Inspection Report Summary
The most recent inspection on August 27, 2025, identified deficiencies related to cleanliness and incomplete criminal background checks for staff. Earlier inspections showed a pattern of issues with maintaining clean and well-repaired physical environments, as well as staff background and training documentation. Prior reports also noted medication errors and lapses in resident safety measures, including elopement risks and emergency preparedness. Complaint investigations were mostly substantiated when deficiencies were found, with no fines or enforcement actions listed in the available reports. The facility’s inspection history indicates ongoing challenges with environmental maintenance and staff compliance, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
5.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 27, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004893. The onsite visit and investigation were conducted on 8/27/25.
Complaint Details
The visit was complaint-related, investigating intake #GA50004893. The investigation was completed on 8/27/25.
Findings
The facility failed to ensure that floors, walls, and ceilings were clean and in good repair, evidenced by water stains in Resident #2's apartment ceiling. Additionally, the facility failed to ensure that criminal history background checks were completed for 3 of 3 sampled staff members prior to employment.
Deficiencies (2)
Floors, walls, and ceilings were not kept clean and in good repair, as evidenced by water stains in Resident #2's apartment ceiling.
Failure to ensure criminal history background checks were completed for 3 of 3 sampled staff members prior to employment.
Report Facts
Number of sampled staff without criminal background checks: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | One of the 3 sampled staff members without criminal background checks. | |
| Staff C | One of the 3 sampled staff members without criminal background checks. | |
| Staff D | One of the 3 sampled staff members without criminal background checks. | |
| Staff A | Interviewed staff aware of leaks in Resident #2's apartment and missing criminal background checks. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238825, starting on 10/11/2023 and completed on 11/1/2023.
Complaint Details
Investigation was initiated due to intake #GA00238825.
Findings
The facility failed to ensure that walls, floors, and ceilings were kept clean and in good repair, with observations including stained carpets, stained toilets, sticky floors, old food in the refrigerator, scattered items and strong odors in resident rooms, and a hole in the wall near the baseboard.
Deficiencies (1)
Facility failed to ensure that the walls were kept clean and in good repair, including stained carpets, stained toilets, sticky floors, old food in refrigerator, and a hole in the wall near the baseboard.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding room conditions and resident cooperation with cleaning. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00231057, GA00230038, and GA00229700.
Complaint Details
Investigation was started on 2/1/2023 and completed on 2/10/2023. No rule violations were found.
Findings
No rule violations were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 18, 2022
Visit Reason
The purpose of this visit was to investigate intake# GA00227187 regarding an incident where Resident #1 received incorrect medications.
Complaint Details
The investigation was triggered by a complaint intake# GA00227187 concerning a medication error on 8/17/22 where Staff B dispensed incorrect medications to Resident #1. The incident was substantiated by interviews and review of the facility incident report. Resident #1 was transported to the ER after 911 was called and did not return to the facility.
Findings
The facility failed to provide and document medication training for Staff B, who was not proxy trained or certified and dispensed incorrect medications to Resident #1. Resident #1 received another resident's medications, was transported to the ER, and never returned to the facility.
Deficiencies (2)
The facility failed to provide and document medication training regarding Staff B.
The facility failed to provide Resident #1 adequate and appropriate care after the medication error.
Report Facts
Date of incident: Aug 17, 2022
Date of interviews: Oct 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Staff B's training and medication error | |
| Staff B | Caregiver | Dispensed incorrect medications to Resident #1 and acknowledged lack of proxy training |
| Staff C | Placed medications into cups and notified 911 and Resident #1's family after error | |
| AA | Resident #1's family member notified of the incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 21, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223018.
Complaint Details
Investigation started on 2022-04-19 and was completed on 2022-04-27. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 31, 2022
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaints #GA0022463, #GA0022463, #GA00221961, and #GA00221852. The investigation started on 2022-03-15, with an onsite visit on 2022-03-31.
Complaint Details
The investigation was complaint-driven, investigating complaints #GA0022463, #GA0022463, #GA00221961, and #GA00221852. The investigation started on 2022-03-15, with onsite visit on 2022-03-31. Staff and resident interviews confirmed awareness of findings.
Findings
The facility failed to comply with disaster preparedness plans, including no fire drills conducted in 2021, failed to ensure direct care staff had at least 16 hours of annual training for 2 of 4 sampled staff, failed to comply with local fire safety ordinances due to a window that could not be opened manually, failed to keep ceilings and floors in good repair, and failed to update the medication administration record (MAR) for one resident.
Deficiencies (5)
No fire drills conducted in 2021.
Direct care staff failed to have at least sixteen (16) hours of training per year for 2 of 4 sampled staff.
Window in the living room of Resident #2 was closed and unable to open manually, violating fire safety ordinances.
Ceiling tiles were cracked and missing, exposing cement roof; dining room floors had holes and stains.
Medication Administration Record (MAR) was not updated each time medication was offered or taken for Resident #2.
Report Facts
Staff training hours: 16
Number of sampled staff lacking training: 2
Number of sampled residents with MAR issues: 1
Date of MAR with missing entries: Mar 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and aware of multiple findings including fire drills, training hours, window issue, ceiling and floor conditions, and MAR updates | |
| Staff B | Interviewed and noted holes in vinyl floors; identified as one of the staff lacking required training hours | |
| Staff C | Identified as one of the staff lacking required training hours |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 4, 2022
Visit Reason
The visit was conducted to investigate intake #GA00219915.
Complaint Details
Investigation of intake #GA00219915 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 26, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00216778.
Complaint Details
Investigation of intake #GA00216778 completed with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 26, 2021
Visit Reason
The purpose of this inspection was to investigate intake #GA00212738 and #GA00213013, and conduct the compliance inspection. An unannounced visit was made to the facility on 3/26/21, with the investigation starting on 3/22/21 and completed on 4/9/21.
Complaint Details
The inspection was initiated to investigate complaint intake numbers GA00212738 and GA00213013.
Findings
The facility failed to maintain required physical examinations for staff, did not ensure satisfactory criminal background checks prior to employment for some staff, failed to maintain staff files for inspection, and lacked a three-day supply of non-perishable food and water for emergency needs.
Deficiencies (4)
Failed to maintain a physical examination completed by a licensed healthcare provider for 1 of 6 sampled staff (Staff B).
Failed to ensure a satisfactory records check determination prior to employment for 1 of 6 sampled staff (Staff E).
Failed to maintain a staff file in the facility or make it available for inspection by Departmental staff.
Failed to maintain a three day supply of non-perishable food and water for emergency needs.
Report Facts
Number of sampled staff: 6
Dates of inspection: Investigation started 2021-03-22, unannounced visit on 2021-03-26, completed on 2021-04-09
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 11, 2021
Visit Reason
The purpose of this inspection was to investigate complaint intakes GA00211797 and GA00211972.
Complaint Details
Investigation began on 2021-02-08 and was completed on 2021-02-11. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control measures.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 31, 2020
Visit Reason
The purpose of this visit was to conduct a follow-up to the 10/25/19 complaint investigation.
Complaint Details
Follow-up to the 10/25/19 complaint investigation; no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 16, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00200021 and #GA00199935 with an on-site visit conducted on 10/16/2019 and investigation completed on 10/25/2019.
Complaint Details
The investigation was triggered by complaint intakes #GA00200021 and #GA00199935. The complaint involved residents eloping from the facility, inadequate care, failure to report serious injury, and falsification of resident check documentation. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to ensure effective safety devices to protect residents at risk of elopement, resulting in two residents eloping. Additionally, the facility failed to provide adequate care and services for a resident at elopement risk, failed to report a serious injury requiring medical treatment, and staff knowingly falsified documentation regarding resident checks.
Deficiencies (4)
Failed to ensure safety devices were utilized to protect residents at risk of eloping from the premises for 2 of 4 sampled residents.
Failed to ensure each resident received adequate, appropriate care and services in compliance with applicable laws for 1 of 4 sampled residents.
Failed to report a serious injury to the Department for 1 of 4 sampled residents.
Facility staff knowingly falsified information on a facility record regarding resident checks.
Report Facts
Number of sampled residents: 4
Incident dates: Aug 21, 2019
Incident dates: Sep 30, 2019
Incident dates: Oct 6, 2019
Shift hours: 8
Temperature high: 96
Temperature low: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Interviewed regarding alarm sound audibility | |
| CC | Interviewed regarding alarm sound audibility | |
| AA | Interviewed regarding resident elopement, falsified documentation, and incident details | |
| Staff G | Interviewed regarding missing resident and notification | |
| DD | Interviewed regarding resident elopement and video footage | |
| Staff C | Interviewed regarding falsified documentation and resident checks | |
| Staff B | Interviewed regarding resident injury and hospital transfer |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 19, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00195495 following a complaint about an unknown person entering the facility and stealing property.
Complaint Details
The complaint investigation was triggered by intake #GA00195495 regarding an unknown person entering the facility on 3/9/19 at approximately 1:00 a.m. through an unsecured door, wandering the facility, and stealing clothes and a cell phone from Resident #2's apartment. Police responded but did not locate the suspect.
Findings
The facility failed to ensure personnel files included evidence of a satisfactory fingerprint record check for the director/administrator. Additionally, the facility failed to provide reasonable safeguards for resident personal property after an unknown person entered through an unsecured door and stole items from a resident's apartment.
Deficiencies (2)
Personnel file lacked evidence of a satisfactory fingerprint record check determination for the director, administrator, or manager (Staff A).
Failed to ensure reasonable safeguards for the protection and security of resident personal property, resulting in theft from Resident #2.
Report Facts
Residents affected: 1
Total residents: 27
Date of onsite visit: Mar 19, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in fingerprint record check deficiency and interview regarding the incident | |
| Staff B | Reported the unknown person to Staff A and instructed staff to call police |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Sep 7, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/2/18 inspection.
Findings
The facility failed to display the plan of correction from the previous inspection and did not utilize effective safety devices to protect residents at risk of eloping, particularly on the fourth and fifth floors. Cameras were added but were not monitored 24 hours a day, and no safety devices were installed on stairwell doors.
Deficiencies (2)
Facility failed to display a copy of the plan of correction in a location routinely used to communicate information to residents and visitors.
Facility failed to ensure effective safety devices were utilized to protect residents at risk of eloping from the premises, with no safety devices on stairwell doors and inadequate monitoring of cameras.
Report Facts
Residents with cognitive impairment: 4
Inspection dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding lack of plan of correction display and safety devices on stairwell doors. | |
| Staff I | Identified Resident #7 as confused with wandering behaviors. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 27, 2018
Visit Reason
The purpose of this visit was to investigate complaints #GA00186363 and GA00186563. The investigation started on 2018-03-21 and was completed on 2018-03-27.
Complaint Details
The visit was complaint-related, investigating complaints #GA00186363 and GA00186563. The investigation was substantiated by findings of medication disposal and emergency food storage deficiencies.
Findings
The facility failed to properly dispose of unused medications for one discharged resident and failed to ensure that non-perishable emergency food supplies were rotated according to shelf life, with expired cereal observed in storage.
Deficiencies (2)
Failed to properly dispose of unused medications for 1 discharged resident (#9).
Failed to ensure non-perishable food for emergency needs was rotated in accordance with shelf life; 8 boxes of expired cereal found.
Report Facts
Expired food items: 8
Discharged residents with medication disposal issue: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding medication disposal for discharged resident. | ||
| Staff G interviewed regarding expired emergency food items. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 20, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184920 and #GA00185447 with an on-site visit made on 2/20/18 and the investigation completed on 3/2/18.
Complaint Details
The visit was complaint-related, investigating complaints #GA00184920 and #GA00185447. The investigation found substantiated issues including failure to provide personal assistance, improper locking of a resident's room, lack of safety devices for elopement risk, and failure to report an elopement incident.
Findings
The facility failed to provide adequate personal assistance to residents unable to keep themselves neat and clean, locked a resident into his/her room against regulations, failed to utilize appropriate safety devices to protect residents at risk of elopement, and failed to report an elopement incident to the Department within required timeframes.
Deficiencies (4)
Facility staff failed to provide assistance to residents who were unable to keep themselves neat and clean, evidenced by Resident #2's poor hygiene and soiled clothing.
Facility locked Resident #1 into his/her room, violating the rule that residents must not be locked into or out of their bedrooms.
Facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping from the premises, with no safety devices observed on exterior or stairwell doors.
Facility failed to report the initiation and discontinuation of a Mattie's call to the Department within 30 minutes of communications with local law enforcement for Resident #1's elopement.
Report Facts
Complaint numbers: 2
Incident dates: Feb 3, 2018
Observation date: Feb 20, 2018
Investigation completion date: Mar 2, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Instructed maintenance to change lock on Resident #1's room door and confirmed no safety devices on doors | |
| Staff B | Observed Resident #1 locked in room and assigned staff to sit with Resident #1 | |
| Staff G | Changed lock on Resident #1's room door as directed by Staff A |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 10, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 25, 2017
Visit Reason
The purpose of this visit was to investigate self-reported incident #GA00179817 involving a resident who experienced a sudden change in condition.
Complaint Details
Investigation of self-reported incident #GA00179817 regarding failure to perform CPR on Resident #1 who was found unresponsive and later pronounced dead. Staff did not perform CPR due to lack of knowledge and facility lacked policies for change in resident condition.
Findings
The facility failed to initiate cardiopulmonary resuscitation immediately when Resident #1 experienced cardiac or respiratory arrest, despite no valid Do Not Resuscitate order being present. Staff did not perform CPR as they were unaware it was required, and the facility lacked policies or procedures for handling changes in resident condition.
Deficiencies (1)
Failure to initiate cardiopulmonary resuscitation immediately when resident experienced cardiac or respiratory arrest.
Report Facts
Incident report date: Sep 15, 2017
Resident death date and time: Sep 15, 2017
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 13, 2017
Visit Reason
The purpose of this visit was to investigate intake #GA00176643.
Complaint Details
Visit was complaint-related to intake #GA00176643. The complaint was substantiated based on findings of training and personnel file deficiencies.
Findings
The facility failed to ensure that at least one staff member with required training was present at all times when residents were present, specifically Staff E lacked CPR and First Aid certification. Additionally, the facility failed to maintain a personnel file for Staff E, who was a volunteer driving transport vehicles for approximately one month.
Deficiencies (2)
Failure to ensure at least one staff member with required training was present at all times; Staff E lacked CPR and First Aid certification.
Failure to maintain a personnel file for Staff E, a volunteer who drove facility vehicles.
Report Facts
Duration Staff E drove facility vehicles: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Staff member lacking CPR and First Aid certification and missing personnel file; volunteer driver | |
| Staff A | Interviewed regarding Staff E's role and training |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 17, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00174667.
Complaint Details
The visit was complaint-related, investigating complaint #GA00174667.
Findings
The facility was found deficient in multiple areas including failure of the governing body to provide proper oversight, incomplete written care plans lacking descriptions of social needs, preferences, responsible staff, and family involvement for Resident #1, inadequate Medication Assistance Record (MAR) documentation, and unsafe food handling practices in the kitchen.
Deficiencies (7)
Governing body failed to provide oversight necessary to ensure compliance with applicable requirements, including conflicting admission agreements and improper use of 'assisted living' terminology.
Facility failed to include in the written care plan a description of the resident's social needs, including frequency to address care and social needs for Resident #1.
Facility failed to include in the written care plan a description of the resident's particular preferences regarding care, activities and interests for Resident #1.
Facility failed to include in the written care plan the staff primarily responsible for implementing the care plan for Resident #1.
Facility failed to include evidence of resident and family involvement in the development of the resident's Individual Service Plan (ISP) for Resident #1.
Medication Assistance Record (MAR) did not include known allergies, name and telephone number of resident's health care provider, and summary of severe side effects and adverse reactions for each medication for Resident #1.
Facility failed to ensure food stored was protected from spoilage, contamination, and safe for human consumption, including unsealed food items, undated containers, dirty kitchen equipment, and improper sealing of food containers.
Report Facts
Date of admission: Mar 11, 2017
MAR month: 3
Number of unsealed food items observed: 7
Number of undated food containers: 4
Number of days for rent late payment notice: 10
Maximum term of agreement: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding admission agreement conflict | |
| Staff B | Chef | Interviewed regarding food sealing and kitchen conditions |
| Staff C | Interviewed regarding care plan compliance and MAR regulation awareness |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 21, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA00172448.
Complaint Details
Complaint GA00172448 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Census: 33
Deficiencies: 2
Date: Mar 14, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 10/11/2016 complaint investigation.
Complaint Details
This was a follow-up visit to a complaint investigation originally conducted on 10/11/2016.
Findings
The facility failed to provide sufficient staff time to keep residents comfortable and clean, as evidenced by a resident found lying on the floor with food-stained clothing and poor living conditions. Additionally, the facility failed to keep floors clean and in good repair, with stained carpets, food debris, and presence of a dead cockroach observed.
Deficiencies (2)
Facility failed to provide sufficient staff time such that each resident is kept comfortable and clean, including a resident found lying on the floor with food stains on clothing.
Facility failed to keep floors clean and in good repair, including stained carpets, food debris, and a dead cockroach found in resident areas.
Report Facts
Census: 33
Staff shifts: 3
Staff shifts: 3
Staff shifts: 2
Staff shifts: 2
Sponge baths: 3
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 24, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00170573.
Complaint Details
Complaint #GA00170573 was investigated. Resident #1 was awakened early in the morning on multiple days to be dressed, which did not respect the resident's right to choose activities and schedules. Resident #1 reported no upset feelings about this. Staff indicated that if this was a problem, the night shift could place Resident #1 last on their list for continent care and dressing.
Findings
The facility failed to ensure that each resident had the right to choose activities and schedules consistent with their interests and assessments, as evidenced by Resident #1 being awakened early in the morning on multiple days to be dressed despite being asleep.
Deficiencies (1)
Facility failed to ensure residents' right to choose activities and schedules consistent with their interests and assessments.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding Resident #1's care and dressing schedule. |
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