Inspection Reports for Gardens of Gainesville
3315 Thompson Bridge Rd, Gainesville, GA 30506, United States, GA, 30506
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 2, 2025, found deficiencies related to non-functional pendant alert systems and missing documentation. Earlier inspections showed a pattern of issues primarily involving medication administration errors, documentation problems, and staffing concerns in the memory care unit. Several complaint investigations substantiated failures in timely and accurate medication delivery, incomplete or falsified medication records, and lapses in staff training and resident care. Enforcement actions included a violation for falsifying records, but fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with medication management and staff oversight, with no clear trend of sustained improvement or worsening in recent months.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 2, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50005833 and #GA50005783, with the onsite visit conducted on 10/2/2025 and investigation completed on 10/3/2025.
Complaint Details
Investigation was conducted based on complaints #GA50005833 and #GA50005783. The complaint was substantiated by findings that alert systems were non-functional and documentation was unavailable.
Findings
The facility failed to maintain and make available pendant alert documentation for residents, and medical alert pull cords used by residents to call for help had not been operative for two months, resulting in residents being unable to contact caregivers even in emergencies.
Deficiencies (1)
Failed to make available for review and maintain pendant alert documentation for residents.
Report Facts
Sampled residents: 4
Residents affected: 1
Duration of non-operation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Interviewed staff who stated medical alert pull cords were non-operative for two months | |
| CC | Interviewed staff who stated residents had requested assistance by pressing alert buttons | |
| Staff A | Interviewed staff who stated pendant alert reports were not available but a ticket had been submitted |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 5, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50004723, #GA50004720, and #GA50005410 with an onsite visit on 9/5/2025 and investigation completion on 9/15/2025.
Complaint Details
The investigation was complaint-driven, focusing on allegations related to medication administration timing and falsification of medication records. The complaints were substantiated based on record reviews and staff interviews.
Findings
The facility staff failed to administer medications to residents at the right time for 2 of 3 sampled residents (Resident #3 and Resident #4). Additionally, staff falsely documented medication administration records (MARs) by using credentials of a staff member who did not work that day and backdating medication administration times.
Deficiencies (3)
Failure to administer medications to residents at the right time for 2 of 3 sampled residents (Resident #3 and Resident #4).
Falsification of medication administration records for 2 of 5 sampled residents (Resident #3 and Resident #4) by documenting MARs using credentials of a staff member who did not work on the date of administration.
Enforcement violation for knowingly making false statements or falsifying facility records.
Report Facts
Number of sampled residents with medication timing issues: 2
Number of sampled residents with falsified MAR documentation: 2
Date of onsite visit: Sep 5, 2025
Date survey completed: Sep 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings for falsifying medication administration records and not working on 9/5/25 despite initials on MARs. | |
| Staff E | Administered medications on 9/5/25 and used Staff C's login credentials to update MARs. | |
| Staff D | Interviewed and confirmed Staff C did not work on 9/5/25. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 8, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50004080, #GA50004105, and #GA50004163 with an onsite visit conducted on 2025-08-08 and investigation completed on 2025-08-19.
Complaint Details
The investigation was complaint-driven based on complaints #GA50004080, #GA50004105, and #GA50004163. The findings substantiated failures in medication record keeping and infection control related to cleanliness.
Findings
The facility failed to ensure staff updated the Medication Assistance Record (MAR) for 1 of 4 sampled residents, and failed to clean the room of 1 sampled resident, resulting in unsanitary conditions and unwashed clothing.
Deficiencies (2)
Failure to ensure staff updated the MAR each time medication was offered or taken for Resident #3, with multiple instances of missing staff initials on medication administration records.
Failure to clean the resident's room for Resident #2, with dirty clothing and food observed on the floor and a strong odor detected in the hallway.
Report Facts
Deficiencies cited: 2
Dates with missing staff initials: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed and stated staff did not sign on 7/6/25 and 7/7/25 on the MAR | |
| Staff B | Interviewed and stated Resident #2 had smelly and dirty clothing in his/her room that had not been washed in several days |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
The purpose of this survey was to investigate complaint numbers GA50003428, GA50003470, and GA50003309.
Complaint Details
Investigation of complaints GA50003428, GA50003470, and GA50003309 resulted in no rule violations.
Findings
The onsite visit was conducted from 2025-06-12 to 2025-06-24. No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50003101, #GA50003020, and #GA50002711, with the investigation beginning on 2025-05-27, an onsite visit on 2025-05-28, and completion on 2025-05-28.
Complaint Details
Investigation of three intakes (#GA50003101, #GA50003020, and #GA50002711) was conducted and completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
The purpose of this visit was to investigate intakes GA50001170 and GA5001814, with the investigation beginning on 2025-04-01 and ending on 2025-04-10.
Complaint Details
Investigation of intakes GA50001170 and GA5001814 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
The purpose of this visit was to investigate intake GA00249901.
Complaint Details
Investigation of intake GA00249901 with no rule violations cited.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00249405, #GA00249330, and #GA00249298.
Complaint Details
Investigation of complaint intakes #GA00249405, #GA00249330, and #GA00249298 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 1
Date: Jul 19, 2024
Visit Reason
The purpose of this survey was to investigate complaints #GA00248451 and GA00246889 during an onsite visit on 7/19/24.
Complaint Details
The visit was complaint-related, investigating complaints #GA00248451 and GA00246889. The deficiency was substantiated based on observation and interviews.
Findings
The facility failed to ensure that at least one registered professional nurse, licensed practical nurse, or certified medication aide was on-site in the memory care unit at all times. Specifically, no med-tech was observed in the memory care unit from 12:20 p.m. to 1:10 p.m. on 7/19/24.
Deficiencies (1)
Failure to provide one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times in the memory care center.
Report Facts
Resident census in memory care unit: 14
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246056 during an onsite visit on 5/10/24.
Complaint Details
Investigation of complaint #GA00246056 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246056 during an onsite visit on 5/10/24.
Complaint Details
Investigation of complaint #GA00246056 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246056 during an onsite visit on 5/10/24.
Complaint Details
Investigation of complaint #GA00246056 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246056 during an onsite visit on 5/10/24.
Complaint Details
Investigation of complaint #GA00246056 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 20, 2023
Visit Reason
The purpose of this inspection was to investigate intake #GA00241427.
Complaint Details
Investigation of intake #GA00241427 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241127. The investigation was started on 11/28/23 and completed on 12/4/23.
Complaint Details
Investigation of intake #GA00241127 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238359.
Complaint Details
Investigation of intake #GA00238359 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
The purpose of this visit was to investigate complaints #GA00237638 and #GA00236732 related to medication administration at the facility.
Complaint Details
Investigation of complaints #GA00237638 and #GA00236732. The violation was substantiated and previously cited on 4/6/23.
Findings
The facility failed to ensure proper medication administration for Resident #3, who was not capable of self-administering medications. Multiple doses of prescribed medications were not given as ordered, including Vancomycin and Doxazosin, leading to worsening tremors and difficulty eating for the resident. Blood pressure monitoring was also not documented as required.
Deficiencies (1)
Failure to provide medication administration services in accordance with physicians' orders and residents' needs for Resident #3.
Report Facts
Residents affected: 1
Medication doses not given: 8
Quantity of Vancomycin pills: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Interviewed on 8/23/23 regarding Resident #3's medication and blood pressure documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 4, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00232652 and #GA00231603 with an onsite visit made on 4/4/23 and the investigation completed on 4/6/23.
Complaint Details
Investigation was triggered by complaint intakes #GA00232652 and #GA00231603. The medication error for Resident #1 was substantiated based on record review and staff interviews. The delay in obtaining new prescriptions for Resident #2 was also substantiated.
Findings
The facility failed to provide medication administration services according to physicians' orders for 1 of 3 residents, resulting in medication given more frequently than prescribed. Additionally, the facility failed to obtain new prescriptions within 48 hours of receipt for 1 of 3 residents.
Deficiencies (2)
Failed to provide medication administration services in accordance with physicians' orders for Resident #1, who received Lorazepam four times in one day instead of twice as prescribed.
Failed to ensure new prescriptions were obtained within 48 hours of receipt of notice of the prescription for Resident #2.
Report Facts
Residents sampled: 3
Lorazepam doses given: 4
Dates medication given against orders: 7
Prescription receipt delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed regarding medication administration errors for Resident #1 | |
| Staff F | Interviewed regarding delay in sending prescription to pharmacy for Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 4, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00232170 and #GA00232711 with onsite visits on 3/16/23 and 4/4/23, and the investigation completed on 4/4/23.
Complaint Details
The investigation was complaint-driven based on intake #GA00232170 and #GA00232711. The complaint involved allegations that staff failed to assist Resident #1 after a fall and used inappropriate language. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to ensure that all staff received required training on residents' rights and abuse reporting within the first 60 days of employment for 1 of 7 sampled staff. Additionally, the facility failed to provide adequate care and assistance to Resident #1 who fell and was left on the floor for approximately 40 minutes without staff assistance, during which a staff member used inappropriate and vulgar language toward the resident.
Deficiencies (2)
Failure to ensure all staff received training within the first 60 days on residents' rights and abuse reporting requirements (Staff D).
Failure to provide adequate care and assistance to Resident #1 who fell and was left on the floor for approximately 40 minutes; staff used inappropriate language and did not assist resident off the floor.
Report Facts
Number of sampled staff: 7
Number of sampled residents: 2
Duration resident left on floor: 40
Date of incident: Feb 4, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Failed to complete required training and used inappropriate language toward Resident #1 | |
| Staff B | Reported Resident #1 fall and described Staff D's behavior | |
| Staff C | Assisted Resident #1 and described Staff D's behavior | |
| Staff E | Notified about Staff D's incomplete training and aware of findings | |
| Staff F | Reported incident to Staff E and observed verbal altercation | |
| Staff A | Aware of findings |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 22, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00222281 with an onsite visit made on 3/22/22 and the investigation completed on 4/7/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00222281. The complaint was substantiated based on record review and interviews revealing training and medication administration documentation deficiencies.
Findings
The facility failed to ensure that all direct care staff received required initial orientation training within the first thirty days, specifically Staff C and Staff D. Additionally, the facility failed to ensure proper updating of the medication administration record for one resident, Resident #1, with multiple instances of blank documentation on medication administration records for February and March 2022.
Deficiencies (2)
Failure to ensure all direct care staff received initial orientation training within the first thirty days, including general training components, for Staff C and Staff D.
Failure to ensure staff providing assistance or administration of medications updated the medication administration record for Resident #1, with multiple blank cells and undocumented medication refusals.
Report Facts
Staff involved: 2
Residents involved: 1
Medication blank cells: 14
Previous citation date: Jan 14, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiency for lack of initial orientation training. | |
| Staff D | Named in deficiency for lack of initial orientation training. | |
| Staff A | Provided files and emails related to training and medication records. | |
| Staff B | Interviewed and acknowledged training was completed by staffing agency and commented on medication administration documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00221918.
Complaint Details
Investigation of intake #GA00221918 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jan 14, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00219995 and to conduct the compliance inspection with onsite visits on 1/6/22 and 1/12/22, completed on 1/14/22.
Complaint Details
The visit was complaint-related to intake #GA00219995.
Findings
The facility failed to ensure proper record checks for direct access employees, adequate infection control and evacuation training within 60 days for staff, operation of the memory care center without certification, compliance with fire safety rules including fire drills, required memory care training for staff, quarterly drug reviews for residents, and proper medication administration record updates for residents.
Deficiencies (8)
Failed to ensure that a record check was completed for each direct access employee upon application or prior to placement for 1 of 10 staff (Staff C).
Failed to ensure staff received infection control training within the first 60 days for 3 of 10 staff (Staff H, Staff I, Staff D).
Failed to ensure staff received evacuation procedure training within the first 60 days for 2 of 10 staff (Staff H, Staff I).
Memory care center operated and residents admitted without a certificate.
Failed to comply with fire and safety rules; only one fire drill conducted in 2021 on 6/31/21.
Failed to ensure memory care unit staff received required training within 30 days for 2 of 10 staff (Staff D, Staff E).
Failed to conduct quarterly drug reviews for 5 of 6 residents (Resident #1, #2, #3, #4, #5).
Failed to update medication administration record each time medication was offered or taken for 2 of 6 residents (Resident #1 and Resident #5).
Report Facts
Staff with missing record check: 1
Staff missing infection control training: 3
Staff missing evacuation training: 2
Staff missing memory care training: 2
Residents missing quarterly drug reviews: 5
Residents with MAR update issues: 2
Fire drills conducted in 2021: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Agency employee missing record check | |
| Staff H | Missing infection control and evacuation training | |
| Staff I | Missing infection control and evacuation training | |
| Staff D | Missing infection control and memory care training | |
| Staff E | Missing memory care training | |
| Staff A | Interviewed and aware of multiple findings | |
| Staff K | Interviewed about fire drills | |
| AA | Interviewed about medication issues for Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 11, 2021
Visit Reason
The purpose of this survey was to investigate complaint GA00209478 regarding an incident involving three residents who went missing from the memory care unit on 10/23/2020.
Complaint Details
Investigation started on 2020-11-06 and completed on 2021-02-11. The complaint involved an elopement incident on 2020-10-23 where three residents went missing from the memory care unit. The facility failed to report the incident and failed to provide requested documentation.
Findings
The facility failed to ensure policies and procedures were enforced, specifically failing to report a serious incident involving three residents to the Department within 24 hours. Incident reports and related documentation were not available or submitted as required.
Deficiencies (2)
Failure to ensure policies and procedures were enforced to ensure compliance, including lack of documentation for an incident involving elopement of three residents.
Failure to report a serious incident involving three residents to the Department within 24 hours after the incident occurred.
Report Facts
Number of residents involved in incident: 3
Incident report submission timeframe: 24
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 21, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208094.
Complaint Details
Investigation of intake #GA00208094 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating infection control procedures at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 26, 2020
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint # GA00202606 with onsite visits on 02/25/20 and 02/26/20.
Complaint Details
Investigation of complaint # GA00202606. Substantiation status not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to ensure staff completed required continuing education, failure to maintain clean environment (ceiling vents), incomplete resident care plans, lack of required physician reports for memory care admissions, uncertified medication aides, incomplete medication administration records, untimely medication procurement, inadequate pest control, and failure to provide adequate care resulting in residents being soaked in urine and untreated injuries.
Deficiencies (9)
Facility failed to ensure staff had 16 hours of continuing education units for 4 of 7 sampled staff.
Facility failed to keep ceiling vents clean, with black debris observed.
Facility failed to develop a care plan including description of resident's care and social needs for 1 of 11 sampled residents.
Facility failed to obtain a physician's report of physical examination within 30 days prior to admission to memory care unit for 1 of 6 sampled residents.
Facility failed to ensure Certified Medication Aides were listed as active and in good standing on the Georgia CMA registry for 2 of 2 sampled CMAs.
Facility failed to update Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 11 sampled residents.
Facility failed to obtain new prescriptions within 48 hours of receipt or sooner if medication change was immediate for 1 of 11 sampled residents.
Facility failed to maintain an insect, rodent or pest control program protecting resident health; insects and cockroaches observed.
Facility failed to ensure residents received adequate and appropriate care; residents observed soaked in urine and with untreated injuries.
Report Facts
Sampled staff without required CEUs: 4
Sampled residents with care plan deficiency: 1
Sampled residents without required physician report: 1
Sampled CMAs not active on registry: 2
Sampled residents with MAR deficiencies: 1
Sampled residents with untimely medication procurement: 1
Sampled residents with inadequate care: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in continuing education deficiency and acknowledged lack of training. | |
| Staff D | Named in continuing education deficiency and CMA registry issue. | |
| Staff E | Named in continuing education deficiency. | |
| Staff F | Named in continuing education deficiency. | |
| Staff G | Acknowledged multiple deficiencies including training, clean vents, missing physician forms, CMA registry, MAR issues, pest control, and resident care. | |
| Staff B | Named in CMA registry deficiency. | |
| Staff H | Interviewed regarding MAR deficiencies and medication cart observation. | |
| AA | Interviewed regarding residents soaked in urine and staffing shortages. | |
| BB | Interviewed regarding lack of training and resident care issues. | |
| DD | Interviewed regarding resident falls and urine soaked residents. | |
| EE | Interviewed regarding pest sightings and resident care issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 7, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00202059. An onsite visit was made on 2020-01-21 and the investigation was completed on 2020-02-07.
Complaint Details
Investigation of complaint #GA00202059 regarding potential missing narcotic medication. The community could not substantiate that the medication was missing or destroyed due to improper destruction documentation.
Findings
The facility failed to inventory medications appropriately to prevent loss and unauthorized use for 1 of 3 residents (Resident #1). The investigation revealed missing documentation for destroyed expired narcotic medications and inconsistent destruction paperwork.
Deficiencies (1)
Failed to inventory medications appropriately to prevent loss and unauthorized use for Resident #1, including missing or improperly documented destruction of expired narcotic medications.
Report Facts
Medication count: 30
Date: Dec 31, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in medication destruction and audit interviews | |
| Staff C | Named in medication destruction and audit interviews | |
| Staff E | Named in medication destruction and audit interviews | |
| Staff G | Named in medication destruction and audit interviews | |
| Staff A | Reported statements from Staff B and Staff C regarding medication destruction | |
| Staff H | Present during medication destruction but did not sign paperwork |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 10, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00197046 with an on-site visit made on 2019-06-11 and the investigation completed on 2019-07-10.
Complaint Details
Investigation of complaint #GA00197046 revealed missing money from residents' purses and wallets, a stolen credit card used by Staff H, and police involvement.
Findings
The facility failed to ensure that residents' personal property and possessions were safeguarded, as evidenced by multiple incidents of missing money and stolen credit card involving residents and staff admission of misuse.
Deficiencies (1)
Failed to ensure that all residents' property and possessions were safeguarded for 3 of 7 sampled residents.
Report Facts
Missing money amount: 80
Missing money amount: 30
Missing money amount range: 80
Missing money amount range: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Admitted to local law enforcement that he/she had used the resident's credit card | |
| Staff I | Stated that Resident #1's phone went missing for 80 to 90 minutes and that every staff had a key |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 24, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint number GA00196790.
Complaint Details
Investigation of complaint #GA00196790 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 12, 2018
Visit Reason
The purpose of this visit was to investigate intake #GA00190653 related to concerns about protective care and oversight in the assisted living community.
Complaint Details
The visit was complaint-related, investigating intake #GA00190653. The complaint involved failure to provide protective care and oversight, resulting in multiple falls and injuries to residents, and failure to report a serious incident involving Resident #8. The complaint was substantiated based on record review, staff interviews, and incident reports.
Findings
The facility failed to provide protective care and watchful oversight for 7 of 8 sampled residents, resulting in multiple unwitnessed falls causing fractures and injuries. Additionally, the facility failed to provide adequate care and services for Resident #8, who sustained multiple bruises and a traumatic fall resulting in a left distal periprosthetic femur fracture. The facility also failed to report a serious incident involving Resident #8 to the Department within the required timeframe.
Deficiencies (3)
Failure to provide protective care and watchful oversight for 7 of 8 sampled residents, resulting in multiple unwitnessed falls and injuries.
Failure to provide adequate care and services in compliance with state law for Resident #8, resulting in multiple bruises, skin tears, and a traumatic fall with fracture.
Failure to report a serious incident involving Resident #8 to the Department within 24 hours.
Report Facts
Number of sampled residents with failed protective care: 7
Number of staples received by Resident #2: 8
Number of sutures received by Resident #3: 6
Morse Fall Risk Evaluation score for Resident #8: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Conducted assessment on Resident #8, conferred with hospice nurse, and agreed to send Resident #8 to emergency room | |
| Staff E | Found Resident #8 during medication pass and reported left leg deformity | |
| Staff F | Found Resident #8 in bed complaining of pain and noted bruises and skin tears | |
| Staff H | Transferred Resident #8 from bed to wheelchair without requesting assistance, causing skin tear | |
| Staff B | Notified about Resident #8 being sent to emergency room and stated incident report should have been completed | |
| AA | Received calls regarding Resident #8's bruises and fall, and communicated with emergency room doctor |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 17, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA 00187375 with an on-site visit made to the facility on 4/17/18 and the investigation completed on 4/18/18.
Complaint Details
Complaint GA 00187375 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 21, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184937. An on-site visit was made on 2/21/18 and the investigation was completed on 2/27/18.
Complaint Details
Complaint #GA00184937 was investigated. The complaint involved allegations of Staff D shouting at and roughly handling residents, including pulling and pushing Resident #1 and others. Staff interviews corroborated these behaviors. Staff D was suspended during the investigation and received additional training before returning to work, but was reassigned away from certain units.
Findings
The facility failed to ensure that all residents were treated with dignity, kindness, consideration, and respect in the provision of assisted living care for 1 of 6 residents. Multiple staff interviews and incident reports documented inappropriate staff behavior including shouting, rough handling, and poor attitude by Staff D toward residents.
Deficiencies (1)
Facility failed to ensure residents were treated with dignity, kindness, consideration, and respect; specifically, Staff D was witnessed shouting at and roughly handling Resident #1 and other residents.
Report Facts
Complaint number: GA00184937
Incident date: 2018-01-29 5:15 a.m.
Staff work shift time: 11:00 p.m. to 7:00 a.m. on 2018-01-28
Investigation interview dates: Between 2018-01-31 and 2018-02-02
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in multiple findings related to shouting, rough handling, and poor attitude toward residents. | |
| Staff C | Witnessed Staff D shouting and reported resident statements about rough handling. | |
| Staff B | Conducted investigation and interviews; reported Staff D suspension and reassignment. | |
| Staff E | Reported incidents involving Staff D's attitude and handling of residents. | |
| Staff F | Reported Staff D's poor approach and witnessed incidents. | |
| Staff G | Witnessed Staff D pushing Resident #4. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 1, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the assisted living community Gardens of Gainesville.
Findings
The inspection identified multiple deficiencies including failure to ensure staff had current CPR and First Aid recertifications, failure to display the most recent inspection report and plan of correction in a visible location, failure to maintain daily Medication Assistance Records (MAR) for residents, and failure to obtain timely medication refills resulting in medication unavailability.
Deficiencies (4)
Staff failed to obtain current recertification in cardiopulmonary resuscitation (CPR) and first aid trainings for 1 of 5 sampled staff (Staff C).
The community failed to display a copy of the Department's most recent inspection report and plan of correction in a location routinely used to communicate information to residents and visitors.
The community failed to maintain a daily Medication Assistance Record (MAR) for each resident who received assistance or administration of medications, for 2 of 6 sampled residents (Resident #2 and Resident #6).
The community failed to ensure that refills of prescribed medications were obtained timely so that there was no interruption in routine dosing for 1 of 6 sampled residents (Resident #6).
Report Facts
Sampled staff: 5
Sampled residents: 6
Deficiencies cited: 4
Previous inspection violations: 2
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