Inspection Reports for Oaks at Tucker
1300 Montreal Rd, Tucker, GA 30084, United States, GA, 30084
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Inspection Report
Follow-Up
Deficiencies: 0
Dec 3, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 8/22/19 investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 22, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198316 regarding staff conduct and infection control practices.
Findings
The facility failed to demonstrate proper infection control practices and respect for residents' privacy. Staff was found cleaning vomit from their shirt in another resident's room without the resident present, which was deemed inappropriate.
Complaint Details
Investigation of intake #GA00198316. Staff B was found in Resident #1's bathroom with shirt off cleaning vomit from his/her shirt. The resident was not present. Staff B acknowledged the inappropriateness. Staff infection control training was insufficient regarding handling soiled clothing.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff failed to demonstrate understanding of proper infection control practices, including inappropriate cleaning of clothing in another resident's room. | D |
| Facility failed to honor residents' rights to privacy by allowing staff to be in a resident's bathroom with shirt off without the resident present. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to infection control and privacy violations. | |
| Staff C | Interviewed regarding infection control training. | |
| Staff A | Reported observation of Staff B and verbally counseled Staff B. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 14, 2018
Visit Reason
The purpose of this visit was to investigate complaints GA 00192692 and GA00192509 regarding medication administration and resident abuse at the assisted living facility Northlake Gardens.
Findings
The facility failed to ensure residents received adequate and appropriate care, including proper medication administration by staff, with multiple incidents of staff signing medication records without giving medications. Additionally, the facility failed to protect residents from mental, verbal, and physical abuse, including an incident where a resident reported being thrown into bed by a caregiver.
Complaint Details
The investigation was initiated based on complaints GA 00192692 and GA00192509. The medication administration complaints involved Staff E and Staff F failing to give medications but signing MARs as if given. The abuse complaint involved Resident #1 reporting that Staff D threw him/her into bed, causing bruising. The investigation was unable to substantiate the abuse incident, and Staff D resigned during suspension.
Severity Breakdown
E: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate and appropriate care and services, including medication administration errors by staff signing MARs without giving medications. | E |
| Failure to ensure residents' right to be free from mental, verbal, and physical abuse, including an incident where a resident was thrown into bed by a caregiver. | D |
Report Facts
Dates of medication errors: 6
Resident admission dates: 2
Staff hire dates: 2
Incident report date: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Named in multiple medication administration errors and investigation. |
| Staff F | Certified Medication Aide (CMA) | Named in multiple medication administration errors and investigation; resigned during investigation. |
| Staff D | Caregiver | Named in abuse allegation of throwing resident into bed; resigned during suspension and investigation. |
| Staff A | Interviewed regarding medication errors and abuse investigation. | |
| Staff B | Interviewed regarding abuse allegation. | |
| Staff C | Interviewed regarding abuse allegation. | |
| Staff G | Interviewed regarding abuse allegation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 19, 2018
Visit Reason
The purpose of this visit was to investigate self reported incident #GA00189529.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of self reported incident #GA00189529 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 2, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00187923.
Findings
The community failed to ensure that Resident #1 received adequate and appropriate care and services as required by state law and regulations. Specifically, bathing assistance was not documented as provided on multiple scheduled days, and staff failed to record whether the resident refused the bath.
Complaint Details
Complaint GA00187923 was investigated. The complaint involved failure to provide adequate care and services to Resident #1, specifically regarding bathing assistance and documentation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide and document bathing assistance for Resident #1 on scheduled days as required by the care plan. | SS= D |
Report Facts
Scheduled bath days without documentation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding uncertainty if Resident #1 refused baths on specific days and failure to record the outcome. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00186826.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00186826 was investigated and found to have no rule violations.
Inspection Report
Annual Inspection
Deficiencies: 3
Feb 28, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate self-reported complaint #GA00185357.
Findings
The facility failed to ensure that all staff received required physical examinations and TB screenings within 12 months of employment for 2 of 6 sampled staff. Additionally, the facility failed to administer skills competency checks and quarterly medication administration observations for certified medication aides as required.
Complaint Details
The visit included investigation of self-reported complaint #GA00185357.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure all staff received a physical examination and TB screening within 12 months of employment for 2 of 6 sampled staff (Staff C and Staff G). | SS= D |
| Failed to administer skills competency checks for 2 of 2 certified medication aides (Staff G and Staff H). | SS= D |
| Failed to conduct quarterly observations of certified medication aides by a licensed registered professional nurse or pharmacist. | SS= D |
Report Facts
Number of sampled staff missing physical exams: 2
Number of certified medication aides missing skills competency checks: 2
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 3, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00183066 with an onsite visit made to the facility on 1/3/18 and the investigation completed on 2/19/18.
Findings
The facility failed to obtain a satisfactory criminal records check prior to employment for 1 of 4 staff reviewed, specifically Staff D, whose file showed no documentation of a satisfactory criminal records check.
Complaint Details
Complaint #GA00183066 was investigated with findings that the facility did not have a satisfactory criminal records check for Staff D.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory criminal records check prior to employment for 1 of 4 staff (Staff D). | D |
Report Facts
Staff reviewed: 4
Staff without documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff member whose file lacked documentation of a satisfactory criminal records check | |
| Staff A | Interviewed staff who stated they thought Staff D had done the criminal records check but was unable to locate it |
Inspection Report
Deficiencies: 0
Sep 18, 2017
Visit Reason
The document is a statement of deficiencies and plan of correction for Northlake Gardens, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or details of deficiencies.
Inspection Report
Annual Inspection
Deficiencies: 10
May 8, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and investigate complaint #GA00174238.
Findings
The facility was found to have multiple deficiencies including knowingly falsifying medication records, failure to ensure staff had current emergency first aid and CPR certifications, lack of physical examinations and tuberculosis screenings for staff, failure to obtain criminal background checks, non-compliance with fire safety drill requirements, incomplete admission agreements regarding medication handling, lack of specialized certified medication aides on duty, failure to verify medication aide certification standings, and failure to securely store medications for residents.
Complaint Details
The inspection included investigation of complaint #GA00174238.
Severity Breakdown
SS= D: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility knowingly falsified medication records for 4 of 4 sampled residents. | SS= D |
| Facility failed to ensure staff had current certification in emergency first aid training for 1 of 5 sampled staff. | SS= D |
| Facility failed to ensure staff had current certification in cardiopulmonary resuscitation (CPR) training for 1 of 5 sampled staff. | SS= D |
| Facility failed to ensure staff received physical examination and tuberculosis screening within 12 months for 2 of 5 sampled staff. | SS= D |
| Facility failed to obtain criminal records check for 2 of 5 sampled staff. | SS= D |
| Facility failed to comply with fire safety rules requiring one fire drill per quarter per shift. | SS= D |
| Facility failed to disclose how and by what level of staff medications are handled in admission agreements for sampled residents. | SS= D |
| Facility failed to have specialized certified medication aide staff on duty during the 7:00 a.m. through 3:00 p.m. shift. | SS= D |
| Facility failed to verify certification medication aides were in good standing with the Georgia certified nurse aide registry for 2 of 4 sampled staff. | SS= D |
| Facility failed to store medications securely under lock and key for 1 of 3 sampled residents. | SS= D |
Report Facts
Sampled residents with falsified medication records: 4
Sampled staff lacking emergency first aid certification: 1
Sampled staff lacking CPR certification: 1
Sampled staff lacking physical exam and TB screening: 2
Sampled staff lacking criminal records check: 2
Fire drills documented in 2016: 3
Certified Medication Aides scheduled on 4/23/17 7am-3pm shift: 1
Sampled staff lacking verification of good standing in nurse aide registry: 2
Sampled residents with unsecured medications: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided medications without licensure or certification; interviewed regarding medication administration and staff certifications. | |
| Staff B | Reported CMA absence on 4/23/17 and inability to find replacement; interviewed regarding medication administration. | |
| Staff C | Initialed medication records for 4/23/17 but did not work that shift. | |
| Staff D | Initialed medication records for 4/23/17 but did not work that shift. | |
| Staff E | Observed Staff A provide medications; lacked physical exam, TB screening, and criminal records check documentation. | |
| Staff F | Lacked emergency first aid and CPR certification. | |
| Staff G | Lacked physical exam, TB screening, criminal records check, and verification of nurse aide registry standing. | |
| Staff H | Lacked verification of nurse aide registry standing. | |
| Staff I | Lacked verification of nurse aide registry standing. |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 17, 2016
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up inspection to the complaint investigation; no rule violations cited.
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