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4/9/2019 - ROUTINE HEALTH SURVEY - GLEN AT LAKE OCONEE VILLAGE, THEPRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 UTLO11 If continuation sheet Page 1 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 04/09/2019 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) {L 000} Initial Comments. >>>>The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00195302. An on-site visit was made on 3/28/19 and the survey was completed on 4/9/19. {L 0925} SS= D 111-8-63-.09(12) Criminal History Background Checks- Employees Criminal History Background Checks for Employees Required. Prior to serving as an employee, other than a director of an assisted living community, the community must obtain a satisfactory records check determination for the person to be hired in compliance with the provisions of O.C.G.A. § 31-7-250 et seq. or specific rules passed pursuant to the statute. This REQUIREMENT is not met as evidenced by: >>>>Based on record review and staff interview, the community failed to obtain a criminal records check determination in compliance with the provisions of O.C.G.A 31-7-250- et seq. for 1 of 6 sampled staff (Staff F). Findings include: A review of the file for Staff F, hired 4/12/17, showed no results of a GCIC criminal background check. During an interview on 3/28/19 at 6:45 p.m., Staff A stated that he/she is unsure as to why Staff F did not have GCIC results in the file. {L 1132} SS= D 111-8-63-.11(9)(a) Fire Safety. The assisted living community must comply with applicable fire and safety rules published by the Office of the Safety Fire Commissioner. PRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 UTLO11 If continuation sheet Page 2 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 04/09/2019 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) This REQUIREMENT is not met as evidenced by: >>>>Based record review and staff interview, the facility failed to comply with applicable fire and safety rules published by the Office of the Safety Fire Commissioner (one fire drill per quarter per shift). Findings include: A review of the fire drills for 2018 showed no drills for October and December. During an interview on 3/28/19 at 6:45 p.m., Staff A stated that he/she does not have any other drills. {L 2057} SS= D 111-8-63-.20(12)(c) Storage and Disposal of Medications. Medications must be properly labeled in separate unit or multi-unit dose packaging and handled in accordance with physician's instructions, and laws and regulations applicable to the medications. This REQUIREMENT is not met as evidenced by: >>>>Based on observation and staff interview, the facility failed to ensure resident medications were in unit dose or multi-unit dose packaging for 3 of 5 sampled residents (Resident #1, Resident #4, Resident #6). Finding include: A review of medications for Resident #1, Resident #4, and Resident #6 showed medications in pill bottles. During an interview at 6:45 p.m., Staff A stated that he/she was unaware that medications had to be bubble-packed. {L 2058}111-8-63-.20(12)(d) Storage and Disposal of Medications. PRINTED: 10/24/2019 FORM APPROVED State of GA, Healthcare Facility Regulation Division State of GA Inspection Report STATE FORM 6899 UTLO11 If continuation sheet Page 3 of 3 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: ALC000233 (X2) MULTIPLE CONSTRUCTION A.BUILDING B.WING (X3) DATE SURVEY COMPLETED 04/09/2019 NAME OF PROVIDER OR SUPPLIER GLEN AT LAKE OCONEE VILLAGE, THE STREET ADDRESS, CITY, STATE, ZIP CODE 1070 OLD SALEM ROAD GREENSBORO, GA 30642 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS= D The assisted living community must ensure that it properly disposes of unused medications using the current U.S. Food and Drug Administration or U.S. Environmental Protection Agency guidelines for the specific medications. Authority O.C.G.A. §§ 31-2-7,31-2-8, and 31-7-1 et seq. This REQUIREMENT is not met as evidenced by: >>>>Based on record review and interview, the facility failed to properly dispose of unused medications for 2 of 6 sampled residents (Resident #1 and Resident #2). A review of medications for Resident #1 showed donepezil 23 mg, take one tablet daily. A review of the March 2019 medication administration record (MAR) for Resident #1 showed no listing for donepezil. A review of the medications for Resident #2 showed certavite (take one tablet by mouth once daily). A review of the March 2019 MAR for Resident #2 showed no listing for certavite. During an interview on 3/28/19 at 4:23 p.m., Staff G stated that the donepezil was discontinued on 6/21/18. On the same day at 4:50 p.m., Staff E stated that he/she would call the pharmacy about the certavite.