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 to two hours later, a family member arrived and thought the resident was sleeping until a staff member came to the room and said the resident was unresponsive.

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 as required.

The violations resulted in a $601 fine. The facility now operates under a new owner and name, The Retreat at Buford. The new operator, Phoenix Senior Living, said it couldn’t address a case that occurred under the former operator.

DCH citation: Excerpt from the report documenting the incident at Ivy Springs Manor in which a resident who was thought to be sleeping instead required medical care.