Inspection Reports for The Retreat at Buford
3177 GRAVEL SPRINGS ROAD, BUFORD, GA, 30519
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 17, 2021, found no deficiencies. Earlier inspections showed a mix of results, with some citations related to resident care, facility maintenance, and sanitation issues. Inspectors noted problems such as failure to provide adequate care and monitoring for residents, maintenance issues like inoperable bathroom fixtures and stained carpets, and lapses in cleaning and sanitizing kitchen and bathroom areas. Complaint investigations were mostly unsubstantiated, except for a few substantiated cases involving resident neglect and admission of residents not meeting ambulatory requirements. The inspection history shows some improvement over time, with the latest reports indicating compliance after previous deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216645, which was started on 2021-11-16 and completed on 2021-11-17.
Complaint Details
Investigation of intake #GA00216645 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 4, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 29, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214462 and conduct the compliance inspection. The inspection started on 2021-06-01 and was completed on 2021-06-29 with onsite visits on 2021-06-08 and 2021-06-29.
Complaint Details
Investigation of intake #GA00214462; the inspection was complaint-related.
Findings
The facility failed to maintain bathroom fixtures in good working order, keep floors clean, and sanitize kitchen and bathroom areas daily. Specific deficiencies included an inoperable bathroom light, dirty floors with dust and debris, and unsanitary bathroom and kitchen conditions with feces-like substances and soiled items.
Deficiencies (3)
Bathroom light inoperable in Resident #4's bathroom due to blown light bulb.
Resident #2's bedroom floor had loose white dirt-like particles and dust balls.
Kitchen and bathroom areas not sanitized daily; presence of hair-like substances, soiled adult diaper, feces-like substances, and soiled toilet paper in Resident #3's bathroom and kitchen sink.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding blown light bulb in Resident #4's bathroom. | ||
| Staff D interviewed regarding cleanliness of Resident #2's bedroom floor. | ||
| Staff A and Staff C interviewed regarding cleaning schedules and sanitation issues. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 17, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210706, which started on 2021-02-08 and was completed on 2021-02-17.
Complaint Details
Investigation was initiated due to intake #GA00210706. Findings included failure to notify the physician and family of low blood pressure readings for Resident #1, and failure to prevent neglect resulting in skin breakdown and poor hygiene. Resident #1 was hospitalized with critical conditions including acute kidney injury, atrial fibrillation, COVID-19, dehydration, elevated INR, sepsis, and hypoxia.
Findings
The facility failed to ensure adequate and appropriate care for Resident #1, including failure to notify the doctor and family of low blood pressure readings and failure to prevent neglect such as skin breakdown and poor hygiene, leading to the resident's hospitalization with life-threatening conditions.
Deficiencies (2)
Facility failed to ensure each resident received adequate care and services in compliance with federal and state regulations, specifically for Resident #1 regarding blood pressure monitoring and notification.
Facility failed to ensure Resident #1 was free from neglect, including failure to report skin breakdown and provide adequate assistance with hygiene and toileting.
Report Facts
Blood pressure readings: 7
Critical INR level: 10
Resident admission date: Jul 13, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed on 2/17/21 regarding blood pressure monitoring and neglect findings for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
The purpose of this inspection was to investigate intakes #GA00205711 and GA00205811, started on 2020-06-16 and completed on 2020-07-23.
Complaint Details
Inspection was complaint-related, investigating two intakes (#GA00205711 and GA00205811). No violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 9, 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 measures.
Inspection Report
Deficiencies: 3
Date: Mar 11, 2020
Visit Reason
The purpose of this visit was to conduct a change of owner inspection and investigate intake #GA00203423.
Complaint Details
Investigation included intake #GA00203423 related to resident care and safety concerns.
Findings
The facility was found to have deficiencies including failure to keep floors in good repair with stained carpet in the memory care unit, failure to obtain timely medication refills resulting in interruption of medication for one resident, and failure to ensure adequate care and monitoring for a resident with multiple falls and unexplained bruises.
Deficiencies (3)
Facility failed to keep floors in good repair; carpet in halls and common area of memory care unit was stained.
Facility failed to ensure timely procurement of prescribed medication (Nystatin Ointment) resulting in interruption of routine dosing for Resident #2.
Facility failed to ensure adequate, appropriate care and monitoring for Resident #1 with history of falls and unexplained bruises; lack of documentation of safety monitoring and service plan adherence.
Report Facts
Medication interruption days: 5
Resident falls: 5
Inspection date: Mar 11, 2020
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00196914.
Complaint Details
Investigation of intake #GA00196914 with no rules violations cited.
Findings
No rules violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Jan 31, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection conducted on 1/30/19 and 1/31/19.
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 3
Date: May 14, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00188409.
Complaint Details
The visit was complaint-related, investigating complaint #GA00188409.
Findings
The facility failed to provide a wheelchair-accessible bathroom for one wheelchair-dependent resident and did not keep the physical plant in good repair. Additionally, the facility admitted and retained residents who were not ambulatory or capable of self-preservation with minimal assistance, contrary to admission requirements.
Deficiencies (3)
Failed to provide at least one wheelchair-accessible bathroom for 1 of 8 wheelchair-dependent residents.
Failed to keep floors, walls, and ceilings in good repair; ceiling and walls in Resident #8's room were damaged.
Failed to admit and retain only ambulatory residents capable of self-preservation with minimal assistance for 4 of 8 sampled residents.
Report Facts
Number of wheelchair-dependent residents: 8
Number of residents not ambulatory or capable of self-preservation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding Resident #8's bathroom and ceiling condition | ||
| Staff F interviewed regarding pushing residents in wheelchairs and care provided | ||
| Staff G interviewed regarding assistance with wheelchair propulsion and transfers | ||
| Staff H interviewed regarding total care needs of residents | ||
| Staff E interviewed regarding total care needs of residents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00186549.
Complaint Details
Complaint GA00186549 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 18, 2017
Visit Reason
The visit was conducted to perform a compliance inspection and investigate complaint #GA00182898. No violations were cited during the compliance inspection, but violations were found during the complaint investigation.
Complaint Details
Complaint #GA00182898 was investigated. Violations were cited during the complaint investigation related to Resident #1's declining health and care needs.
Findings
The facility failed to retain only ambulatory residents capable of self-preservation with minimal assistance for 1 of 3 sampled residents (Resident #1), failed to update the care plan more frequently when the resident's needs changed substantially, and failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 3 sampled residents (Resident #1 and Resident #3).
Deficiencies (3)
Facility failed to retain only ambulatory residents capable of self-preservation with minimal assistance for Resident #1 who required three-person assist for transfer.
Facility failed to update the care plan more frequently where the needs of Resident #1 changed substantially, including no assessment of a swollen, red nose and foot ulcers.
Facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for Resident #1 and Resident #3.
Report Facts
Number of sampled residents with medication MAR issues: 2
Number of sampled residents with care plan update issues: 1
Number of sampled residents with ambulatory retention issues: 1
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