Inspection Report
Routine
Deficiencies: 0
Aug 26, 2021
Visit Reason
An onsite visit was made to the facility on 8/26/21 to complete a compliance inspection.
Findings
The building was vacant and the owner confirmed the facility is closed.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 26, 2020
Visit Reason
The purpose of this survey was to investigate intake #GA00208068.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation initiated on 2020-10-24 and completed on 2020-10-26. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jul 31, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205451, which started on 2020-05-28 and was completed on 2020-07-31.
Findings
The facility failed to provide adequate supervision and care for Resident #1, who had a diabetic foot wound that was not healing properly due to the resident removing dressings. The facility also failed to ensure appropriate care for Resident #2, who had mental illness and was unable to communicate effectively during medical visits. Additionally, the facility failed to comply with requests for documentation during the complaint investigation.
Complaint Details
The investigation was complaint-driven based on intake #GA00205451. The facility was found to have failed in providing adequate care and supervision to Resident #1 and Resident #2, and failed to provide requested documentation during the investigation.
Severity Breakdown
SS=J: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure staff provided oversight necessary to comply with applicable rules for Resident #1 with a diabetic wound who removed dressings and was at risk for neglect. | SS=J |
| Facility failed to retain residents who did not require care beyond what the facility was permitted to provide for Resident #1 with complex medical needs including diabetic foot ulcer and mental illness. | SS=J |
| Facility failed to ensure each resident received adequate and appropriate care for Resident #1 and Resident #2, including wound care and supervision. | SS=J |
| Facility failed to comply with requests for documentation during complaint investigation, including medical records and incident reports. | SS=J |
Report Facts
Dates wound observed without dressing: Resident #1 was observed without dressing on 4/20/20, 4/27/20, 4/30/20, 5/11/20, 5/14/20, 5/18/20, 5/21/20.
Wound measurements: Left heel wound measured 6 cm x 3.5 cm x 0.3 cm on 5/11/20 and 3 cm x 6.5 cm x 1 cm on 5/18/20.
Home health dressing changes frequency: 2
Hospital admission dates: Resident #1 hospitalized from 5/22/20 to 6/2/20 and sent to emergency room on 6/18/20.
Requested records not provided by: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed multiple times regarding Resident #1's wound care and facility's inability to keep dressing on the wound; agreed to provide requested records but did not. | |
| Staff B | Interviewed regarding Resident #1's diabetic status, wound care, and Resident #2's medical appointments. | |
| Staff C | Stated facility staff could not perform dressing changes for Resident #1. | |
| GG | Home health agency representative who provided dressing changes twice weekly and reported Resident #1 was often barefoot and without dressing. | |
| II | Expressed dissatisfaction with care Resident #1 received and noted missed appointments and hospitalizations. | |
| HH | Reported Resident #1 missed wound care appointments and was sent to emergency room; also commented on Resident #2's inability to communicate. | |
| JJ | Reported observations of Resident #1's wound condition and facility staff's inability to keep dressing on the wound. |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 3
Nov 14, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00200593 and #GA00200757 with an onsite visit made on 11/14/19 and inspection completed on 11/15/19.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken by residents, failed to obtain timely refills of prescribed medications resulting in missed doses for one resident, and failed to maintain adequate heating in the building, leaving some resident rooms cold.
Complaint Details
The visit was complaint-related to investigate intakes #GA00200593 and #GA00200757. The complaint included issues with medication administration and facility conditions.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken by residents. | SS= D |
| Failure to obtain timely refills of prescribed medications resulting in interruption of routine dosing for one resident. | SS= D |
| Failure to maintain adequate heating system resulting in cold temperatures in resident rooms. | SS= D |
Report Facts
Residents without MAR documentation: 13
Missed medication days: 3
Temperature measured: 60
Thermostat setting: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Took the MAR book home, responsible for medication refills, and was interviewed regarding medication and heating system issues. | |
| Staff C | Observed giving medications without documenting on MAR and interviewed about missing MAR book. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Oct 23, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes GA00199409 and GA00199548.
Findings
The facility failed to have written evidence of satisfactory initial and annual work performance reviews for unlicensed staff performing specialized tasks such as medication administration. The facility also failed to maintain plumbing and bathroom fixtures, provide sufficient lighting, keep walls clean and in good repair, maintain yards free of hazards, and maintain the exterior of the home in safe and good repair. Additionally, the facility failed to ensure adequate and appropriate care and services for Resident #1, who walked approximately 14 miles back to the facility from the hospital due to lack of transportation arrangements.
Complaint Details
The inspection was conducted in response to complaint intakes GA00199409 and GA00199548. The complaint investigation found that Resident #1 was discharged from the hospital without arranged transportation back to the facility, resulting in Resident #1 walking approximately 14 miles back to the facility in hot weather. The facility staff failed to arrange transportation or provide adequate follow-up.
Severity Breakdown
SS= D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to have written evidence of satisfactory initial and annual work performance reviews for unlicensed staff performing specialized tasks such as medication administration. | SS= D |
| Failed to maintain all plumbing and bathroom fixtures in good working order and presenting a clean and sanitary appearance for 4 of 8 sampled residents. | SS= D |
| Failed to provide sufficient lighting in hallways and other areas of the facility such that residents may move safely and objects may be observed. | SS= D |
| Failed to keep walls clean and in good repair. | SS= D |
| Failed to maintain yards free of hazards such as equipment and debris. | SS= D |
| Failed to maintain the exterior of the home in safe and good repair. | SS= D |
| Failed to ensure each resident received care and services which were adequate, appropriate and in compliance with applicable federal and state law and regulations. | SS= D |
Report Facts
Sampled residents: 8
Residents affected by medication administration deficiency: 4
Residents affected by plumbing deficiency: 4
Residents affected by lighting deficiency: 4
Miles walked by Resident #1: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Unlicensed staff who performed medication administration without proxy caregiver training | |
| Staff A | Staff who acknowledged lack of proxy caregiver training for Staff B and discussed facility repairs and transportation issues | |
| MM | Person who communicated about Resident #1's transportation and reported Resident #1's walk back to the facility |
Inspection Report
Follow-Up
Deficiencies: 1
Dec 19, 2018
Visit Reason
The purpose of this visit was to conduct a follow up to the 07/17/18 compliance inspection and complaint investigation.
Findings
The facility failed to ensure that the exterior of the home was properly maintained to remain safe and in good repair, specifically the deck at the rear smoking area had warped and rotten boards. Staff was unaware of the condition of the deck.
Complaint Details
This visit was a follow up to a complaint investigation conducted on 07/17/18.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The deck at the rear smoking area had warped and rotten boards. | E |
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 8
Jul 10, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaints #GA00189595 and #GA00189668.
Findings
The facility failed to meet multiple regulatory requirements including staff training, provision of laundering facilities, fire and safety compliance, cleanliness and repair of physical plant, sanitation of kitchen and bathroom areas, maintenance of the exterior, and adequate resident care and services. Several deficiencies were observed and substantiated through interviews and observations.
Complaint Details
The inspection was conducted to investigate complaints #GA00189595 and #GA00189668. Findings included substantiated deficiencies related to staff training, facility maintenance, resident care, and sanitation.
Severity Breakdown
D: 6
E: 1
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Facility failed to ensure all staff involved with personal services received at least sixteen hours of training per year for 3 sampled staff. | D |
| Facility failed to provide laundering facilities on the premises for residents' personal laundry; washing machine was inoperable. | D |
| Facility failed to ensure compliance with fire and safety rules; emergency lighting fixtures did not function. | E |
| Facility failed to keep floors, walls, and ceilings clean and in good repair; issues included sagging ceiling, broken tiles, stained carpet. | F |
| Facility failed to sanitize kitchen and bathroom areas daily to ensure cleanliness and sanitation. | D |
| Facility failed to properly maintain the exterior of the home; loose rails, warped steps, missing handrails, rotten boards observed. | D |
| Facility staff failed to provide assistance to residents unable to keep themselves neat and clean; residents observed with dirty clothes. | D |
| Facility failed to ensure each resident received adequate and appropriate care and services; insufficient food supply and residents reported not getting enough to eat. | D |
Report Facts
Resident census: 13
Food supply counts: 2
Food supply counts: 3
Food supply counts: 2
Food supply counts: 4
Food supply counts: 1
Food supply counts: 3
Food supply counts: 2
Food supply counts: 1
Food supply counts: 2
Food supply counts: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staff training, facility maintenance, and resident care deficiencies | |
| Staff B | Staff file reviewed for training hours deficiency | |
| Staff C | Staff file reviewed for training hours deficiency | |
| Staff D | Staff file reviewed for training hours deficiency |
Inspection Report
Follow-Up
Deficiencies: 3
Nov 7, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 06/23/17 compliance inspection.
Findings
The facility failed to ensure space heaters were not in use, failed to ensure fire extinguishers were checked annually, and failed to keep floors, walls, and ceilings clean and in good repair with multiple physical environmental issues observed.
Severity Breakdown
J: 1
D: 1
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure that space heaters were not in use. | J |
| Facility failed to ensure the fire extinguishers were checked annually. | D |
| Facility failed to keep floors, walls, and ceilings clean and in good repair. | F |
Report Facts
Size of space heater: 11
Date last serviced: Sep 7, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding space heater removal and fire extinguisher service |
Inspection Report
Annual Inspection
Deficiencies: 5
Jun 20, 2017
Visit Reason
The visit was conducted to perform an annual inspection and to investigate complaint #GA00176195, with the onsite visit on 6/20/17 and investigation completed on 6/23/17.
Findings
The facility was found deficient in multiple areas including workforce qualifications and training, physical plant health and safety standards, cleanliness and repair of floors and walls, and nutrition. Specific issues included expired CPR and first aid certifications for staff, lack of required supporting documentation for staff qualifications, failure to comply with fire and safety rules including fire drills and sprinkler system problems, unclean carpets and mold presence, and failure to provide nutritious snacks as required.
Complaint Details
Complaint #GA00176195 was investigated during this visit. The complaint investigation was completed on 6/23/17.
Severity Breakdown
D: 4
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure all staff received required trainings; Staff A had expired CPR and first aid certifications. | D |
| Failure to maintain supporting documentation reflecting basic qualifications for Staff C, including registry check upon hire. | D |
| Failure to comply with fire and safety rules including fire drills not conducted in last 6 months, sprinkler system yellow tagged, and main control panel issues. | D |
| Failure to keep floors and walls clean and in good repair; stained carpets and black mold observed. | E |
| Failure to provide one nutritious snack each mid-afternoon and evening; no snacks offered during observation period. | D |
Report Facts
Staff reviewed: 3
Fire drills frequency: 2
Inspection dates: 201703
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Owner/Administrator | Named in findings for expired CPR and first aid certifications and interview regarding registry checks and fire safety system |
| Staff C | Named in findings for lack of supporting documentation for qualifications |
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