Inspection Report Summary
The most recent inspection on May 6, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed pattern, with some deficiencies related primarily to incident reporting, resident care, and staff training. Prior investigations substantiated issues such as failure to report a serious incident timely, inadequate protective oversight for a resident who eloped, and concerns about mistreatment and medication management. Most complaint investigations were unsubstantiated, except for a few substantiated cases involving resident mistreatment and oversight failures. The facility’s recent clean inspection suggests some improvement compared to earlier findings.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002508.
Complaint Details
Investigation of intake #GA50002508 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 12, 2025
Visit Reason
The purpose of this visit was to investigate intake GA 30001384, with the investigation beginning on 2025-04-09 and ending on 2025-04-15.
Complaint Details
Investigation of intake GA 30001384 was conducted from 2025-04-09 to 2025-04-15 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 6, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00251936 and GA00252196.
Complaint Details
Investigation of intakes #GA00251936 and GA00252196 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 29, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00248921.
Complaint Details
Investigation of intake# GA00248921 with no rule violations cited.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 7, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245570, which involved an allegation of staff aggression towards a resident. The investigation was conducted onsite starting on 2024-05-07 and completed on 2024-05-08.
Complaint Details
The complaint investigation was initiated due to intake #GA00245570 regarding staff aggression towards Resident #1. The facility did not report the incident to the Department within the required 24-hour timeframe and also failed to notify law enforcement. Staff interviews confirmed awareness of the incident and failure to report timely.
Findings
The facility failed to report a serious incident involving a resident to the Department within 24 hours as required by state regulations. Specifically, staff were aware of an incident of aggression by a staff member towards Resident #1 on 2024-04-02 but did not report it timely. Additionally, the facility failed to notify law enforcement as required by the Long Term Care Resident Abuse Reporting Act.
Deficiencies (2)
Failure to report a serious incident involving a resident to the Department within 24 hours after the incident occurred.
Failure to report abuse of a resident to the Department in accordance with the Long Term Care Resident Abuse Reporting Act.
Report Facts
Incident date: Apr 2, 2024
Incident report submission date: Apr 8, 2024
Survey completion date: May 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed staff who reported the incident upon return to work and stated other staff were aware but did not report | |
| Staff A | Interviewed staff who confirmed the incident occurred and that staff present failed to report it within 24 hours | |
| Staff C | Staff member alleged to have slapped, shoved, and yelled at a memory care resident |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
The purpose of this survey was to follow-up on the 1/20/2023 survey.
Findings
No rule violations were cited during the onsite visit on 12/13/2023.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240961.
Complaint Details
Investigation of intake #GA00240961 found no rule violations.
Findings
An on-site visit was made on 12/6/2023. No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The visit was conducted to investigate intake #GA00233165 with onsite visits on 2022-03-30 and 2023-04-12, starting the investigation on 2023-03-27 and completing it on 2023-04-13.
Complaint Details
Investigation of intake #GA00233165 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 21, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00229368 and #GA00228469. The onsite visit occurred on 12/21/2022, with the investigation completed on 01/20/2023.
Complaint Details
The investigation was initiated due to complaint intakes #GA00229368 and #GA00228469 regarding the elopement of Resident #4 from the memory care unit on 10/31/2022. The complaint was substantiated based on findings.
Findings
Based on record reviews and interviews, the facility failed to provide protective care and watchful oversight for one of six sampled residents (Resident #4), who eloped from the memory care unit on 10/31/2022 and was found in the neighborhood. Staff interviews confirmed the resident left without staff knowledge and was returned after about 20 minutes.
Deficiencies (1)
Facility failed to provide protective care and watchful oversight for Resident #4 who eloped from the memory care unit and was found outside the facility.
Report Facts
Number of sampled residents: 6
Time resident was missing: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Interviewed regarding Resident #4's elopement and search efforts. | |
| Staff F | Interviewed regarding Resident #4's elopement and search efforts. | |
| Staff B | Made aware of findings on 1/20/2023. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 20, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00226643 and GA00227007, with an onsite visit made to the facility on 9/20/22.
Complaint Details
The visit was complaint-related, investigating intake GA00226643 and GA00227007. The investigation started on 8/25/22 and was completed on 10/13/22.
Findings
The facility failed to ensure staff received necessary training in residents' rights and long-term care abuse reporting, failed to ensure resident family participation in care plan development for sampled residents, and failed to protect food from contamination during serving.
Deficiencies (4)
Facility failed to ensure staff received training necessary in residents rights and Long-Term Care Resident Abuse Reporting for 1 of 1 sampled staff (CC).
Facility failed to ensure staff hired to provide hands-on personal services received training necessary in residents rights and individualized resident care for 1 of 1 sampled staff (CC).
Facility failed to ensure the resident's family participated in the development of the resident's written care plan for 3 of 3 sampled residents (Resident #1, Resident #3, and Resident #4).
Facility failed to ensure food while being served was protected from contamination and safe for human consumption; staff served food without gloves and did not use serving trays.
Report Facts
Number of sampled residents with family participation deficiency: 3
Date of video recording showing deficient care: Jun 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staff training and agency staff care | |
| Staff C | Observed serving food without gloves and improper food handling | |
| Staff G | Interviewed about scheduling agency staff and training | |
| Staff H | Interviewed about agency staff training and caregiver assignment review | |
| Staff I | Interviewed about agency staff providing care independently | |
| Staff B | Interviewed about resident care plan reviews and food serving procedures | |
| AA | Discussed facility failure to train agency staff for Resident #2 care needs |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 25, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00225417. An onsite visit was made to the facility on 8/25/22 to investigate allegations of mistreatment and inadequate care of Resident #1.
Complaint Details
The investigation was initiated due to complaint intake GA00225417 regarding mistreatment and rough handling of Resident #1 by agency care staff. The complaint was substantiated based on interviews, video review, and staff statements.
Findings
The facility failed to ensure Resident #1 received adequate and appropriate care, including being roughly handled, dressed in another resident's clothing, not allowed to select clothing, and not given proper hygiene care. Resident #1 was visibly upset and reported feeling violated and mistreated. Video evidence and staff interviews confirmed these findings, resulting in removal and termination of the agency staff involved.
Deficiencies (2)
Facility failed to ensure Resident #1 received adequate, appropriate care and services in compliance with state law and regulation.
Facility failed to ensure Resident #1 was treated with dignity, kindness, consideration, and respect.
Report Facts
Dates of video recording: Jun 23, 2022
Date of admission: Feb 21, 2022
Date of physician evaluation: Feb 5, 2022
Number of sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed video recording, removed and terminated agency staff after concerns. | |
| Staff B | Reviewed video, met with Resident #1 family, ensured agency staff removal. | |
| AA | Witnessed video recording and described rough handling of Resident #1. | |
| BB | Reported Resident #1's complaints of rough handling and rushed care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 5, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223410 and GA00223549.
Complaint Details
Investigation started on 2022-05-05 and was completed on 2022-05-13. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 9, 2022
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaint #GA00221373. The investigation started on 2022-03-04 and was completed on 2022-03-09.
Complaint Details
Investigation of complaint #GA00221373 regarding medication errors and staff certification issues.
Findings
The facility failed to have evidence of recertifications for one staff member, failed to administer medications according to physicians' orders for one resident, and failed to ensure timely refills of prescribed medications for two residents, resulting in medication errors and missing medications.
Deficiencies (3)
Facility failed to have evidence of current first aid and CPR certifications for 1 of 6 sampled staff (Staff D).
Facility failed to administer medications in accordance with physicians' orders for 1 of 6 sampled residents (Resident #1), including administration of another resident's medication.
Facility failed to ensure timely refills of prescribed medications for 2 of 6 sampled residents (Resident #2 and Resident #3), resulting in missing medications.
Report Facts
Number of sampled staff with certification issues: 1
Number of sampled residents with medication administration issues: 1
Number of sampled residents with medication refill issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff member lacking current CPR and first aid certifications. | |
| Staff E | Staff member who administered medication prescribed for Resident #6 to Resident #1. | |
| Staff A | Staff member aware of Staff D's certification deficiencies. | |
| Staff G | Staff member who confirmed missing medications for Residents #2 and #3. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 1, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00211779. The inspection started on 2021-02-17 and was completed on 2021-03-01.
Complaint Details
Investigation of intake #GA00211779 with no violations cited.
Findings
No 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
Original Licensing
Deficiencies: 0
Date: Mar 3, 2020
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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