required criminal background check upon employment or prior to placement for 1 of 10 sampled staff (Staff J).
Failed to ensure staff providing hands-on personal services had minimum sixteen hours of job-related continuing education annually for 1 of 10 staff (Staff F).
Failed to ensure sufficient staff time so that each resident received services, treatments, medications, and diet as prescribed for 5 of 11 residents.
Failed to ensure initial staff training within first six months of employment on dementia care topics for 2 of 9 staff (Staff D and Staff F).
Report Facts
Resident census: 92
Memory care residents: 33
Residents with insufficient services: 5
Staff sampled: 10
Staff lacking required continuing education hours: 1
Staff lacking initial dementia care training: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Failed to have required criminal background check upon employment | |
| Staff F | Had insufficient continuing education hours and lacked initial dementia care training | |
| Staff D | Lacked initial dementia care training | |
| Staff A | Interviewed regarding background check and staffing issues | |
| AA | Family member reporting staffing shortages and resident neglect | |
| BB | Family member reporting medication omissions and staffing issues | |
| CC | Reported insufficient night staffing and missed resident care | |
| GG | Reported multiple incidents of missed medications due to staffing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 8, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00212172, with the investigation starting on 2021-03-01 and completing on 2021-03-08.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to keep an inventory of valuable personal items brought to the assisted living community for residents #2, #3, and #4.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 15, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00209362 and GA00209483, opened on 2020-11-17 and completed on 2020-12-15.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure refills of prescribed medications were obtained timely, causing missed doses of Trazodone 50 mg for Resident #1 on 10/22/2020, 10/23/2020, and 10/24/2020.
Failed to ensure each resident and resident's representative have the right to inspect his or her record on request for Resident #1.
Report Facts
Missed medication doses: 3
Resident sample size: 3
Emergency contacts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding missed medication doses for Resident #1 | |
| Staff B | Interviewed regarding medication ordering and corrective actions for Resident #1 | |
| Staff A | Involved in record request handling for Resident #2; did not submit request for incident report | |
| Staff D | Interviewed regarding proper submission of record requests for Resident #2 | |
| AA | Family member of Resident #2 who requested incident report multiple times |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 11, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207034, which involved allegations of staff to resident abuse at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure of the governing body to provide oversight ensuring compliance with licensing and state laws.
Failure to ensure staff completed memory care training within six months of employment for Staff B.
Failure to ensure Resident #1 was free from verbal and physical abuse by Staff B.
Report Facts
Dates of incidents: Jul 13, 2020
Dates of incidents: Jul 23, 2020
Dates of investigation: Aug 14, 2020
Dates of investigation: Sep 11, 2020
Staff B hire date: Jan 20, 2020
Resident #1 admission date: Nov 4, 2019
Number of sampled staff: 7
Number of sampled residents: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to resident abuse and failure to complete memory care training; terminated for abuse. | |
| Staff C | Witnessed incident between Staff B and Resident #1 and provided interview statements. | |
| Staff D | Witnessed incident and provided interview statements regarding Resident #1's bruise and incident details. | |
| Staff E | Witnessed incident and provided interview statements about Staff B and Resident #1 altercation. | |
| Staff G | Aware of the incident and findings; provided interview statements. | |
| Staff A | Reported knowledge of the incident and Staff B's admission of throwing water and grabbing Resident #1. | |
| BB | Family member or representative notified about Resident #1's bruise and incident. |
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review was to monitor COVID 19 cases and assess infection control processes.
Findings
The report focused on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2020
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 7/15/19 investigation.
Findings
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.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 8
Date: Nov 1, 2019
Visit Reason
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.
Complaint Details
The inspection was conducted to investigate complaint #GA00199656. The complaint investigation revealed multiple deficiencies including staffing shortages, medication errors, and inadequate resident care.
Findings
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.
Deficiencies (8)
Failed to ensure staff received tuberculosis screening and physical examination within 12 months for 2 of 8 staff sampled.
Failed to maintain minimum on-site staff to resident ratio to meet residents' ongoing health, safety, and care needs.
Failed to provide sufficient staff time to ensure residents were kept comfortable and clean for 2 of 8 residents sampled.
Failed to comply with applicable fire and safety rules including conducting fire drills once per quarter on each shift at alternating times.
Failed to have sufficient staff on duty at all times to meet the needs of residents for 4 of 8 sampled residents.
Failed to update Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 8 residents sampled.
Failed to obtain new prescriptions within 48 hours of receipt of notice for 2 of 8 sampled residents.
Failed to ensure residents' private living spaces were cleaned as needed to prevent health hazards for 5 of 11 residents.
Report Facts
Residents: 97
Residents incapable of self preservation: 10
Residents requiring two person assist: 5
Staff on duty 11:45 p.m. to 4:30 a.m. on 9/29/19: 3
Staff scheduled 11:00 p.m. to 7:00 a.m. shift on multiple dates: 3
Staff scheduled 11:00 p.m. to 7:00 a.m. shift on 9/8/19, 9/22/19, 9/29/19: 2
Staff scheduled 11:00 p.m. to 7:00 a.m. shift on 9/1/19: 1
Fire drills conducted in 2019: 9
Residents participating in fire drill on 9/13/18: 28
Residents participating in fire drill on 9/17/19: 33
Residents participating in fire drill on 9/12/19: full building evacuation
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged findings related to staff health exams and fire safety compliance | |
| Staff F | Named in findings related to missing TB screening and insufficient staffing during resident care | |
| Staff H | Named in findings related to missing TB screening | |
| Staff B | Involved in medication order handling and found to have prescription order in office | |
| Staff J | Wellness Director (acting) | Investigated missing medication order and ensured medication delivery |
| Staff D | Reported responsibility for medication ordering and noted agitation when medications were unavailable | |
| GG | Reported staffing shortages and resident care concerns | |
| DD | Reported need for more help in memory care and resident care challenges | |
| EE | Reported staffing and housekeeping issues | |
| FF | Reported observations of resident care delays and staffing shortages |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 15, 2019
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Facility failed to maintain awareness of Resident #1's normal appearance and intervene when health was in jeopardy.
Facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping.
Facility failed to provide adequate, appropriate care and services in compliance with state law for Resident #1.
Report Facts
Dates of elopement: Resident #1 eloped on 2019-05-13 and 2019-05-14.
Temperature: 48
Duration missing: 30
Hospital stay: 7
Number of times Resident #1 was up the night of elopement: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Documented Resident #1's confusion and elopement attempts; stated room check frequency. | |
| Staff C | Reported noticing Resident #1's strange behavior and initiated search during elopement. | |
| Staff A | Reviewed security camera footage showing Resident #1's elopement. | |
| AA | Family member who reported Resident #1's condition and incidents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 5, 2019
Visit Reason
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.
Complaint Details
The visit was complaint-related, investigating intake # GA00193349. Violations cited related to this intake were listed in the report.
Findings
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.
Deficiencies (1)
Failure to treat Resident #3 with dignity, kindness, consideration, and respect, including forcibly pushing the resident in a wheelchair.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 5/30/18 inspection and to investigate intake #GA00193349.
Complaint Details
Investigation of intake #GA00193349 was conducted during this visit.
Findings
No violations were cited as a result of the 5/30/18 follow-up inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 31, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00190131 regarding the care and safety of Resident #1 at the facility.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to update the care plan at least annually or more frequently where the needs of the resident changed substantially for Resident #1.
Failure to provide adequate and appropriate care and services in compliance with state law, evidenced by Resident #1 eloping from the facility and staff failing to perform required safety rounds.
Report Facts
Date of incident: Jul 17, 2018
Time resident found: 948
Time resident went missing: 830
Date of survey completion: Jul 31, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Reviewed security camera footage and reported Resident #1 left the building around 9:00 p.m. on 7/17/18. | |
| Staff F | On duty on 7/17/18 morning shift; initiated search for Resident #1 and notified family and law enforcement. | |
| Staff C | Corrective action plan for failure to ensure resident safety through rounding; failed to check Resident #1's room. | |
| Staff E | Corrective action plan for failure to ensure resident safety through rounding; failed to check Resident #1. | |
| Staff D | Corrective action plan for failure to ensure resident safety through rounding; failed to check Resident #1 every two hour checks. | |
| Staff A | Reported staff sightings of Resident #1 at night were later found to be untrue. | |
| AA | Interviewed regarding Resident #1's wandering behavior and care needs. |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 4
Date: May 30, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00188425, which began on 2018-05-14 and ended on 2018-05-30.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to staff above minimum on-site staff to resident ratio to meet residents' ongoing health, safety and care needs.
Failed to provide sufficient staff time such that each resident receives services, treatments, medications and diet as prescribed for 9 of 13 sampled residents.
Failed to provide medication administration services in accordance with physician's orders for 3 of 9 sampled residents.
Failed to notify resident's next of kin/legal representative related to a change in the resident's condition for 3 of 14 sampled residents.
Report Facts
Residents present during inspection: 106
Resident call response times (minutes): 11.2
Resident call response times (minutes): 24.6
Resident call response times (minutes): 28.5
Resident call response times (minutes): 13.5
Resident call response times (minutes): 14.6
Resident call response times (minutes): 53.1
Resident call response times (minutes): 82.2
Medication administration missing documentation: 5
Medication administration duration: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Technician | Named in staffing deficiency and medication administration findings; usually assigned one hall. |
| Staff D | Medication Technician | Named in staffing deficiency for memory care hall. |
| Staff E | Caregiver | Caregiver for 300 hall with residents incapable of self-preservation. |
| Staff F | Caregiver | Caregiver for 200 hall. |
| Staff G | Caregiver | Caregiver for 100 hall with residents incapable of self-preservation. |
| Staff H | Caregiver | Caregiver for 100 hall with residents incapable of self-preservation. |
| Staff I | Caregiver | Caregiver in memory care with residents incapable of self-preservation. |
| Staff J | Caregiver | Caregiver in memory care with residents incapable of self-preservation. |
| Staff L | Signed in at 6:58 a.m. on 5/6/18; mentioned in staffing review. | |
| Staff B | Stated goal to respond to call lights in under 10 minutes. | |
| BB | Interviewed regarding staffing concerns and medication administration delays. | |
| AA | Interviewed regarding staffing shortages and delayed responses to resident calls. | |
| EE | Interviewed regarding delayed staff response times to call lights. |
Inspection Report
Original Licensing
Deficiencies: 4
Date: Apr 26, 2018
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failed to provide medication administration services according to physician's orders for 3 of 13 sampled residents (Residents #1, #3, and #10).
Failed to maintain daily Medication Assistance Records (MAR) accurately for 2 of 13 residents (Residents #10 and #13).
Failed to immediately take appropriate actions for a sudden adverse change in Resident #2's condition and failed to document the incident properly.
Failed to report a serious injury requiring medical attention to the Department within 24 hours for Resident #13.
Report Facts
Residents sampled: 13
Medications not given per physician orders: 3
Dates with missing MAR entries: 10
Incident date: Mar 1, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Interviewed regarding Resident #3's medication discontinuation | |
| Staff A | Interviewed about medication training and MAR updates | |
| Staff C | Interviewed about reporting serious injury incident for Resident #13 | |
| Staff E | Documented skin tear on Resident #2's leg | |
| Staff F | Interviewed about dressing on Resident #2's leg | |
| Staff G | Interviewed about dressing on Resident #2's leg | |
| Staff H | Sent incident report email regarding Resident #2 | |
| Staff I | Completed incident report regarding Resident #2 | |
| Staff AA | Interviewed about Resident #2's wound and condition | |
| Staff DD | Interviewed about discovery of Resident #2's wound | |
| Staff EE | Interviewed about medication administration timing for Resident #10 | |
| Staff CC | Interviewed about medication counts for Resident #3 |
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