Inspection Report Summary
The most recent inspection on August 15, 2023, identified a deficiency related to the facility’s failure to notify a resident’s legal representative after a change in the resident’s condition. Earlier inspections showed a mix of deficiencies, including issues with staff recordkeeping, care plan documentation, and family involvement, particularly concerning a resident with behavioral challenges. Complaint investigations mostly found no violations, except for the substantiated case involving notification failures and prior citations related to personnel files and care planning. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows some recurring documentation and communication issues, with no clear pattern of improvement or worsening over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 15, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237299 with an on-site visit made on 8/15/23 and the investigation completed on 8/18/23.
Complaint Details
Investigation of intake #GA00237299 regarding failure to notify Resident #1's family of condition change; family was notified by hospice care instead.
Findings
The facility failed to ensure immediate appropriate action was taken in response to an accident or sudden adverse change in a resident's condition, including failure to notify the resident's legal representative for 1 of 4 residents reviewed (Resident #1).
Deficiencies (1)
Facility failed to notify Resident #1's legal representative when the resident's condition changed after an incident on 7/16/23.
Report Facts
Residents in sample: 4
Incident date: Jul 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding failure to notify Resident #1's family |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00231003.
Complaint Details
The visit was complaint-related, investigating intake #GA00231003. Resident #1 exhibited frequent combative, aggressive, and self-harm behaviors including verbal and physical aggression, agitation, suicidal ideations, and resistance to care. Staff interviews revealed unawareness of the resident's care plan and that the resident was placed under hospice care due to behavioral issues.
Findings
The facility failed to obtain satisfactory fingerprint records checks for 2 of 4 sampled staff, failed to include required physical examination documentation and skills competency determinations for 1 of 4 sampled staff, and failed to include specific behavioral interventions and evidence of family involvement in the care plan for 1 of 4 sampled residents. Resident #1 exhibited frequent combative and aggressive behaviors documented from September to December 2022, and staff were unaware of the resident's care plan.
Deficiencies (5)
Failed to obtain a satisfactory fingerprint records check determination for 2 of 4 sampled staff (Staff B and Staff C).
Failed to include in the personnel file a report of physical examination completed within 12 months preceding date of hire for 1 of 4 sampled staff (Staff B).
Failed to include documentation on skills competency determinations for 1 of 4 sampled staff (Staff B).
Failed to include specific behaviors to be addressed with interventions in the resident's care plan for 1 of 4 sampled residents (Resident #1).
Failed to include evidence of family involvement in the development of the care plan for 1 of 4 sampled residents (Resident #1).
Report Facts
Sampled staff: 4
Sampled residents: 4
Behavioral incident dates: 15
Staff involved in cleaning Resident #1: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fingerprint checks, physical exam documentation, skills competency, and family communication for Resident #1 | |
| Staff B | Sampled staff missing fingerprint check, physical exam, and skills competency documentation | |
| Staff C | Interviewed about Resident #1's behavior and care plan unawareness | |
| Staff D | Interviewed about Resident #1's combative behavior and care plan unawareness |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 24, 2021
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 20, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00206524.
Complaint Details
Investigation of intake #GA00206524 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 6, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205635. The investigation began on 2020-06-15 and was completed on 2020-08-06.
Complaint Details
Investigation of intake #GA00205635 initiated on 2020-06-15 and completed on 2020-08-06.
Findings
The report documents the investigation of a complaint intake over a period from June 15, 2020 to August 6, 2020. No specific findings or deficiencies are detailed in the provided page.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 9, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204323, which started on 2020-05-19 and was completed on 2020-06-09.
Complaint Details
Investigation of intake #GA00204323 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00192704 and conduct the compliance inspection.
Complaint Details
Investigation of complaint GA00192704 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jul 5, 2017
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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