Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2025
Visit Reason
The purpose of this visit was to investigate intake# GA50005655.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA50005655 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jun 25, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate an intake complaint at the assisted living facility.
Findings
The inspection found multiple deficiencies related to staff training and fire safety compliance, including failure to provide required initial training within 60 days of employment, lack of current certification in emergency first aid and CPR for certain staff, and missing fire drill logs for 2024.
Complaint Details
The visit was triggered by an intake complaint, and the investigation found substantiated deficiencies related to staff training and fire safety compliance.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Administrator did not ensure staff received initial training within the first 60 days of employment for Staff D. | Level D |
| Administrator failed to ensure staff hired to provide hands-on personal services had current certification in emergency first aid for Staff B and Staff E. | Level D |
| Administrator failed to ensure staff hired to provide hands-on personal services had current certification in cardiopulmonary resuscitation with competency demonstration for Staff E. | Level D |
| Assisted living community failed to comply with fire and safety rules; no fire drill logs for 2024 were found. | Level D |
Report Facts
Staff hire date: 202501
Staff hire date: May 13, 2024
Staff hire date: Apr 15, 2024
Year: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and provided statements regarding lack of training and missing fire drill logs | |
| Staff B | Staff hired May 13, 2024, lacked emergency first aid and CPR certification | |
| Staff D | Staff hired January 2025, lacked initial training within 60 days | |
| Staff E | Staff hired April 15, 2024, lacked emergency first aid and CPR certification |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 23, 2025
Visit Reason
The purpose of this visit was to investigate intake GA 50002594 and GA 50003165.
Findings
No rules were cited as a result of these investigations conducted from 2025-05-14 to 2025-05-20.
Complaint Details
Investigation of complaint intakes GA 50002594 and GA 50003165 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 20, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00252481.
Findings
There were no rule violations as a result of this investigation.
Complaint Details
Investigation of intake #GA00252481 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 13, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00248609.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00248609 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 11, 2024
Visit Reason
The purpose of this visit was to investigate intakes GA00247726, GA00245975, and GA00246930.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of three intakes GA00247726, GA00245975, and GA00246930 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 13, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241626 with an onsite visit made on 12/13/2023.
Findings
The facility failed to maintain a safe environment as the dining room floor was slippery, posing a safety risk to residents. Additionally, the facility failed to ensure adequate and appropriate care for residents by not providing functioning alert call pendants for two residents, which compromised their ability to summon assistance.
Complaint Details
The investigation was initiated due to intake #GA00241626. The complaint involved unsafe conditions and inadequate resident care related to slippery floors and non-functioning alert call pendants. The complaint was substantiated based on observations and interviews.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The dining room floor was slippery due to excessive soap, creating an unsafe condition for residents. | SS= D |
| The facility failed to provide functioning alert call pendants for two residents, impairing their ability to call for assistance. | SS= D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed slippery floor, stated cleaning staff used too much soap, and was involved in addressing alert call pendant issues. | |
| Staff B | Observed slippery floor and stated Resident #1's alert call pendant was not working and was being repaired. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235479. An onsite visit was made to the facility on 7/19/23. The investigation was started on 7/17/23 and completed on 7/19/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00235479 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00230051 and GA00230055 with an onsite visit made to the facility on 3/1/2023.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00230051 and GA00230055 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 1, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00223947.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00223947 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220195. An on-site visit was made on 2/9/22.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2/9/22 and was completed on 2/17/22. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 8
Jan 13, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00219085 and GA00219104, with an onsite visit made on 2021-12-06 and the investigation completed on 2022-01-13.
Findings
The facility failed to ensure staff received required emergency first aid and CPR training within 60 days of employment, maintain the interior in good repair, keep accurate and timely medication administration records and refills, protect food from contamination, post weekly menus, and ensure residents' private living spaces were cleaned adequately.
Complaint Details
The visit was complaint-related, investigating intake GA00219085 and GA00219104. The investigation started on 2021-11-16 and was completed on 2022-01-13.
Severity Breakdown
SS= D: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Staff hired to provide hands-on personal services did not receive emergency first aid training within the first 60 days of employment for 3 of 5 sampled staff. | SS= D |
| Staff hired to provide hands-on personal services did not receive CPR training with required competency demonstration for 3 of 5 sampled staff. | SS= D |
| Facility failed to keep the interior clean and in good repair, including a quarter size hole in a resident's bedroom wall, a dripping faucet, and a missing toilet paper holder bar. | SS= D |
| Medication Administration Record (MAR) lacked required details and documentation for prescribed medications for Resident #4. | SS= D |
| Facility failed to ensure timely refills of prescribed medications, resulting in missed doses for Resident #4. | SS= D |
| Facility failed to protect food from contamination; food preparer wore mask improperly and prepared food near uncovered trash can. | SS= D |
| Facility failed to post or make available weekly planned regular and therapeutic diets menu to residents. | SS= D |
| Facility failed to ensure residents' private living spaces were cleaned as needed to prevent health hazards. | SS= D |
Report Facts
Sampled staff: 5
Staff non-compliant: 3
Resident sampled for medication issues: 4
Medication doses missed: 3
Inspection visit date: Dec 6, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staff training, medication management, repairs, food safety, and menu posting | |
| Staff C | Led facility tour, involved in medication and cleaning issues, interviewed about medication and cleaning | |
| Staff D | Sampled staff missing training, checked resident for pain after missed medication | |
| Staff E | Sampled staff missing training | |
| Staff G | Sampled staff missing training, observed preparing food with improper mask use | |
| Staff B | Mentioned as managing medication refills with new pharmacy | |
| Staff F | Interviewed about menu posting |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 22, 2021
Visit Reason
The visit was conducted to investigate intake #GA00216559, with the investigation starting in September 2021 and completing on 09/22/2021.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00216559 was completed with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00211157, #GA00211382, #GA00211568 and #GA00211612, with the investigation starting on 2021-08-19 and completing on 2021-09-21.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of four intakes (#GA00211157, #GA00211382, #GA00211568, #GA00211612) was conducted with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 19, 2020
Visit Reason
The purpose of the visit was to investigate intake #GA00209548 through an unannounced visit made on 11/19/2020, with the investigation completed on 11/30/2020.
Findings
The facility failed to ensure timely staff response to emergency pendants for 5 of 7 sampled residents, with response times ranging from 37 minutes to over 77 hours. Additionally, the facility failed to report a serious incident involving a resident fall within 24 hours as required.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00209548. The complaint involved delayed staff response to emergency pendants and failure to report a serious resident incident. The substantiation status is not explicitly stated.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure sufficient staff time was provided to each resident to protect from avoidable injury, evidenced by delayed response times to emergency pendants for 5 residents. | D |
| Failed to report a serious incident involving a resident fall within 24 hours to the Department. | E |
Report Facts
Response time to emergency pendant: 37
Response time to emergency pendant: 58
Response time to emergency pendant: 85
Response time to emergency pendant: 42
Response time to emergency pendant: 11618
Response time to emergency pendant: 75
Response time to emergency pendant: 4622
Incident report date: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 28, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206266, which was opened on 2020-07-17 and completed on 2020-07-28.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care in compliance with state law, specifically failing to notify the resident's family and responsible parties about an injury sustained by Resident #1. Staff responsible for reporting the incident were found to have not notified the family, resulting in termination of one staff member.
Complaint Details
Investigation of intake #GA00206266 regarding failure to notify Resident #1's family about an injury. The complaint was substantiated as staff failed to notify the family, and one staff member was terminated for not reporting the incident.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify Resident #1's family and responsible parties about an injury sustained by Resident #1. | SS=F |
| Failure to follow procedures for change in resident's condition by not notifying the resident's next of kin/legal representative. | SS=F |
Report Facts
Dates of incident and reports: Incident occurred on 2020-06-28; incident report dated 2020-06-30; investigative report dated 2020-07-02.
Previous citations: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and stated the family was not notified and that Staff C was terminated for failure to report the incident. | |
| Staff C | Responsible for completing incident report and notifying family; terminated for failure to notify. | |
| Staff D | Observed and treated Resident #1's injury and reported it to Staff C. |
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 evaluating the infection control procedures at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 3
Apr 2, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00203474, which opened on 2020-03-17 and completed on 2020-04-02.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care, including failure to properly assess and report bruises and changes in condition, failure to notify the resident's next of kin/legal representative timely, and failure to report a serious incident to the Department within 24 hours. Resident #1 experienced bruising, vomiting, diarrhea, dehydration, and was ultimately hospitalized with a small bowel obstruction requiring surgery.
Complaint Details
The investigation was initiated due to intake #GA00203474 concerning Resident #1's bruising, vomiting, diarrhea, and subsequent hospitalization. The complaint included failure to properly assess and report bruises, failure to notify family and legal representatives timely, and failure to report incidents to the Department.
Severity Breakdown
Level K: 1
Level E: 1
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide adequate and appropriate care and services to Resident #1, including failure to assess and report bruises and changes in condition. | Level K |
| Failure to follow procedures for change in resident's condition, including failure to notify resident's next of kin/legal representative. | Level E |
| Failure to report a serious incident involving a resident to the Department within 24 hours. | Level D |
Report Facts
Incident dates: 3
Previous citations: 3
Incident date: Feb 29, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Involved in failure to report bruises and incidents; provided statements about Resident #1's condition and facility policies. | |
| Staff C | Notified about bruises and Resident #1's condition; involved in communication with family. | |
| Staff D | Observed bruises and Resident #1's symptoms; did not report bruises or notify family. | |
| AA | Interviewed regarding observations of bruises and Resident #1's condition and communication with staff. | |
| Staff A | Reported care staff failed to notify nursing staff and family about bruises. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Jan 29, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00202199 with an on-site visit made on 1/29/20 and the investigation completed on 3/13/20.
Findings
The facility failed to provide adequate staffing consistent with residents' needs, failed to ensure staff wore visible identification badges, failed to obtain timely physical examinations for residents, failed to update care plans annually, failed to maintain daily Medication Assistance Records, and failed to provide adequate care resulting in pressure ulcers and neglect for residents #4 and #09. The facility also failed to notify residents' representatives of changes in condition.
Complaint Details
The visit was complaint-related to intake #GA00202199. The investigation found substantiated deficiencies related to staffing, resident care, documentation, and notification failures.
Severity Breakdown
Level J: 2
Level E: 3
Level D: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide watchful oversight consistent with residents' needs due to inadequate staffing. | Level J |
| Failed to ensure staff wore visible employee identification badges with credentials. | Level E |
| Failed to ensure all residents had a physical examination within 30 days prior to admission. | Level D |
| Failed to obtain medical information and current physical examination after significant change in condition. | Level D |
| Failed to update resident care plans annually and more frequently as needs changed. | Level E |
| Failed to maintain daily Medication Assistance Records for residents receiving medication assistance. | Level E |
| Failed to provide adequate care resulting in pressure ulcers and neglect for residents #4 and #09. | Level J |
| Failed to notify resident's next of kin or legal representative of change in condition. | Level D |
Report Facts
Number of caregivers on first and second shifts: 2
Number of residents requiring two-person assistance: 9
Date of physical examination for Resident #4: Jan 7, 2020
Date of physical examination for Resident #09: May 1, 2018
Date of pressure ulcer diagnosis for Resident #4: Feb 11, 2020
Size of pressure ulcer on Resident #09: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Provided assistance with continent care to Resident #4 and reported observations of residents requiring two-person assistance. | |
| Staff C | Observed without visible employee ID badge and described staffing duties and shortages. | |
| Staff D | Reported staffing patterns and supervision concerns during second shift in memory care. | |
| AA | Interviewed regarding staffing levels and duties impacting resident care. | |
| BB | Interviewed regarding staffing and resident care concerns, including physical examination documentation. | |
| Staff A | Interviewed regarding care plan updates, medication records, and notification requirements. | |
| CC | Visited Resident #09 and reported lack of facility response and notification regarding resident's condition. | |
| EE | Reviewed photo and provided information about Resident #4's bedsore development and referral. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 2, 2020
Visit Reason
The visit was conducted to investigate intake #GA00201591, with the investigation starting on 2019-12-31 and the onsite visit occurring on 2020-01-02.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00201591 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 2, 2019
Visit Reason
The purpose of this visit was to investigate complaints #GA00199556 and #GA00199890.
Findings
The facility failed to provide protective care and watchful oversight for 1 of 19 memory care residents (#2), who was found outside the facility unsupervised despite having dementia and other diagnoses.
Complaint Details
The visit was complaint-related to investigate incidents #GA00199556 and #GA00199890 involving a resident with dementia found outside the memory care unit unsupervised.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide protective care and watchful oversight for 1 of 19 memory care residents (#2) who was found outside the facility. | D |
Report Facts
Memory care residents: 19
Incident date: Sep 14, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding resident walking outside the memory care unit |
Inspection Report
Original Licensing
Deficiencies: 0
Aug 29, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection.
Findings
The report documents the initial inspection visit for the facility; no specific findings or deficiencies are detailed in the provided page.
Inspection Report
Follow-Up
Deficiencies: 4
May 7, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 2/9/2019 inspection.
Findings
The facility failed to ensure staff wore visible employee identification badges, failed to post the most recent inspection report and plan of correction in a public area, failed to timely manage medication procurement resulting in medication refills not obtained for two residents, and failed to provide adequate care for one resident as evidenced by urine odor on bedding.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff failed to wear employee identification badges which are readily visible with abbreviations for professional/special credentials for two of ten sampled staff (Staff K and Staff L). | D |
| Facility failed to post a copy of the most recent inspection report and plan of correction in a location routinely used by the community to communicate information to residents and visitors. | D |
| Community failed to notify the physician of the unavailability of prescriptions, request direction, and obtain refills timely for 2 of 3 residents sampled (Resident #10 and Resident #11), resulting in medication not being available. | D |
| Facility failed to ensure each resident received adequate and appropriate care in compliance with state law for 1 of 4 sampled residents (Resident #9), as evidenced by urine odor on bedding. | E |
Report Facts
Staff sampled: 10
Residents sampled: 4
Residents with medication issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Failed to wear employee identification badge and acknowledged urine odor on Resident #9 bedding | |
| Staff L | Failed to wear employee identification badge | |
| Staff J | Forgot to wear name badge and aware of medication refill issues | |
| Staff A | Had copy of inspection report and plan of correction but unsure where to post | |
| Staff M | Notified families about medication refills needed for residents |
Inspection Report
Original Licensing
Deficiencies: 12
Feb 6, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection and to investigate GA00194355. An onsite visit was made to the facility on 2/6/19 and the investigation was completed on 2/9/19.
Findings
The facility was found to have multiple deficiencies including failure to obtain required criminal background checks and employment histories for staff, failure to maintain personnel files with physical exams and TB screenings, unsafe conditions such as locked interior doors not removed, hot water temperature exceeding 120 degrees Fahrenheit, outdated resident care plans, medication administration errors including giving medications at incorrect times and failure to update medication records, inadequate competency reviews for certified medication aides, failure to provide adequate resident care and assistance, and lack of a disaster preparedness plan.
Complaint Details
The inspection included an investigation of complaint GA00194355.
Severity Breakdown
SS= D: 12
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory fingerprint records check determination for the Executive Director prior to serving. | SS= D |
| Failed to obtain a criminal records check determination for one of six sampled staff. | SS= D |
| Failed to obtain and maintain employment history or satisfactory reference check for five of six sampled staff. | SS= D |
| Failed to ensure all staff received a physical examination and TB screening within 12 months of employment for five of six sampled staff. | SS= D |
| Failed to maintain the interior free of unsafe conditions; locked interior door requiring a green push pad to open was not removed. | SS= D |
| Failed to maintain heated water temperature that did not exceed 120 degrees Fahrenheit; water temperature measured at 124.9 degrees F. | SS= D |
| Failed to update resident care plans annually and more frequently as needs changed for Resident #1 and Resident #6. | SS= D |
| Failed to follow written doctor's orders when administering medications to Resident #012; medications prescribed for bedtime were given at 2:00 p.m. | SS= D |
| Failed to complete annual competency reviews for certified medication aides Staff D and Staff F. | SS= D |
| Failed to update Medication Assistance Record (MAR) each time medication was offered for Resident #012. | SS= D |
| Failed to provide adequate, appropriate care and services; Resident #8 and Resident #9 waited 45 minutes to an hour for assistance to change adult brief despite calling for help multiple times. | SS= D |
| Failed to provide a Disaster Preparedness Plan meeting regulatory requirements; no documentation of plan was available. | SS= D |
Report Facts
Date of inspection visit: Feb 6, 2019
Date survey completed: Feb 9, 2019
Medication administration error: 1
Medication Assistance Record errors: 6
Hot water temperature: 124.9
Wait time for assistance: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Failed fingerprint records check prior to serving; involved in hot water temperature observation |
| Staff F | Failed criminal records check; no employment history; no physical exam and TB screening; no competency review | |
| Staff G | Interviewed multiple times regarding deficiencies and facility status | |
| Staff C | Interviewed regarding locked door and resident placement | |
| Staff B | Nurse | Notified staff of resident calls for assistance |
| Staff D | No annual competency review for medication aide |
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