Inspection Report Summary
The most recent inspection on August 1, 2023, found deficiencies related to the facility’s failure to implement policies and provide protective care for memory-impaired residents, following a substantiated complaint about a resident eloping from the memory care unit. Earlier inspections generally showed no deficiencies, except for a substantiated complaint in October 2019 involving inadequate protective care that resulted in a resident injury. The main themes of deficiencies have involved protective care and oversight, particularly for residents with memory impairments. Complaint investigations prior to the most recent one were mostly unsubstantiated, with no fines or enforcement actions listed in the available reports. The record shows some recurring issues with resident supervision, with recent findings indicating ongoing challenges in this area.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
0.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236760 regarding an elopement incident involving Resident #1.
Complaint Details
The investigation was initiated following a complaint intake #GA00236760 about Resident #1 eloping from the memory care unit on 7/1/2023. The complaint was substantiated based on record review and staff interviews.
Findings
The facility failed to implement policies and procedures to support memory-impaired residents in a safe environment, resulting in Resident #1 eloping from the memory care unit. The investigation revealed lapses in protective care and oversight, with staff unable to determine how the resident exited the secured area despite all exit doors reportedly secured.
Deficiencies (2)
Failure to implement policies, procedures, and practices to support memory impaired residents in a safe environment.
Failure to provide protective care and watchful oversight meeting the needs of residents admitted and retained.
Report Facts
Incident date: Jul 1, 2023
Incident report submission date: Jul 3, 2023
Resident admission date: Jun 30, 2023
In-service training date: Jul 5, 2023
Staff work shift: 12
Staff work shift: 12
Elopement duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported the elopement incident and was interviewed regarding the investigation | |
| Staff B | Worked 7:00 a.m. to 7:00 p.m. on 7/1/2023, contacted Staff E to return Resident #1 safely | |
| Staff C | Observed Resident #1 wandering and was interviewed about the incident | |
| Staff D | Worked 7:00 p.m. to 7:00 a.m. on 7/1/2023, spoke with Resident #1 after elopement | |
| Staff E | Escorted Resident #1 back to memory care and completed incident report | |
| Staff F | Worked 7:00 p.m. to 7:00 a.m. on 7/1/2023, counted medications and observed Resident #1's exit | |
| GG | Interviewed and advised by Staff A of the incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
The purpose of this visit was to complete the compliance inspection and to investigate intake #GA00226649.
Complaint Details
Investigation was related to intake #GA00226649; no rule violations were found.
Findings
No rule violations were cited during the investigation completed on 09/16/2022.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 27, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212412 and GA00213990.
Complaint Details
Investigation of complaint intakes #GA00212412 and GA00213990 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 22, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00206157, which was started on 2020-07-13 and completed on 2020-07-22.
Complaint Details
Investigation of intake #GA00206157 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 20, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00203406.
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 process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 30, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint #GA00199802. The investigation was started on 2019-10-08 and completed on 2019-10-30.
Complaint Details
Complaint #GA00199802 was investigated and substantiated based on the incident where Resident #1 was left alone for over 10 minutes, leading to injury.
Findings
The facility failed to provide protective care and watchful oversight for one resident who was left alone in a wheelchair, resulting in the resident sliding out and breaking their left tibia. Staff responsible were identified and terminated following the incident.
Deficiencies (1)
Failed to provide protective care and watchful oversight for 1 of 10 sampled residents, resulting in a resident sliding out of a wheelchair and breaking a left tibia.
Report Facts
Number of sampled residents: 10
Duration resident left alone: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding the incident and investigation | |
| Staff B | On duty during incident; terminated after incident | |
| Staff C | On duty during incident; terminated after incident |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Apr 24, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection, converting the facility from a personal care home to an assisted living community.
Findings
No rule violations were cited as a result of this inspection.
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