Summer Breeze Senior Living at 351 Wilmington Island Road in Savannah. (Hyosub Shin / Hyosub.Shin@ajc.com)
Photo: HYOSUB SHIN / AJC
Photo: HYOSUB SHIN / AJC

20 deaths linked to violations at Georgia senior care homes

At these 20 assisted living or personal care homes, state regulators cited violations in cases linked to residents’ deaths.

Cedar Hill Senior Living Facility, Cedartown. A resident suffocated after becoming pinned between a bed and a raised bedrail. The home was using the rails because the resident, who had cognitive impairments, had the habit of getting out of bed. In a 2015 report, the Department of Community Health said the home should not have retained anyone who needed physical restraints for behavioral control. The death occurred before Chicago-based Charter Senior Living became involved in the community, said Hilary King, a regional director for the company: “We wouldn’t know anything about it.”

The Bridge at Lawrenceville. The Heimlich maneuver was performed when a resident was seen slumped over a table, unresponsive. The resident then started to breathe but became unresponsive again, and EMS was notified. The next day, the resident died of conditions that included “aspiration as evidence by food particle removal in the ER.” The resident had been served food that didn’t conform to a prescribed therapeutic diet. The resident had asked for a hot dog, so employees chopped one into pieces and put them on a bun before serving it, according to a 2017 DCH report. Another employee said the hot dog should have been run through a process to grind up the meat and not served on a bun. The facility did not respond to an AJC message seeking comment.

Morningside of Savannah at 7410 Skidaway Road in Savannah. (Hyosub Shin / Hyosub.Shin@ajc.com)
Photo: HYOSUB SHIN / AJC

Morningside of Savannah. A resident who was required to have assistance with walking and bathing was found one morning in the shower with the water running, leaning his/her head against the shower stall. The resident was lethargic, wasn’t able to respond verbally, and had a bump on the head and redness on the legs and feet. Staff called 911, and the resident was taken to a hospital emergency room. From there, the resident was transported to another hospital’s burn unit with burns to the lower left leg from the hot shower. The resident died six days later. A staff member told DCH the resident had not been checked during the night. The staff member also said the resident was not supervised when walking or bathing, according to a January 2015 inspection report. A family member later said that the doctor had ordered supervision during showers because of the resident’s poor vision. The facility declined to comment to AJC for this report.

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John-Wesley Villas, Macon. A 2015 sheriff’s report shows that a 92-year-old with dementia was found dead about 4 a.m. in the grass at the bottom of a steep embankment outside her apartment. A Georgia Department of Community Health report says the alarm that should have alerted the staff that she was wandering couldn’t be heard two doors down from the activated room, so the staff didn’t hear it when she left. The facility did not respond to an AJC message seeking comment.

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Ivy Springs Manor, Buford. A resident who usually was able to walk without assistance moved slowly and held on to the railing walking to the dining room one morning in 2015. That evening, the resident fell asleep at dinner and didn’t eat, then needed two staff members’ help to return to his/her own room. Another staff member was notified of the resident’s unusual behavior. The next morning, a staff member was unable to wake the resident. The resident’s temperature and blood pressure were found to be normal, but the resident didn’t respond even when his/her face was wiped with a cool cloth. About 90 minutes later, a family member arrived and told about the resident’s condition when a staff member came to the room. Another staff member was then notified and decided 911 should be called. At the hospital, the resident was diagnosed with a large subdural hematoma, or bleeding on the brain, and died two days later. In citing the home, DCH said it failed to respond appropriately to an adverse change in the resident’s condition and did not report the death to the agency. The facility now operates under a new owner and name, The Retreat at Buford. The new owner said it couldn’t address a case that occurred under the former owner.

Summer's Landing Senior Living Community, located at 311 Jerriel Street, in Vidalia. (Alyssa Pointer/alyssa.pointer@ajc.com)
Photo: Alyssa Pointer

Summer’s Landing, Vidalia. A resident who was on a blood thinner suffered a knot on the head and was sleepy throughout the day after falling at the home. But there was no documentation that the resident’s physician was called. The next day, the resident was found on the floor again. Employees called the resident’s representative to report the fall and were told to call 911. An EMS report showed the home’s call came in 51 minutes after the resident had been found. At the emergency room, doctors found the resident had suffered a subdural hematoma — a type of severe head injury that causes blood to pool and put severe pressure on the brain. A few days after this 2016 incident, the resident died. A manager told DCH he/she didn’t know why the staff took 51 minutes to call 911. It may be because the staff wasn’t trained on what to do when a person taking a blood thinner suffers a fall, the manager said. Affinity Living Group assumed management of the facility in late July 2019 and is working to reinvent the community and has zero tolerance for negligence, a spokesman said. As part of that effort, the new executive director has replaced more than 20 staff members and overhauled care practices, the spokesman told the AJC.

Peregrine’s Landing at Emory Heights, Decatur. When a caregiver turned away to get disposable washcloths while providing incontinence care, a 90-year-old resident rolled out of bed and fell to the floor. Staff members reported the resident was conscious and talking after the fall and put the resident back onto the bed before calling hospice, the resident’s family and 911. Seventeen days later, the resident died. The staff told EMS that the resident had climbed over a bedrail. But a doctor who looked at the patient was unsure that the resident, who recently had had a stroke and suffered from severe dementia and an irregular heartbeat, would have been able to climb out of bed, DCH reported. It cited the facility in 2016 for failure to provide watchful oversight. The facility now has a new owner and name, the Madeline of Decatur. The company said it is aware of the tragic event and has worked to improve safety throughout the facility.

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Summer Breeze Senior Living, Savannah. After an emergency call bell wasn’t answered for 26 minutes, according to the call bell system log, a resident was found with no pulse and not breathing. It was an additional 19 minutes before EMS dispatch received a call of a possible cardiac arrest. Eight minutes after that, EMS arrived and took the resident by ambulance to the hospital, but it was too late. When the state later investigated the 2016 death, a staff member reported responding to the resident’s emergency pager but leaving the room after finding the resident in bed with no complaints. Five minutes later, the staff member told DCH, the pager sounded again. When the staff member returned to the room, the resident was on the floor with no pulse and not breathing. CPR was unsuccessful, so the staff member went looking for another caregiver, who was upstairs, to help. It took six to eight minutes to find the other staffer, then both went to the resident’s room and resumed CPR. The first staff member explained that employees were to stay on their own floors and the only way to contact one another was to go and search. Staff weren’t allowed to carry cellphones and did not have walkie-talkies. The manager told DCH that walkie-talkies were not given out free but the staff could purchase them from the facility. A facility administrator declined to comment other than to say that the state’s report didn’t provide a full picture of what happened.

Sparks Inn Retirement Center, Union City. In mid-December 2015, a resident who was supposed to have help with walking and transferring from bed to chair fell and suffered a concussion, then the next month had 10 more unwitnessed falls. Five of the January falls resulted in medical attention for issues including a bruised foot, a broken ankle and broken toes. The resident later died of a cerebral hemorrhage. The home’s administrator said the resident became increasingly confused and would attempt to get up without requesting assistance. The staff’s intervention was to monitor the resident every two hours. DCH said the home shouldn’t have retained a resident whose needs it couldn’t meet. The facility did not respond to an AJC message seeking comment.

Lanier Place, a senior living facility located at 440 Tribble Gap Road in Cumming. (Alyssa Pointer/alyssa.pointer@ajc.com)
Photo: Alyssa Pointer

Lanier Place, Cumming. The home admitted a resident who needed services beyond what the home was permitted to provide, then didn’t provide adequate supervision, DCH found in a 2016 report. This was a resident who had dementia and muscle weakness, needed to be in a specialized memory care unit and required total assistance with walking, bathing, dressing, grooming and transferring to bed, chair or wheelchair. At night, the resident needed help with toileting and incontinence care. About two weeks after being admitted, the resident fell out of a wheelchair, suffering a large hematoma on the forehead. At a hospital, the resident was diagnosed with a closed head injury then discharged back to the facility the same day. Four days later, the resident was found on the floor of an empty room. This time, the resident was diagnosed with a broken pelvis and discharged to the facility the next day with an order for two weeks of bed rest. Five days after being discharged, the resident was found not breathing and was rushed backed to the hospital and found to have severe sepsis. Four days later, the resident died. The facility did not respond to an AJC message seeking comment.

Ivy Hall, a senior living facility located at 5690 State Bridge Road in Johns Creek. (Alyssa Pointer/alyssa.pointer@ajc.com)
Photo: Alyssa Pointer

Ivy Hall Assisted Living, Johns Creek. A resident had an unwitnessed fall in his/her room in January 2016 and was sent to the emergency room, where it was found the resident had a broken rib. The same day, the resident returned to the home. The next day, the resident had another unwitnessed fall and was sent to the hospital again. A day later, the resident died. The home’s administrator didn’t report the death to DCH for more than two weeks. When DCH inspected the facility, the administrator was no longer employed there, and a staff member said he/she had no additional information. A spokesman described the late reporting of the incident as a clerical error and told the AJC that the community is now deficiency free.

Sunrise of Decatur. A staff member turned a memory care resident onto his/her side to give incontinence care but then left to go get some “wipes” in the bathroom, DCH reported in 2016. When the staff member returned, the resident was on the floor. The staff member summoned another employee to help get the resident back onto the bed, noting the only injury as a scrape on the forehead. Hospice and the family were notified. Over the next 12 days, on as many as four occasions, various staff members reported that the resident’s body language indicated that he/she was in pain. In one instance, a staff member wrote that the resident looked as though he/she “wanted to scream.” A staffer said when the resident’s legs were moved, the resident would make a face and shake. Hospice services prescribed pain medication, and X-rays were ordered. On the 12th day after the incident, the resident was hospitalized. Diagnosed with a broken hip, the resident died 11 days after being admitted. A company spokeswoman declined to comment to the AJC.

Dalton Place senior living community, located at 1300 West Waugh Street in Dalton. (Alyssa Pointer/alyssa.pointer@ajc.com)
Photo: Alyssa Pointer

Dalton Place, Dalton. In 2017, the home didn’t take immediate actions or call 911 when a resident who was taking blood pressure medications became disoriented, struggled to breathe and lay in bed crying and sweating profusely. Shortly after 8 the evening that the resident fell ill, an employee found the resident had a blood pressure reading of 197/113, a crisis level. The employee called another staff member for advice and was directed to perform a manual blood pressure check. It was still high, 186/122. The employee asked if the resident wanted blood pressure medication, but the resident shook his/her head and made a strange sound. So the staff member made a second call to the colleague, who said to call the resident’s family and ask family members to persuade the resident to take the medication. Later, a family member told DCH that the home didn’t say the resident’s blood pressure was elevated. It was 10:32 p.m. before the home called 911. The resident died the next morning of a stroke. The facility did not respond to an AJC message seeking comment.

Sunrise at East Cobb assisted living is a facility where resident Adam Bennett died. Bob Andres / robert.andres@ajc.com
Photo: Bob Andres/robert.andres@ajc.com

Sunrise at East Cobb, Marietta. A World War II veteran died after suffering broken ribs, a punctured lung, a damaged kidney and other injuries in August 2017. Police accused a caregiver of abuse in the death of 91-year-old Adam Bennett. But in July, a Cobb County jury rejected murder charges against the caregiver, Landon Terrel, and convicted him of elder neglect, the least serious charge he had faced. In August, Terrel was sentenced to five years behind bars. “This situation still weighs heavily on all of us here in Atlanta,” said Michelle Minor, vice president of operations at Sunrise Senior Living. “We have some of the most compassionate, dedicated team members in the industry, and this tragic situation is not representative of our larger team’s values.” Minor said the company had made staffing changes and retrained workers on abuse and neglect protocols.

Arbor Terrace Peachtree City. A dementia resident who had fallen 17 times over nine months fell again, calling for help using a call pendant. A staff member found the resident face down on the floor. The resident was taken to the emergency room, then transferred to another hospital and diagnosed with bleeding of the brain, according to the family. A staff member told DCH that after discharge from the hospital, the resident went to a rehabilitation center and fell again and was admitted back into the hospital with bleeding on the brain. This was a resident who had been admitted to Arbor Terrace using a rolling walker to get around and whose family provided a private sitter for five hours every day, DCH noted in 2017 as it cited the facility for failing to ensure adequate and appropriate care. The facility did not respond to an AJC message seeking comment.

Perfect Care at 114 Sullivan Drive in Americus. HYOSUB SHIN / HSHIN@AJC.COM
Photo: HYOSUB SHIN / AJC

Perfect Care, Americus. In 2017, DCH found the home had not taken appropriate actions when a resident who used a walker fell in the activity room and later died of an active brain bleed. An incident report on the date of the fall showed that the resident reported having no pain or discomfort after falling, but a small hematoma was seen on the back of the head. A staff member wrote “OK” regarding neuro checks, though there was no documentation of the resident’s vital signs or neurological vital signs. In an assessment the next morning, the resident showed signs of “altered mental status,” high blood pressure and lethargy. The resident died six days after being hospitalized. In a written statement to the AJC, the company said it thought it had provided proper care to the resident under the circumstances. The owner attributed the state citation to a nurse’s failure to document the resident’s vital signs, not to improper care.

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Scepter Senior Living Center, Snellville. The center admitted a resident who had dementia with behavior disturbance and muscle weakness. A physician’s medical evaluation showed the resident required supervision with walking and eating, as well as assistance with bathing, dressing, grooming and transferring to a bed, chair or wheelchair. The home’s service plan for the resident said the resident also required help with toileting and that staff was to help prevent falls by toileting the resident every two hours or as needed. The resident had a bed and chair alarm to alert staff if the resident tried to walk unassisted. A family member told DCH that the facility also said that the staff in the memory care unit would stay with the resident in the bathroom to prevent falls. Nevertheless, one day a staff member helped the resident to the bathroom, then left to help someone else. Left alone, the resident walked out without pulling up a diaper and fell. A hospital found the resident suffered bleeding on the brain and a broken femur. The resident never woke up from hip surgery. Immediate cause of death was multiple medical conditions aggravated by closed head trauma with fracture of the left hip, according to a 2017 DCH report. The facility now is under a new operator and a new name, Senior Living Suites at Parkside. The new management did not respond to an AJC call seeking comment.

Suites at Willow Pond, Statesboro. At the dining room table, a memory care resident slumped over and was drooling and unresponsive. Staff members found a pulse, though, and saw the resident was breathing. So one employee went to call 911 and the family, while another staff member took the resident to his/her room and pounded on the resident’s back twice, fearing there might be something lodged in the throat. The resident took two deep breaths, but nothing came out, the employee said. By the time EMS arrived, the crew found the resident slumped in a wheelchair with no pulse and not breathing. Three staff members were just standing by the resident, one EMS crew member later told DCH. Another EMS crew member reported asking if there was a “do not resuscitate” order, thinking there must have been one if no one on the staff was doing CPR. An employee left the unit to see if there was a order. Told by staff that there was none, the crew took the resident out of the wheelchair and began CPR. The resident was taken to the hospital in cardiac arrest and died. The staff later told DCH that staffers hadn’t taken the resident out of the wheelchair because they were afraid of hurting him/her. They also said the family had asked that everything possible be done to revive the resident. The facility declined to comment.

Mountain View Personal Care Home at 3675 Kensington Road in Decatur. (Hyosub Shin / Hyosub.Shin@ajc.com)
Photo: HYOSUB SHIN / AJC

Mountain View, Decatur. One day, a resident who recently had been up walking around the facility was noted in bed, screaming out in pain. The woman, who had trouble speaking and suffered from dementia, couldn’t say why. Administrators denied that the woman had fallen. But her daughter kept insisting something was wrong and pressing for answers. Days later, as the woman continued to be in pain, a hospice nurse obtained an order for an X-ray. It revealed that the resident had a broken hip. A hospital also found she had pressure ulcers at the base of her spine, buttocks and right elbow and that she was severely dehydrated. She had surgery on the hip but died a few months later. Complications from her broken hip contributed to her death, records show. The state cited the facility for failing to provide proper care and failing to take appropriate action when the woman’s condition changed. The facility did not respond to AJC messages seeking comment. In response to a lawsuit filed by the woman’s family, the facility denied any negligence.

Somerby Sandy Springs. A week after a 92-year-old woman was repeatedly bitten by ants in her bed, she died. Ants had been reported in Betty Perloe’s room a week before the first attack, but a facility maintenance crew missed the work order to eradicate the insects, state records show. Then on Oct. 1, 2018, ants bit Perloe while she was in bed. The room was sprayed, but the next day ants again were found in her bed and over her body. They bit her midsection, her breasts and arms, records show. She died on Oct. 9. A lawsuit filed by her family says she endured horrible pain in her final days and was given large doses of morphine to ease her suffering. The lawsuit alleges that her injuries contributed to her death. When the state investigated the incident months later, a staff member told regulators they were still unsure why the work order for pest control was missed. The facility was cited by state regulators for failing to maintain safe conditions in the home and for failing to have an adequate pest control program. The facility didn’t respond to AJC requests for comment.

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