Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250483.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00250483 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 20, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244476.
Findings
An on-site visit was made on 3/20/2024. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00244476 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2024
Visit Reason
The visit was conducted to investigate intake #GA00243784 with an onsite visit made on 2024-02-29 and inspection completed on 2024-03-01.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00243784; no rule violations found.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 17, 2023
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/17/2023 inspection.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 29, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238203, #GA00238209, #GA00238495, and #GA00238551. An onsite visit was made on 2023-09-21 and the inspection was completed on 2023-09-29.
Findings
The facility failed to provide protective care and watchful oversight for 2 of 5 sampled residents who eloped from the facility and were returned unharmed. Additionally, the facility failed to report an unanticipated death of one resident to the Department.
Complaint Details
The visit was complaint-related, investigating multiple intakes (#GA00238203, #GA00238209, #GA00238495, #GA00238551). The findings included elopement incidents involving Residents #1 and #2, and failure to report the death of Resident #5. The death was determined to be natural causes. Staff interviews confirmed the incidents and uncertainty about reporting the death.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide protective care and watchful oversight for 2 of 5 sampled residents who eloped from the facility. | SS= D |
| Failed to report to the Department an unanticipated death for 1 of 5 sampled residents. | SS= D |
Report Facts
Intake numbers investigated: 4
Sample residents reviewed: 5
Elopement incidents: 2
Resident death date: 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 25, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237008. An onsite visit was made to the facility on 7/25/23 and the investigation was completed on 7/26/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00237008 with no rule violations cited.
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 2
Apr 17, 2023
Visit Reason
The purpose of this visit was to investigate multiple complaint intakes related to alleged incidents at the facility, including an alleged sexual assault involving residents.
Findings
The facility failed to have sufficient staff on schedule to ensure residents were treated with dignity and respect, and failed to ensure a resident's right to be free from sexual abuse. An incident involving Resident #1 entering Resident #4's bedroom and inappropriate contact was confirmed by video footage and staff interviews. Staff involved were terminated and Resident #1 was discharged.
Complaint Details
The investigation was triggered by multiple complaint intakes alleging sexual assault involving Resident #1 and Resident #4. Video footage confirmed Resident #1 was in Resident #4's bedroom engaging in inappropriate behavior. Law enforcement was involved but did not prosecute due to Resident #1's dementia. Staff involved were suspended and terminated. Resident #1 was given a 30-day discharge notice and discharged.
Severity Breakdown
G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to have sufficient staff on schedule such that each resident was treated with dignity, kindness, and respect for 1 of 3 sampled residents (Resident #4). | G |
| Facility failed to ensure each resident has the right to be free from sexual abuse for 1 of 4 sampled residents (Resident #4). | G |
Report Facts
Residents in memory care unit: 22
Care staff on duty: 2
Medication aide on duty: 1
Residents requiring toileting every 2 hours: 3
Duration of video footage: 90
Sitter hours: 24
Discharge notice period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported and investigated the incident, confirmed video footage, and coordinated with law enforcement | |
| Staff C | Care staff working during the incident, interviewed regarding rounds and observations | |
| Staff D | Care staff working during the incident, interviewed regarding rounds and observations | |
| HH | Reviewed video footage, informed staff and law enforcement, did not pursue prosecution | |
| II | Family member notified by facility, arranged 24-hour sitter for Resident #1 | |
| DD | Staff who made rounds and denied seeing Resident #1 in Resident #4's bedroom |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 3, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00230326, #GA00230354, and #GA00228632.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of three intakes (#GA00230326, #GA00230354, and #GA00228632) with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 20, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00222504. An onsite visit was made on 5/20/22 and the investigation was completed on 5/26/22.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00222504 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 31, 2022
Visit Reason
The purpose of this visit was to investigate intakes #GA00222013, #GA00222143, and #GA00222316. The investigation started on 2022-03-08 and was completed on 2022-03-31, with an onsite visit on 2022-03-17.
Findings
The facility failed to maintain complete personnel files for four sampled staff members, failed to display the most recent inspection report and plan of correction in a common area, and failed to obtain new prescriptions within 48 hours for one resident, resulting in medication administration issues and hospitalization.
Complaint Details
Investigation of three intakes (#GA00222013, #GA00222143, #GA00222316) related to personnel file deficiencies, failure to post inspection reports, and medication errors. Resident #2 did not receive all prescribed medications due to pharmacy communication issues and was hospitalized with a blood glucose of 1400.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain personnel files with required training and screening documentation for four staff members. | SS= D |
| Failed to display the most recent inspection report and plan of correction in a location routinely used to communicate with residents and visitors. | SS= D |
| Failed to obtain new prescriptions within 48 hours or sooner, resulting in medication administration errors for Resident #2. | SS= D |
Report Facts
Intakes investigated: 3
Resident admission date: Feb 28, 2022
Medication dose: 8
Blood glucose level: 1400
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in personnel file deficiency | |
| Staff D | Named in personnel file deficiency | |
| Staff E | Named in personnel file deficiency | |
| Staff F | Named in personnel file deficiency | |
| Staff A | Interviewed regarding missing inspection report posting and medication issues | |
| Staff B | Interviewed regarding medication issues for Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 2, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00218821. An on-site visit was made on 12/2/2021, with the inspection started on 12/2/2021 and completed on 2/23/2022.
Findings
The facility failed to ensure each resident had the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation. Specifically, Staff C was found to have roughly handled Resident #1 without consent, leading to Staff C's termination.
Complaint Details
Investigation was initiated due to intake #GA00218821. The complaint was substantiated as Staff C was terminated following the incident reported on 10/26/2021 involving rough handling of Resident #1.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' rights to be free from abuse, neglect, and exploitation, including an incident where Staff C roughly handled Resident #1 without consent. | G |
Report Facts
Dates related to incident and actions: Incident occurred on 10/26/2021; Staff C terminated on 10/27/2021; investigation visit on 12/2/2021; inspection completed on 2/23/2022
Inspection Report
Original Licensing
Deficiencies: 0
Oct 15, 2021
Visit Reason
The purpose of this visit was to conduct the change of ownership initial inspection.
Findings
No rule violations were cited as a result of this inspection.
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