Lake Emory Post Acute Care

In the surveyor’s words

From the most serious findings on record at Lake Emory Post Acute Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 14, 2024

  Based on interview, record review, and review of facility policy, the facility failed to ensure Residents (R)2 and R3 were free from neglect, which resulted in R2 and R3 successfully eloping from the facility, for 2 of 6 residents reviewed for neglect. On 08/13/24 at 6:31, PM, the Administrator was notified that the failure to properly supervise two residents, resulting in the two residents successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at F600. On 08/14/24 at 12:52 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 08/11/24. The IJ was related to 42 CFR 483.25 - Freedom from Abuse, Neglect, and Exploitation. […]

• Immediate jeopardy, isolatedF689Aug 14, 2024

  Based on interviews, record review and review of facility policy, the facility failed to provide appropriate supervision to prevent Resident (R)2, and (R)3's elopement from the facility. On 08/13/24 at 6:31 PM, the Administrator was notified that the failure to properly supervise two residents, resulting in the two residents successfully eloping from the facility, constituted Immediate Jeopardy (IJ) at F689. On 08/13/24 at 6:31 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 08/11/24. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision. On 08/14/24, the facility provided an acceptable IJ Removal Plan. […]

• Immediate jeopardy, isolatedF678Apr 5, 2021

  Based on record review, interview, and review of facility files, the facility failed to provide basic life support to Resident #1, 1 of 6 sampled residents reviewed for death in the facility. Cardiopulmonary Resuscitation (CPR) was initiated for Resident #1 and was discontinued prior to the arrival of emergency medical personnel. The findings included: Resident #1 was admitted to the facility with Full Code status on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation, including witness statements, on [DATE] at 10:11 AM, revealed Resident #1 was found in bed, on [DATE] at 12:30 AM, unresponsive with no pulse and no respirations. […]

• Immediate jeopardy, isolatedF684Apr 5, 2021

  Based on record review, interview, review of facility files and facility policy, the facility failed to provide care in accordance with professional standards of practice and the resident's choices for 1 of 6 sampled residents reviewed for death in the facility. Cardiopulmonary Resuscitation (CPR) was initiated for Resident #1 and was discontinued prior to the arrival of emergency medical services (EMS). The findings included: Resident #1 was admitted to the facility with Full Code status on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility investigation, including witness statements, on [DATE] at 10:11 AM, revealed Resident #1 was found in bed, on [DATE] at 12:30 AM, unresponsive with no pulse and no respirations. […]

• Actual harm, isolatedF689Jan 23, 2026

  Based on observations, record reviews, interviews, and policy review, the facility failed to provide adequate supervision and maintain an environment free from accidental hazards for one (1) of two (2) residents reviewed for falls (Resident (R)15). R15 had ten documented falls between August 24, 2025, and December 12, 2025, three (3) of which resulted in fractures. A fall on August 24, 2025, resulted in a nasal fracture, and a fall on September 10, 2025, resulted in a subdural hematoma and right clavicle fracture. Specifically, the facility failed to identify an environmental hazard for a resident with a known history of falls. On December 12, 2025 at 3:20 p.m., the facility failed to identify an environmental hazard for a resident with a known history of falls. […]