Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50003098.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2025-05-13 with an on-site visit at 10:30 am and completed the same day. No violations were found.
Inspection Report
Routine
Deficiencies: 1
Mar 26, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection at the assisted living community.
Findings
The facility failed to keep the foods stored in the freezer dated and labeled as required by emergency food supply regulations. Despite being given an opportunity to label the foods during the inspection day, the foods remained unlabeled at the end of the visit.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to keep the foods stored in the freezer dated and labeled. | SS= D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed regarding labeling of chicken and meat in freezer. | |
| Staff A | Interviewed and stated he/she would bring labeling issue to Staff E's attention. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250834.
Findings
No rules violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00250834 found no rules violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00242457 and #GA00242055.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted for two complaint intakes; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 24, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236868.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00236868 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00218745 and GA00236868.
Findings
No violations were cited as a result of this survey.
Complaint Details
The visit was complaint-related, investigating two intakes (#GA00218745 and GA00236868). No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 9, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232489. The onsite visit and investigation started on 2023-03-08 and were completed on 2023-03-09.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00232489 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 12, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00229644, GA00229678, GA00230031, and GA00230104.
Findings
The facility failed to have a full-time administrator for a period, lacked documentation of memory care staffing patterns, failed to ensure a nurse or certified medication aide was on-site in the memory care unit at all times, and did not provide adequate care and timely response to call bells for residents in assisted living, resulting in delays of up to 59 minutes.
Complaint Details
The visit was complaint-related, investigating multiple intakes. The report documents substantiated issues including lack of administrator, inadequate staffing and supervision in memory care, and delayed response to resident call bells in assisted living.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to have a full-time administrator to provide day-to-day leadership from 10/12/22 to 12/5/22. | D |
| Facility failed to provide documentation of an accurate written description of the memory care center staffing patterns. | D |
| Facility failed to ensure at least one registered nurse, licensed practical nurse, or certified medication aide was on-site in the memory care unit at all times. | D |
| Facility failed to ensure each resident received adequate and appropriate care, with documented excessive call bell response times and insufficient staffing on assisted living unit. | D |
Report Facts
Call bell response time: 59
Call bell response time: 30
Call bell response time: 23
Call bell response time: 18
Call bell response time: 21
Call bell response time: 17
No CMA scheduled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator | Hired 12/5/22; stated no administrator was present from 10/12/22 to 12/5/22. |
| Staff C | Lead Certified Medication Aide (CMA) | Responsible for making CMA schedule; confirmed many shifts had no CMA or nurse in memory care. |
| Staff D | Certified Medication Aide (CMA) | Only CMA in building; had to leave memory care unit to pass medications in assisted living. |
| Staff F | Caregiver working 7:00 a.m. to 3:00 p.m. on 12/9/22; involved in transferring Resident #1 when resident slid to floor. | |
| Staff G | Stated Staff A began 12/5/22 and previous administrator left 10/12/22; no administrator in interim. | |
| Staff H | Caregiver assisting Staff F with Resident #1 transfer on 12/9/22. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00228057 and GA00227955.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00228057 and GA00227955 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225259.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00225259 found no rule violations.
Inspection Report
Routine
Deficiencies: 0
Aug 30, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 22, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/2/19 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 6
Apr 2, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection of the assisted living community.
Findings
The facility failed to ensure that staff received required training within the first 60 days of employment, including residents' rights, emergency preparedness, and medical/social needs training for 1 of 5 sampled staff. Additionally, quarterly medication administration observations were not conducted by a licensed RN or pharmacist for 2 of 5 staff. The facility also failed to provide adequate care and services to 1 of 4 sampled residents, specifically regarding pressure ulcer care and documentation of adverse changes in condition.
Severity Breakdown
SS= D: 5
SS= J: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure staff received training on Residents' Rights within the first 60 days of employment for 1 of 5 sampled staff (Staff B). | SS= D |
| Failure to ensure staff received training on emergency preparedness within the first 60 days of employment for 1 of 5 sampled staff (Staff B). | SS= D |
| Failure to ensure staff received training on medical and social needs and characteristics of the resident population within the first 60 days of employment for 1 of 5 sampled staff (Staff B). | SS= D |
| Failure to ensure quarterly medication administration observations were conducted by a licensed RN or pharmacist for 2 of 5 sampled staff (Staff D and Staff E). | SS= D |
| Failure to provide adequate, appropriate care and services in compliance with state law for 1 of 4 sampled residents (Resident #1), including pressure ulcer care and documentation. | SS= J |
| Failure to immediately take appropriate actions and retain records for adverse changes in resident condition for 1 of 4 sampled residents (Resident #1). | SS= D |
Report Facts
Staff sampled: 5
Residents sampled: 4
Pressure ulcer measurements: 3
Pressure ulcer measurements: 1.75
Pressure ulcer measurements: 1
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to lack of training documentation on Residents' Rights, emergency preparedness, and medical/social needs | |
| Staff A | LPN | Completed CMA observations but was not an RN or pharmacist; also interviewed regarding Resident #1 wound care |
| Staff D | Named in findings related to lack of quarterly medication administration observations by RN or pharmacist | |
| Staff E | Named in findings related to lack of training documentation and lack of quarterly medication administration observations by RN or pharmacist |
Inspection Report
Original Licensing
Deficiencies: 1
Feb 7, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the assisted living facility.
Findings
The facility failed to obtain a fingerprint check for the executive director prior to the individual assuming the role, as evidenced by record review and staff interview.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain a fingerprint check for the executive director prior to serving in the role. | D |
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