ATLANTA, GA - Federal inspectors documented multiple serious violations at Nurse Care of Buckhead, including failure to conduct required criminal background checks on key staff members and systematic failures in laboratory testing protocols that left residents without critical medical monitoring for months.
Background Check System Breakdown
The most extensive violation centered on the facility's failure to conduct required criminal background checks and fingerprint screenings for multiple staff members in direct contact with residents. According to the inspection report, the facility failed to complete criminal background checks for a Registered Nurse serving as MDS Director and a Licensed Practical Nurse working as MDS Coordinator, despite offer letters specifically stating employment was contingent on passing these screenings.
More concerning was the facility's failure to conduct Georgia Criminal History Check System (GCHEXS) fingerprint checks for numerous employees, including two administrators, three Certified Medication Aide Techs, one Certified Nursing Assistant, the Regional Director of Business Development, and the Maintenance Director. Additionally, two CNAs who had been employed for years had not undergone required re-fingerprinting under the state's Rap Back system.
The inspection revealed that employee files for an administrator and a medication aide could not be located anywhere in the facility. The Regional Human Resource Director acknowledged that "the employees' fingerprints had not been retained under the Rap Back program" and confirmed she was "unable to produce an employee roster for the surveyor to review."
Background screening serves as a fundamental safeguard in healthcare settings. Criminal history checks help identify individuals who may pose risks to vulnerable populations, particularly elderly residents who may have cognitive impairments or physical limitations that make them unable to protect themselves. The Georgia Rap Back system provides ongoing monitoring that alerts facilities if employees are arrested or convicted of crimes after their initial hiring.
Laboratory Testing Failures Put Residents at Risk
The facility systematically failed to obtain ordered laboratory tests for residents, creating potentially dangerous gaps in medical monitoring. The most serious case involved a resident taking Coumadin (warfarin), a blood-thinning medication that requires regular monitoring through PT/INR testing to prevent life-threatening bleeding or clotting complications.
Records showed that between February and May 2024, multiple physician orders for PT/INR testing went unfulfilled. The resident's Nurse Practitioner documented concerns about the facility's laboratory practices, noting: "The facility lab has been slacking with INR draws, I had a conversation with their nurse manager regarding INR every week."
Another resident experienced similar problems when ordered laboratory tests for new onset confusion and routine diabetes monitoring were not completed in January 2025. These tests included complete blood counts, comprehensive metabolic panels, and diabetes screening - all essential for monitoring the resident's multiple medical conditions.
PT/INR monitoring is critical for patients on warfarin therapy because the medication has a narrow therapeutic window. Too little anticoagulation can lead to stroke or blood clots, while excessive anticoagulation can cause serious bleeding. Regular monitoring allows physicians to adjust dosages to maintain safe, effective treatment levels.
Similarly, laboratory monitoring for diabetic patients helps detect complications early and guides treatment decisions. Delayed or missed testing can result in unrecognized blood sugar fluctuations, kidney problems, or other serious complications.
Staff Training and Competency Gaps
The facility failed to provide evidence of required annual competency evaluations for Certified Medication Aide Techs, who are responsible for administering medications to residents. Georgia regulations require nursing homes employing medication aides to conduct comprehensive clinical skills competency reviews annually and quarterly unannounced medication administration observations.
When inspectors requested competency documentation for three medication aides, the facility could not produce the required records. One medication aide interviewed stated she did not recall completing any skills competency evaluation. The consultant pharmacist confirmed she had not observed medication administration by these staff members, contrary to regulatory requirements.
Medication administration competency evaluations ensure that staff members maintain the skills necessary to safely prepare and deliver medications. These assessments typically cover proper dosage calculations, medication preparation techniques, patient identification procedures, and recognition of adverse drug reactions. Without regular competency validation, facilities cannot ensure their medication aides possess current knowledge and skills needed to prevent medication errors.
Staffing Information Transparency Issues
The facility violated federal requirements for posting daily nurse staffing information in areas accessible to residents and visitors. During the inspection, staffing information was either completely absent or posted in print so small that staff members confirmed they could not read it.
The Staffing Coordinator acknowledged discarding posted staffing information daily instead of maintaining it for the required 18-month retention period. This information helps residents and families understand the level of care available and make informed decisions about their healthcare.
Public staffing information serves multiple purposes: it helps residents and families assess care quality, enables oversight by regulatory agencies, and promotes transparency in nursing home operations. When facilities fail to post readable staffing information or maintain required records, they undermine public accountability and regulatory oversight.
Additional Issues Identified
The inspection revealed other concerning practices, including an employee working as a Certified Medication Administration Tech who could not be verified on the state's CNA registry and had no employee file available for review. Email correspondence confirmed that no background checks had been completed for the facility through the required system.
The facility's Interim Director of Nursing acknowledged the laboratory testing problems and stated the facility lacked written policies for obtaining laboratory tests. She indicated plans to meet with laboratory management to clarify processes and re-educate staff.
The Regional Human Resource Director committed to implementing weekly and monthly audits of employee files to ensure compliance with state and federal requirements. She acknowledged that the previous human resources employee "was not doing the job" and had been terminated.
These violations highlight the importance of robust administrative systems in nursing home operations. Proper background screening protects vulnerable residents, while systematic laboratory monitoring ensures residents receive appropriate medical care. Regular competency evaluations maintain care quality, and transparent staffing information promotes public accountability.
The facility's acknowledgment of these problems and commitment to corrective measures suggests recognition of the serious nature of these violations and the potential impact on resident safety and care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Nurse Care of Buckhead from 2025-03-04 including all violations, facility responses, and corrective action plans.
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