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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.