Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240472.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake #GA00240472 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 10, 2023
Visit Reason
A visit was made to the facility on 10/10/2023 to investigate intake #GA 00238719 and #GA00238917.
Findings
The investigation was completed on 10/10/2023 with no rule violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA 00238719 and #GA00238917 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 21, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237897.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00237897 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237300.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00237300 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 14, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236386. The onsite visit was made on 7/14/23.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00236386 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 22, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235795. The onsite visit was made on 6/22/23 and completed on 6/23/23.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00235795 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2023
Visit Reason
The visit was conducted to investigate intake #GA00233892 with an onsite visit made on 4/18/2023.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00233892 was conducted starting 4/18/2023 and completed on 4/25/2023 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 15, 2023
Visit Reason
The purpose of this visit was to investigate intakes GA00232731 and GA00232220.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intakes GA00232731 and GA00232220 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2023
Visit Reason
The purpose of this visit was to investigate intake Ga00229040. An onsite visit was made to the facility on 2022-12-13. The investigation was started on 2022-12-13 and completed on 2023-01-05.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake Ga00229040; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 5, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00227399 with an onsite visit made to the facility on 10/5/22.
Findings
The facility failed to ensure each resident received adequate and appropriate care in compliance with state law for 1 sampled resident. An incident was reported where Resident #1 was hit on the back of the hand by a staff member, resulting in staff suspension and police involvement.
Complaint Details
The investigation was triggered by intake GA00227399 regarding an incident on 8/25/22 where Resident #1 was hit on the back of the hand by Staff B. Resident was not injured. Staff B was suspended pending investigation and later terminated. Police report case # 01-22-013289 was filed. Resident #1 was unable to recall the incident due to cognitive impairment.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulation for Resident #1 who was physically contacted inappropriately by staff. | D |
Report Facts
Incident report date: Aug 25, 2022
Police report case number: 13289
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Staff member who hit Resident #1 and was suspended pending investigation and later terminated | |
| Staff A | Interviewed and stated Staff B was terminated and physical contact was made | |
| Staff C | Interviewed and stated Resident #1 has a history of agitation and should have been managed differently |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 23, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00222167 and GA0022265.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2022-03-21, on-site visit was made on 2022-03-23, and it was completed on 2022-04-20.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00221347.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 02/21/22 and on-site visit was made on 02/21/22 and it was completed on 03/16/22.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 4, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00219990 and #GA00220933 with an onsite visit made on 2022-01-24 and the investigation completed on 2022-02-04.
Findings
The facility failed to include a physician order for full assistance with bathing and toileting in the care plan for Resident #1, despite the physician's order dated 2021-11-04. Interviews revealed disagreement among staff regarding the resident's care needs and attempts to obtain physician signature on the care plan were unsuccessful.
Complaint Details
Investigation of complaint intakes #GA00219990 and #GA00220933. The complaint was substantiated based on failure to update care plan per physician order and conflicting staff statements regarding resident care.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to include in the care plan a physician order for full assistance with bathing and toileting for Resident #1. | SS= D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Contacted the resident's physician to request signature on care plan and provided statements regarding resident's care needs. | |
| Staff B | Assessed Resident #1 and stated the resident did not need full ADL care. | |
| AA | Stated Resident #1 was unable to wash face and arms and that the facility changed the standard of care despite physician's order. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 29, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate complaint intakes #GA00217903 and #GA00218156 with onsite visits on 10/6/21 and 10/26/21, and the investigation completed on 10/29/21.
Findings
The facility failed to ensure timely medication refills for one of three sampled residents (Resident #3), resulting in missed doses of Olanzapine due to delayed reorder and medication arrival.
Complaint Details
The investigation was related to complaint intakes #GA00217903 and #GA00218156. The complaint was substantiated as the facility failed to timely reorder Olanzapine for Resident #3, causing missed doses and increased agitation.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure medication refills were obtained timely to prevent interruption in routine dosing for Resident #3. | D |
Report Facts
Missed doses: 2
Missed doses: 1
Medication dosage: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 29, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00206413 and #GA00206338, started on 2020-07-16 and completed on 2020-07-29.
Findings
The facility failed to ensure that Resident #1 was free from physical abuse. Evidence included an incident report, police report, video review, and interviews confirming Staff C caused scratches on Resident #1's neck. Staff C was suspended and subsequently terminated for misconduct and abuse allegations.
Complaint Details
The investigation was triggered by allegations of physical abuse toward Resident #1. The abuse was substantiated based on video evidence and interviews. Staff C was terminated following the investigation.
Deficiencies (1)
| Description |
|---|
| Failure to ensure each resident was free from physical abuse, evidenced by physical abuse of Resident #1 by Staff C. |
Report Facts
Intake start date: Jul 16, 2020
Intake completion date: Jul 29, 2020
Incident date: Jun 28, 2020
Staff C hire date: Apr 1, 2020
Staff C termination date: Jul 7, 2020
Staff C scheduled shift: 8
Resident #1 admission date: Mar 12, 2019
Resident #1 memory care admission date: Jul 9, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in physical abuse allegation and termination for misconduct | |
| Staff B | Interviewed witness who reviewed video and reported incident | |
| Staff A | Interviewed witness who viewed video of incident | |
| Staff E | Received incident report, coordinated police notification, and reviewed video |
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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00200803.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00200803 found no rule violations.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 8, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the complaint investigation intake #GA00191802.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up to complaint investigation intake #GA00191802; no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 15, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00191802 regarding the facility's failure to provide protective care and watchful oversight for a resident at risk of wandering.
Findings
The facility failed to provide adequate protective care and watchful oversight for Resident #1, who had dementia and a history of wandering. The resident left the facility unattended on multiple occasions due to unsecured exit doors without audible alarms. Additionally, the facility did not retain a current photograph of the resident at risk of eloping.
Complaint Details
The investigation was triggered by complaint GA00191802 concerning Resident #1 wandering away from the facility unattended due to inadequate security measures.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide protective care and watchful oversight for Resident #1 with dementia and history of wandering. | SS= D |
| Exit door near side street was unsecured and lacked an audible alarm. | SS= D |
| Third floor stairwell exit door had an inoperable audible alarm and maglock did not engage. | SS= D |
| Failure to retain on file a current photograph of Resident #1 at risk of eloping. | SS= D |
Report Facts
Date of incident report: Sep 26, 2018
Date of incident report: Oct 6, 2018
Resident age: 82
Resident admission date: Sep 24, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding maglock and alarm status on exit doors and lack of photograph for Resident #1 | |
| Staff C | Interviewed regarding inoperable audible alarm on third floor stairwell exit door |
Inspection Report
Original Licensing
Deficiencies: 0
Jun 27, 2018
Visit Reason
The purpose of this visit was to conduct the change of ownership inspection.
Findings
No rule violations were cited as a result of this inspection.
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