05/18/2020- COMPLAINT HEALTH SURVEY- GLEN AT LAKE OCONEE VILLAGE, THEPRINTED: 8/19/2020
FORM APPROVED State of GA, Healthcare Facility Regulation Division
State of GA Inspection Report
STATE FORM 6899 6FH511 If continuation sheet Page 1 of 2
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
05/18/2020
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 investigate intake #GA00205200. The intake was started on
5/14/20 and completed on 5/18/20.
{L 0711}
SS= D
111-8-63-.07(2)(j) Owner Governance.
At a minimum, the policies and procedures that are developed must provide direction for the staff
and residents on the following: ...
(j) the investigation and reporting of abuse, neglect, exploitation of residents, residents' wandering
away from the community, accidents, injuries and changes in residents' conditions to required
parties; ...
This REQUIREMENT is not met as evidenced by:
Based on interviews and record reviews, the facility failed to report changes in residents'
conditions to required parties; ...
A review of the facility COVID -19 audit tool results forms dated 4/25/20. 4/26/20, 5/10/20,
showed zero for the total number of residents who have tested positive for COVID-19.
During an interview on 5/14/20 at 8:30 a.m., Staff A reported that Resident #1 had tested positive
for COVID-19 on 4/11/20.
During an interview on 5/18/20 at 12:37 p.m., AA stated that he/she viewed COVID-19 on
Department of Community Health website and the facility was not listed on the website as having
a resident with COVID-19. AA stated that he/she talked with Resident # 1's last home healthcare
provider and the last facility that he/she received care from, and that facility confirmed that
Resident #1 was diagnosed with COVID-19. AA stated that Resident #1 has had COVID-19 for
one month.
PRINTED: 8/19/2020
FORM APPROVED State of GA, Healthcare Facility Regulation Division
State of GA Inspection Report
STATE FORM 6899 6FH511 If continuation sheet Page 2 of 2
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
05/18/2020
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)
A review of the hospital discharged dated 4/30/20 for Resident #1, showed COVID-19
Pneumonia.
A review of the file for Resident #1, showed the following diagnoses COVID-19, hypertension,
diabetes mellitus type 2. hyperlipidemia, and dementia.