Inspection Reports for Arbor Terrace of Athens
170 Marilyn Farmer Way, Athens, GA 30606, United States, GA, 30606
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, including the most recent report dated April 22, 2025, which identified staffing shortages affecting medication administration and memory care coverage. Earlier reports showed isolated issues such as resident mistreatment, delayed medical response after a fall, and medication refill delays, with some substantiated complaints leading to staff terminations. There was a serious event in February 2022 involving a resident fall from a van lift that caused injury and death, along with regulatory failures related to memory care certification and medication management. Several complaint investigations were unsubstantiated, reflecting a number of concerns that did not result in violations. The facility’s record shows some improvement in staffing and medication practices over time, though occasional serious issues have occurred.
Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 22, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001916 and conduct the compliance inspection.
Findings
The facility failed to ensure sufficient staff time was provided so that residents received services and medications as prescribed, with late medication administration observed for multiple residents. Additionally, the memory care center was not staffed with a certified medication aide on-site at all times as required.
Complaint Details
The visit was complaint-related, investigating intake #GA50001916.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure sufficient staff time was provided so that each resident received services and medications as prescribed for 5 of 12 residents. | SS= D |
| Memory care center was not staffed with a registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times for 1 of 11 staff. | SS= D |
Report Facts
Residents affected: 5
Medications scheduled: 13
Medications scheduled: 8
Staff scheduled: 1
Medication administration times: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Observed administering medications late and assisting with medication administration. | |
| Staff I | Certified Medication Aide | Assisted Staff H with administering medications late to residents. |
| Staff J | Certified Medication Aide | Scheduled to work in memory care but administered medications in assisted living, failing to maintain required on-site staffing. |
| Staff K | Aware of the findings during interview. | |
| AA | Interviewed regarding memory care staffing and medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2024
Visit Reason
The purpose of this survey was to investigate complaint numbers GA00248765, GA00248577, and GA00248821.
Findings
The onsite visit was made on 8/1/24 and no rule violations were cited.
Complaint Details
Investigation of complaints GA00248765, GA00248577, and GA00248821 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2023
Visit Reason
The purpose of this survey was to investigate complaints #GA00238124 and #GA00237123.
Findings
The survey was completed on 2023-09-18. No rule violations were cited.
Complaint Details
Investigation of complaints #GA00238124 and #GA00237123 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 23, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA0023155.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was initiated due to intake #GA0023155 and completed on 4/3/23 with no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 2, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00228662 and GA00228760, with an onsite visit made on 11/2/22 and the investigation completed on 12/19/22.
Findings
The facility failed to ensure that Resident #2 was treated with dignity, kindness, consideration, and respect. Staff D was observed and reported to have fed Resident #2 aggressively, forcing food into the resident's mouth and pushing the resident in a wheelchair with excessive force, causing distress.
Complaint Details
The complaint investigation was based on intake GA00228662 and GA00228760. The investigation included review of incident reports, staff statements, video footage, and interviews. Staff D was terminated for misconduct related to the incident. The complaint was substantiated based on evidence of mistreatment of Resident #2.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect for 1 of 2 sampled residents (Resident #2). | SS= D |
Report Facts
Date of incident: Oct 7, 2022
Date of staff termination: Oct 14, 2022
Date of interviews: Dec 15, 2022
Date of video review: Dec 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in findings for aggressive feeding and mistreatment of Resident #2; terminated for misconduct | |
| Staff F | Witnessed and reported Staff D's aggressive behavior towards Resident #2 | |
| Staff A | Reviewed video footage confirming Staff D's actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 7, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00226629 with onsite visits on 2022-08-24 and 2022-08-31, completed on 2022-09-07.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00226629 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 5, 2022
Visit Reason
The purpose of the survey was to investigate complaint #GA00223269 regarding an unwitnessed fall of Resident #1 on 3/4/2022 and the facility's response to the incident.
Findings
The facility failed to provide protective care and watchful oversight for Resident #1 who suffered a fall resulting in a displaced fracture of the right ninth rib. The resident experienced delayed pain management and delayed hospital transfer, with staff requiring management approval before sending the resident to the emergency room.
Complaint Details
Investigation of complaint #GA00223269 regarding an unwitnessed fall of Resident #1 on 3/4/2022, delayed pain management, and delayed hospital transfer. Resident #1 reported worsening pain and difficulty obtaining staff assistance. Staff required management approval before sending resident to emergency room. Relative took more than three hours to arrive to the facility.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide protective care and watchful oversight for Resident #1 resulting in injury from an unwitnessed fall. | D |
Report Facts
Date of fall: Mar 4, 2022
Date of hospital transfer: Mar 5, 2022
Time between fall and follow-up check: 613
Date of onsite visit: May 5, 2022
Date survey completed: May 27, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E assessed Resident #1 after fall and alerted Staff B | ||
| Staff B assessed Resident #1 and notified relative, physician, and facility nurse | ||
| Staff A | Staff A was aware of the finding during interview on 5/27/2022 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 9, 2022
Visit Reason
The visit was conducted to perform a compliance inspection and investigate complaints #GA00221138 and #GA00221141.
Findings
The facility failed to ensure the memory care center operated with a valid certificate, timely medication refills for residents, and adequate care and services, resulting in a resident fall from a van lift that caused serious injuries and subsequent death.
Complaint Details
The investigation was initiated due to complaints #GA00221138 and #GA00221141. The complaint was substantiated based on findings including lack of valid certificate for memory care, medication refill failures, and a serious resident injury and death following a van lift malfunction.
Severity Breakdown
D: 2
J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure the memory care center would not operate without a certificate. | D |
| Facility failed to ensure timely refills of prescribed medications for 2 of 5 sampled residents, causing interruptions in routine dosing. | D |
| Facility failed to provide adequate care and services for 1 of 5 sampled residents, resulting in a fall from a van lift causing injuries and death. | J |
Report Facts
Sampled residents: 5
Residents with medication refill issues: 2
Resident fall incident date: Jan 18, 2022
Resident death date: Jan 23, 2022
Stitches received: 27
Staples received: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding certificate status and medication refill awareness | |
| Staff D | Involved in resident fall incident; declined to discuss incident | |
| Staff F | Interviewed regarding missing medications in medication cart | |
| AA | Interviewed regarding resident fall and injuries |
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control measures.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 19, 2019
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Arbor Terrace of Athens, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 13, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00193187.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint GA00193187 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 30, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00190861 with an onsite visit made to the facility on 10/30/2018 and investigation completed on 11/9/2018.
Findings
The facility failed to ensure that residents were treated with dignity, kindness, consideration, and respect, as evidenced by Staff G's aggressive and abusive behavior toward multiple residents, including forcibly turning a wheelchair causing a resident's shoe to come off, physical contact such as grabbing and shoving residents, refusal to assist residents properly, and inappropriate verbal interactions. Staff G was terminated due to these behaviors.
Complaint Details
Investigation of complaint #GA00190861 revealed substantiated allegations of staff abuse and mistreatment of residents by Staff G, including physical aggression and refusal to honor residents' rights.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity, kindness, consideration, and respect, including physical abuse and refusal to assist residents properly. | SS= D |
Report Facts
Number of sampled residents involved: 4
Date of verbal warning: Aug 29, 2018
Date of termination: Oct 11, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in multiple findings related to abusive behavior toward residents. | |
| Staff E | Witnessed and reported incidents involving Staff G and residents. | |
| Staff F | Provided written statements documenting Staff G's aggressive behavior. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 5, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint #GA00190861. An onsite visit was made to the facility on 9/5/18 and the investigation was completed on 9/7/18.
Findings
The facility failed to ensure quarterly random medication administration observations by a licensed nurse or pharmacist for 1 of 5 sampled staff, and failed to refill prescribed medications in a timely manner for 1 of 8 sampled residents, resulting in medication unavailability.
Complaint Details
Complaint #GA00190861 was investigated during this visit.
Severity Breakdown
Level D: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that a licensed registered professional nurse or a pharmacist completed quarterly random medication administration observations for certified medication aides. | Level D |
| Failed to refill prescribed medications in a timely manner so that there is no interruption in routine dosing for 1 of 8 sampled residents. | Level E |
Report Facts
Sampled staff: 5
Sampled residents: 8
Medication unavailable: 1
Inspection Report
Follow-Up
Deficiencies: 0
May 28, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 3/22/18 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up to the 3/22/18 complaint investigation; no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 9, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00188242 regarding safety concerns related to resident access and egress within the assisted living community.
Findings
The community failed to ensure safe access for residents with functional impairments, as evidenced by an unsecured gate that allowed Resident #1, diagnosed with Alzheimer's Disease, to exit the facility unsupervised. The gate lock was rusted and came loose, allowing the resident to leave the premises.
Complaint Details
Complaint GA00188242 was investigated. It was substantiated that Resident #1 was able to exit the facility unsupervised through a gate that was supposed to be locked but was unsecured due to a rusted lock.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The community failed to maintain safe access for residents with varying degrees of functional impairments, specifically due to an unsecured gate that allowed a resident to exit unsupervised. | SS= D |
Report Facts
Date of complaint incident: Apr 24, 2018
Date of resident admission: Feb 7, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Provided written statement about resident found outside facility and gate lock status | |
| Staff C | Reported seeing Resident #1 outside and escorted resident back inside | |
| Staff A | Interviewed about gate lock condition and replacement |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 17, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187372. An on-site visit was made on 4/17/18 and the investigation was completed on 5/9/18.
Findings
The facility failed to ensure that no member of the governing body, administration, or staff served as the legal surrogate or representative of a resident, and failed to protect a resident from financial exploitation by staff. Specifically, Staff B, an employee, was appointed durable power of attorney for Resident #1 and exploited the resident financially, including renting and purchasing the resident's home and handling finances improperly.
Complaint Details
Complaint #GA00187372 was investigated. The complaint involved financial exploitation of Resident #1 by staff, including Staff B who was appointed durable power of attorney and exploited the resident financially. The resident had altered mental status and memory loss. Law enforcement was notified. Staff B was charged with identity theft/fraud.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure no member of governing body, administration, or staff served as legal surrogate or representative of a resident (Resident #1). |
| Facility failed to ensure each resident had the right to be free from exploitation; Resident #1 was financially exploited by several staff members. |
Report Facts
Number of sampled residents: 5
Date of incident report: Apr 5, 2018
Date of physical examination: Feb 22, 2017
Date of Durable POA: Jan 23, 2018
Date of Resident #1 death: Apr 22, 2018
Date of police report: Jul 20, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Employee | Named in findings for serving as durable power of attorney and financially exploiting Resident #1 |
| Staff A | Employee | Aware of Staff B's POA status and involved in communication about POA |
| AA | Medical power of attorney for Resident #1 for 15 years, reported concerns about Staff B | |
| DD | Reported to AA about Staff B's POA status and rental of Resident #1's home | |
| FF | Appointed along with Staff B as Durable POA for Resident #1 |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 28, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/29/17 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up to the 9/29/17 complaint investigation; no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 22, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00186221. The investigation began on 2018-03-19 and ended on 2018-03-22.
Findings
The community failed to allow a resident (Resident #1) to associate and communicate freely and privately with persons and groups of the resident's choice without being censored by staff, due to enforcement of a protective order restricting contact with certain individuals.
Complaint Details
The investigation was complaint-related for complaint GA00186221. The complaint involved restrictions placed on Resident #1's communication and visitation rights, including a protective order prohibiting contact by certain individuals. The facility followed directives based on the protective order but had not been provided additional court orders specifying conditions.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to allow each resident to have the right to associate and communicate freely and privately with persons and groups of the resident's choice without being censored by staff for 1 of 4 sampled residents (Resident #1). | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 19, 2018
Visit Reason
The purpose of this visit was to investigate complaints GA00183792 and GA00184597 with an on-site visit made on 1/19/18 and the investigation completed on 2/14/18.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaints GA00183792 and GA00184597 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00180602.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint #GA00180602 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 27, 2017
Visit Reason
The purpose of the visit was to investigate complaints GA00179800, GA00180438, and GA00180383 regarding alleged abuse and neglect at the facility.
Findings
The facility failed to ensure residents were free from mental, verbal, sexual, and physical abuse, neglect, and exploitation. Staff C was found to have been rough, impatient, and used excessive force toward residents, leading to termination. Additionally, the facility failed to report allegations of abuse to the Department as required.
Complaint Details
The investigation was complaint-driven based on three complaints (GA00179800, GA00180438, GA00180383). Staff C was terminated due to complaints from three separate residents' families about inappropriate care and rough handling. Staff interviews and record reviews confirmed abuse. The facility did not report these allegations to the Department, citing no evidence of bruising or injuries.
Severity Breakdown
Level J: 1
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from mental, verbal, sexual, and physical abuse, neglect, and exploitation by Staff C. | Level J |
| Facility failed to report allegations of abuse, neglect, or exploitation to the Department as required by the Long Term Care Resident Abuse Reporting Act. | Level D |
Report Facts
Complaint IDs: 3
Dates Staff C worked with Staff E: 4
Date Staff C terminated: Aug 31, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Employee terminated for abuse and inappropriate care toward residents. | |
| Staff B | Reported abuse allegations and launched investigation; communicated about Staff C's termination. | |
| Staff D | Witnessed Staff C's rough handling of Resident #1 and provided detailed interview statements. | |
| Staff E | Witnessed Staff C being rough with residents and provided interview statements. |
Inspection Report
Annual Inspection
Deficiencies: 3
Aug 25, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate self-reported complaint #GA00178114. Rule violations were not cited as a result of the complaint investigation.
Findings
The inspection identified deficiencies in emergency preparedness related to fire drill compliance, and in residents' files regarding missing inventories of valuable personal items and missing written waivers of personal needs allowance for several residents.
Complaint Details
The complaint investigation was conducted as part of the visit but no rule violations were cited as a result of the complaint investigation.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure fire drills were conducted in compliance with fire safety regulations, including lack of drills on rotating shifts and no drills during the fourth quarter. | D |
| Failure to include an inventory of valuable personal items brought by residents for 5 of 11 residents sampled. | D |
| Failure to provide a copy of the resident's written waiver of the personal needs allowance for 3 of 11 sampled residents. | D |
Report Facts
Residents with missing personal item inventories: 5
Residents with missing personal needs allowance waiver: 3
Fire drills documented: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Interviewed regarding fire drills not completed by maintenance director | |
| Staff A | Interviewed regarding missing personal inventories and personal needs allowance waivers |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 20, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00170460. The investigation started on 2017-01-23 and was completed on 2017-03-20.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00170460 resulted in no rule violations being cited.
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