Inspection Reports for St Mary’s Highland Hills Village
1660 Jennings Mill Rd, Bogart, GA 30622, GA, 30622
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 26, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to timely and appropriate responses to residents’ adverse changes in condition, staff training and certification, and medication record-keeping. Several complaint investigations were substantiated, including issues with fall response, family involvement in care planning, and staff certification verification, but no fines or enforcement actions were listed in the available reports. Most complaints were substantiated based on record reviews and staff interviews, while some investigations found no violations. The facility’s recent clean inspection suggests improvement compared to prior findings.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
The purpose of this visit was to conduct an initial inspection and to investigate intake #GA50001397.
Complaint Details
Investigation of intake #GA50001397 was conducted during this visit.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 6, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00243638. The onsite visit was made on 3/6/24 to investigate the complaint.
Complaint Details
Investigation of complaint #GA00243638 regarding the facility's response to Resident #1's fall and subsequent condition changes. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to ensure immediate and appropriate action was taken following a fall and sudden adverse change in condition of Resident #1 on 2/7/24. Despite notification of the primary physician and nurse practitioner assessment, the resident experienced pain and was sent to the emergency room. Multiple staff interviews confirmed the resident was pale, shaking, lethargic, and not at baseline after the fall.
Deficiencies (1)
Failure to ensure immediate action appropriate to the specific circumstances was taken to address the needs of Resident #1 after a fall and sudden adverse change in condition.
Report Facts
Date of fall: Feb 7, 2024
Date of physician evaluation: Jul 20, 2022
Date of survey completion: Apr 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Accessed Resident #1 after fall, checked vitals, communicated with relative, and reported resident had fractured hip and UTI | |
| Staff C | Observed Resident #1 post-fall, recommended hospital visit, notified relative, and communicated with nurse practitioner | |
| Staff E | Observed Resident #1 on floor, assisted in placing resident in recliner, reported resident was pale and shaking | |
| Staff G | Assisted in placing Resident #1 in recliner and checked vitals | |
| Staff H | Observed Resident #1 post-fall and communicated concerns to Staff C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220173. An on-site visit was made on 2/8/22.
Complaint Details
Investigation started on 2/8/22 and was completed on 2/16/22. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00208140 and #GA00208135.
Complaint Details
Investigation began on 2020-09-21 and was completed on 2020-10-23. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 6, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00202610, with an onsite visit made on 2020-02-12 and the investigation completed on 2020-03-06.
Complaint Details
The investigation was complaint-driven under complaint #GA00202610. The complaint involved concerns about family involvement in care planning, staff training adequacy, and failure to properly respond to changes in Resident #1's condition. The complaint was substantiated based on findings.
Findings
The facility failed to provide evidence of family involvement in care plan development for 4 sampled residents, did not ensure sufficient specially trained staff for residents with dementia-related behaviors, and failed to immediately take appropriate actions and notify representatives in response to sudden adverse changes in a resident's condition.
Deficiencies (3)
Failed to provide evidence of family involvement in the development of residents' care plans for 4 of 4 sampled residents.
Failed to ensure the contained unit was staffed with sufficient specially trained staff to meet the unique needs of residents for 3 of 3 staff reviewed.
Failed to immediately take appropriate actions and notify the resident's representative in case of sudden adverse change in condition for 1 of 4 residents.
Report Facts
Residents sampled for care plan review: 4
Staff files reviewed for training: 3
Hospital transfers for Resident #1: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged findings related to family involvement, staff training, and resident condition response | |
| BB | Interviewed and reported lack of family involvement and concerns about staff understanding of disease and notification practices | |
| AA | Interviewed regarding Resident #1's hospitalizations and behavior | |
| Staff C | Staff file reviewed for training | |
| Staff D | Staff file reviewed for training | |
| Staff E | Staff file reviewed for training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 2, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA0002988. An onsite visit was made on 2019-12-31 and the investigation was completed on 2020-01-02.
Complaint Details
Investigation of complaint #GA0002988 regarding failure to assess and monitor weight loss in Resident #1. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to immediately take appropriate actions in response to a sudden adverse change in condition for one resident (Resident #1), specifically failing to properly assess and monitor significant weight loss. Interviews and record reviews showed inconsistent weight monitoring and lack of communication with the resident's physician regarding the weight loss.
Deficiencies (1)
Failure to immediately take actions appropriate to a sudden adverse change in Resident #1's condition, including failure to assess and monitor weight loss.
Report Facts
Weight loss: 11
Dates of weight records: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 18, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00200507 with onsite visits made on 11/17/19 and 11/18/19.
Complaint Details
Investigation of complaint #GA00200507 regarding failure to verify certification status of medication aides. The complaint was substantiated by findings that Staff F was not actively certified.
Findings
The community failed to check the Georgia Certified Medication Aide Registry to ensure that Certified Medication Aides employed were listed in good standing before permitting them to administer medications, specifically for 1 of 9 sampled staff (Staff F) who had no active certification.
Deficiencies (1)
Failed to verify active certification status of Certified Medication Aide (Staff F) on the Georgia Certified Medication Aide Registry before allowing medication administration.
Report Facts
Sampled staff: 9
Deficiencies cited: 1
Medication administration dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide | Named in deficiency for lack of active certification |
| Staff A | Interviewed regarding Staff F's certification status |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 26, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection of the assisted living facility.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 6 sampled residents, specifically Resident #4, as evidenced by multiple missing staff initials on medication administration records for April and May 2018.
Deficiencies (1)
Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken for Resident #4, with multiple empty cells without staff initials on the MAR for April and May 2018.
Report Facts
Number of sampled residents with MAR issues: 1
Medication administration dates with missing initials: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding missing staff initials on MAR |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint #GA00184964.
Complaint Details
Investigation of complaint #GA00184964 regarding Resident #1's injury during transfer using a mechanical lift. The complaint was substantiated based on observations, record review, and staff interviews.
Findings
The community failed to ensure adequate and appropriate care for Resident #1 who sustained a laceration and bruising after sliding out of a mechanical lift during transfer. Staff interviews revealed improper use and lack of training on the mechanical lift, despite the equipment being operational.
Deficiencies (1)
Failed to ensure each resident received adequate and appropriate care in compliance with state law and regulations, evidenced by Resident #1 sliding out of a mechanical lift and sustaining injury.
Report Facts
Number of sampled residents: 6
Date of incident report: Feb 1, 2018
Date of mechanical lift inspection: Feb 5, 2018
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 31, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
No rule violations were cited during the annual inspection.
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