Inspection Reports for The Phoenix at Johnson Ferry
9 Sherwood Ln, Marietta, GA 30068, United States, GA, 30068
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Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00252084.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted following intake # GA00252084; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 9, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA002467192, with an onsite visit conducted on 7/9/2024 and the investigation completed on 8/6/2024.
Findings
The facility failed to ensure that no resident was admitted or retained who required care beyond what the home is permitted to provide, specifically for Resident #1 who required specialized catheter care and digital disimpaction for bowel movements three times weekly.
Complaint Details
Investigation was initiated based on intake # GA002467192. The complaint was substantiated as the facility admitted a resident requiring care beyond its permitted scope.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure no resident admitted or retained who needs care beyond which the home is permitted to provide, as evidenced by Resident #1 requiring digital disimpaction and suprapubic catheter irrigation three times weekly. | SS= D |
Report Facts
Resident sample size: 4
Admission date: May 25, 2024
Physician evaluation date: May 1, 2024
Frequency of catheter irrigation: 3
Frequency of digital disimpaction: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding Resident #1's care needs |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 5, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246431, with the onsite visit conducted and completed on June 5, 2024.
Findings
The facility failed to ensure that staff respected the personal dignity of residents, evidenced by Staff A making a reference to Resident #1's weight during an argument, which hurt the resident's feelings. Staff A was reprimanded for this comment.
Complaint Details
Investigation of intake #GA00246431 regarding disrespectful behavior by Staff A towards Resident #1, substantiated by interviews and record review.
Severity Breakdown
C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that each staff respects the personal dignity of the residents, specifically Staff A making a reference to Resident #1's weight during an argument. | C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240636.
Findings
There were no rule violations cited as a result of this survey.
Complaint Details
Investigation of intake #GA00240636 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 7, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237312. An onsite visit was made to the facility on 9/7/23.
Findings
The investigation was completed on 9/14/23 with no violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00237312 found no violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2023
Visit Reason
The visit was conducted to investigate complaint intakes #GA00229645, #GA00230186, and #GA00231590.
Findings
No rule violations were cited during the investigation completed on 03/03/2023.
Complaint Details
Investigation of complaint intakes #GA00229645, #GA00230186, and #GA00231590 resulted in no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 8, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00220958 and #GA00221031, with an onsite visit made on 2/8/22 and the investigation completed on 2/18/22.
Findings
The facility failed to provide medication administration services in accordance with physician's orders and resident needs for one sampled resident (Resident #1), who expired on 12/19/21. The investigation revealed that morphine medication was not administered as ordered due to communication and access issues involving agency medication technicians and hospice staff.
Complaint Details
Investigation was initiated based on complaint intakes #GA00220958 and #GA00221031. The complaint was substantiated as the facility failed to administer morphine to Resident #1 as ordered, resulting in the resident struggling during transition and dying without relief.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide medication administration services to Resident #1 in accordance with physician's orders and resident needs. | SS= D |
Report Facts
Dates of resident admission and expiration: Resident #1 admitted 2017-10-09 and expired 2021-12-19
Medication order frequency: Morphine ordered every 2 to 4 hours as needed
Investigation dates: Onsite visit 2022-02-08, investigation completed 2022-02-18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding agency medication technician and morphine administration | |
| Staff E | Resigned 2022-01-31; had access to morphine | |
| Staff H | Witnessed orientation of agency medication technicians on morphine access | |
| Staff F | Explained morphine administration procedure to agency staff | |
| EE | Agency medication technician | Did not administer morphine and was not informed about morphine location |
| AA | Witnessed morphine administration instructions and resident's struggle |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA002170055.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA002170055 found no rule violations.
Inspection Report
Original Licensing
Deficiencies: 0
Jun 11, 2021
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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