Dunwoody Village.

“Resident prescribed a 2-mg tablet every eight hours at scheduled times (6:00, 14:00, and 22:00) did not receive their 22:00 dose on the dates cited, meaning the home failed to follow the prescriber's orders.”

“Medication administration record showed that a narcotic dose scheduled for 22:00 was initialed as administered, but the medication was not actually given to the resident as ordered.”

“Administrator initially refused to provide immediate access to a video recording requested by a Department agent, citing corporate policy and confidentiality concerns, rather than providing access to documentation pertaining to the home and residents upon request.”

“Staff person B was observed slapping a resident's hand, stating disrespectful comments including 'this is why nobody likes you,' and waving a crumpled napkin in front of a resident with visual and hearing impairments. The resident responded by saying 'don't hit me.'”

“A prescription medication pill pack for a resident was taped due to a tear in the packaging, which does not comply with manufacturer's instructions for proper storage under proper conditions of sanitation, temperature, moisture, and light.”

“Staff person spoke to a resident in an angry and disrespectful tone in the Cedar East hallway. The incident was observed by another staff member and reported internally around 6:50pm, but the allegation of abuse was not reported to the Area Agency on Aging as required by the Older Adult Protective Services Act.”

“Staff person communicated to a resident in a harsh, loud, and disrespectful yelling tone about not entering another resident's room during personal care, using demeaning language that was not respectful of the resident's dignity.”

“Staff person directed the spouse of a resident to leave the room while personal care assistance was being provided to the resident, potentially restricting the resident's right to freely associate and communicate with others privately.”

“A resident prescribed pain medication tablets as needed did not have the medication available in the home at the time of inspection (2:20pm on the inspection date), indicating inadequate procedures for safe storage, access, and distribution of medications.”

“A resident reported to staff that they were afraid of a staff member and that the staff member was mean to them. This alleged abuse was not reported to the local area agency on aging until 1:45 PM on the same day, in violation of immediate reporting requirements under the Older Adult Protective Services Act.”

“A resident reported to staff that they were afraid of a staff member and the staff member was mean to them. The home did not report this incident to the department within 24 hours as required.”

“Two resident home contracts (dated 4/15/2024 and 7/30/2024) were not signed by the residents, and there was no indication that the residents were given the opportunity to sign.”

“A resident reported to staff that they were afraid of a staff member and that the staff member was mean to them. On another date, the resident reported to a nurse practitioner that the staff member pressures them to take medication and does not give space to ask questions. The resident became visibly upset when discussing interactions with this staff member, indicating the resident was not being treated with dignity and respect.”

“The administrator's list of staff persons does not include substitute staff members, in violation of the requirement to maintain a current list of names, addresses, and telephone numbers of all staff persons including substitute personnel.”

“A staff member on their first day of work did not receive orientation on telephone use and notification of emergency services, which are required topics for fire safety and emergency preparedness orientation.”

“A resident admitted to the Secure Dementia Care Unit on 4/15/2024 did not have an initial support plan completed until 4/19/2024, which is 4 days after admission instead of the required 72 hours.”

“When a resident alleged that staff member A hit them on the shoulder, the home did not develop and implement a plan of supervision or suspend the staff person involved in the alleged incident as required.”

“One camera was located outside the lobby, two cameras in the lobby, and one camera by the elevator with no signs indicating that these cameras were recording. Staff stated that signage had been removed to make room for wreaths, violating resident privacy rights during sensitive areas.”

“In early July 2024, an unknown person accessed the Cedar Wing and stole credit cards from residents' wallets and possessions. The home did not have a system in place to safeguard residents' money and property.”

“Staff person A completed scheduled work hours on 4/10/2023 but did not complete required orientation training within 40 scheduled working hours, including emergency medical plan, reporting of reportable incidents and conditions, mandatory reporting of abuse and neglect, and resident rights.”

“Direct care staff person D received only 3 hours and 38 minutes of annual training during training year 1/1/2023-12/31/2023, failing to meet the minimum 12 hours required. Training hours for staff person E could not be verified due to incomplete training records.”

“Direct care staff person D did not receive training in personal care service needs, instruction on meeting resident needs from assessment documents, medication self-administration, and safe management techniques during 2023. Staff person E did not receive training in instruction on meeting resident needs, personal care service needs, and safe management techniques during 2023.”

“The home's record of direct care staff training does not include date, source, content, length of each course, and copies of certificates received as required.”

“On 8/5/2024 at 9:51 am, a full uncovered gray trash can containing used masks, water bottles, soda cans and other garbage was located in front of the care center entrance, failing to keep trash in covered receptacles that prevent insect and rodent penetration.”

“The home failed to report an incident of alleged abuse within 24 hours. A resident reported that staff was rough while assisting with medication administration, specifically that the staff person "yanked" the resident's arms. The incident was not reported to the Department within the required 24-hour timeframe.”

“Resident 1 did not have an annual medical evaluation completed as required. The resident's previous medical evaluation was completed more than one year before the inspection date.”

“Suspected abuse of a resident was not immediately reported to the Personal Care Administrator or Older Adult Protective Services. A family member reported observing a resident wearing multiple personal care products on various days in late January 2024, but this allegation was not properly escalated by staff.”

“A resident was wearing multiple incontinence products (2 to 3 incontinence underwear and an additional absorbent pad) simultaneously, violating the resident's right to be treated with dignity and respect. This is a repeated violation from previous inspections.”

“Criminal background checks were not on file for three individuals working at the facility: two painters observed unattended on the Leeland level at 2:30pm on 2/15/24 and a contractor working on the side door of the main corridor hallway at 2:45pm on 2/15/24.”

“Rooms 17a and 114 did not have an operable window, fan, air conditioner or other mechanical ventilation to ensure airflow as required for all areas of the home used by residents.”

“The medical evaluations for resident #1 and resident #2 did not include required medical information regarding diagnosis and treatment as specified in the regulation.”

“A container of artificial tears with a prescription label was observed unlocked in a resident's room. The resident has not been assessed as capable of self-administering medications, so the medication should have been kept locked. This is a repeated violation from a previous inspection.”