Inspection Reports for
Ashton Senior Living, Gainesville

Complaint intake #GA50003235 triggered the inspection. The complaint was substantiated by findings related to community leadership and evaluation of applicants for admission.

The inspection found that the assisted living community failed to designate qualified staff to act on behalf of the administrator or on-site manager, and failed to provide a physical examination for Resident #3 conducted within 30 days prior to admission, reflecting the resident does not require continuous medical or nursing care and is free of active tuberculosis.

The facility failed to ensure proper oversight by the governing body, resulting in repeated violations including failure to conduct criminal background checks for direct access employees, lack of a registered nurse or licensed practical nurse on-site for required hours, and failure to employ certified medication aides to administer medications. These deficiencies were consistent with prior inspections.

The facility was found to have ongoing violations including falsification of medication administration records, failure to designate qualified staff to act in the administrator's absence, failure to obtain criminal background checks for direct access employees, failure to employ certified medication aides to administer medications, and failure to securely store and properly document controlled substances. No rule violations were cited as a result of the follow-up investigation conducted on 3/17/2025.

The visit was complaint-related to investigate allegations including unqualified personnel administering medications, lack of criminal background checks, missed medications, and improper medication handling.

The facility failed to ensure proper oversight by the governing body, resulting in unqualified staff administering medications, lack of criminal background checks for staff, absence of licensed nurses on-site, failure to administer medications as ordered, failure to employ certified medication aides, failure to maintain accurate medication administration records, and improper medication storage and inventory control.

The facility was found to have multiple ongoing deficiencies including submission of falsified medication administration records, failure to designate qualified staff to act on behalf of the administrator, failure to obtain required criminal background checks for staff, failure to employ certified medication aides to administer medications, failure to maintain accurate medication administration records, and failure to securely store and inventory medications, especially controlled substances.

This visit was a follow-up to the complaint investigation initiated on 5/30/24, with onsite visits on 10/10/24 and 10/23/24, completed on 11/1/24.

The facility was found to have multiple deficiencies including falsification of medication administration records, failure to designate qualified staff to act in the administrator's absence, failure to employ certified medication aides, failure to administer medications according to physician orders, failure to maintain accurate medication administration records, and failure to securely store and inventory medications, particularly controlled substances.

The investigation was complaint-driven based on complaints #GA00245921, #GA00245622, and #GA00245465. The investigation included review of records, interviews, and observations related to medication administration, staffing, and background checks.

The facility was found to have multiple deficiencies including failure to obtain satisfactory fingerprint background checks for direct access employees, failure to administer medications according to physician orders for 3 of 8 sampled residents, lack of certified medication aides to administer medications, failure to update medication administration records properly, and failure to securely store and inventory medications, especially controlled substances.

Investigation of complaint #GA00244535. The complaint was substantiated by observations and interviews confirming pest presence.

The facility failed to maintain an effective insect, rodent, or pest control program as evidenced by the observation of bugs on the walls in Resident #3's room and staff reports of bugs in closets and bathrooms despite recent pest control treatments.

The visit was complaint-driven, investigating multiple intake numbers related to medication errors, improper medication administration, and narcotic discrepancies. Substantiation details include confirmed medication errors, altered fentanyl patches, missing narcotics, and unauthorized staff access to medications.

The investigation found multiple deficiencies including medication administration errors, failure to employ certified medication aides, improper medication record keeping, and inadequate secure storage and inventory of medications, especially controlled substances. Specific incidents involved residents receiving incorrect medications, altered fentanyl patches, missing narcotics, and staff unauthorized to administer medications.

The visit was complaint-related, investigating complaint #GA00238309. The complaint was substantiated by findings of uncertified medication administration and missing resident files.

The facility failed to employ a certified medication aide to administer medications for one of three sampled staff, and failed to maintain a resident file for three years after discharge for one of four sampled residents.

The visit was complaint-related, investigating multiple intake numbers. The investigation included review of records and interviews conducted on 3/21/23. The complaint was substantiated with multiple deficiencies found.

The facility was found to have multiple deficiencies including failure to have a valid administrator license, failure to obtain satisfactory fingerprint records checks for staff, failure to maintain required physical exams for residents, and failure to maintain individual resident files. Additionally, the facility lacked a memory care unit despite residents requiring specialized memory care placement.

Investigation was initiated based on complaint intakes #GA00230487 and #GA00230485. The investigation was substantiated by findings of missing required physical examinations for residents.

The facility failed to obtain physical examinations conducted by a licensed physician, nurse practitioner, or physician's assistant dated within 30 days prior to admission for 2 of 3 sampled residents (Resident #1 and Resident #3). The required documentation was not received by the close of business on 2023-01-12.

The investigation was complaint-driven based on complaints #GA00227938, GA00228246, and GA00228419. Findings included substantiated issues with staffing, medication administration, furniture condition, and nutrition.

The facility failed to provide sufficient staff time for residents to receive services and medications, employed uncertified medication aides, failed to update medication administration records properly, did not maintain furniture in good condition, and failed to offer at least one nutritious snack. Multiple residents and staff interviews confirmed these deficiencies.

The investigation was initiated based on multiple complaint intakes (#GA00225701, #GA00225737, #GA00225738, #GA00225810, and #GA00225791). The investigation included interviews and record reviews related to medication administration errors and employment of staff with unsatisfactory background checks.

The facility failed to ensure that an individual with an unsatisfactory criminal background check was not employed, and failed to provide medication administration services in accordance with physicians' orders for multiple residents. Additionally, certified medication aides were not used to administer medications for all residents, and medication errors occurred including wrong medication given to Resident #1.

Investigation of complaint #GA00225673 regarding elevator accessibility. The elevator had been non-operational since 6/13/2022, impacting residents' ability to exit the facility. Staff confirmed the elevator was broken and parts were ordered. Facility staff and local authorities were coordinating to assist residents.

The facility failed to provide at least two wheelchair-accessible exits for residents dependent on wheelchairs due to an elevator that had been out of service since 6/13/2022. Staff reported the elevator was broken for two weeks, and the facility relied on local sheriff deputies and fire department assistance to move residents between floors.

The inspection was conducted in response to complaint #GA00223043. The complaint involved concerns about facility administration licensure, staff certifications, resident care including ingestion of cleaning solution by a resident, and medication management.

The facility failed to have an administrator with a valid license, failed to ensure staff had current CPR certification and required continuing education, failed to ensure satisfactory criminal background checks, failed to provide protective care for a resident who ingested cleaning solution, and failed to properly update medication administration records and obtain timely medication refills for residents.

Investigation was complaint-related based on intake numbers #GA00210418 and #GA00210400. Multiple interviews and record reviews substantiated neglect in resident care, including failure to change or clean residents timely, resulting in discomfort and unsanitary conditions.

The facility failed to provide sufficient staff time to ensure that four of eight residents were kept comfortable and clean, with multiple instances of residents being found soaked, soiled, or left uncleaned for extended periods. Interviews and record reviews confirmed neglect in timely changing and cleaning of residents, contributing to discomfort and unsanitary conditions.

The inspection was complaint-driven based on intake numbers #GA00205236 and GA00205779. The complaint involved failure to conduct required background checks and inappropriate staff behavior involving residents in social media videos.

The facility failed to obtain required fingerprint background checks for certain staff members and failed to ensure residents were treated with dignity and respect, as evidenced by staff posting inappropriate TikTok videos involving residents. Specific deficiencies included missing fingerprint checks for three staff members and inappropriate social media behavior involving two residents with dementia.

Investigation was complaint-driven (#GA00203938). Multiple interviews with residents and staff confirmed substantiated issues of insufficient staffing, poor hygiene care, delayed medication administration, and uncertified staff administering medications.

The facility failed to provide sufficient staff time to assist residents with daily hygiene and medication administration. Several residents and staff reported inadequate staffing, poor hygiene care, delayed medication administration, and uncertified staff administering medications.

The investigation was triggered by allegations of neglect and failure to provide protective care and watchful oversight. Specific complaints included a resident found on the floor after falling and not being checked on overnight, lack of staff documentation for resident checks, presence of children running in halls at night, and failure to notice or report a resident's deteriorating foot condition leading to possible amputation.

The facility failed to maintain personnel files for one staff member, failed to provide adequate protective care and watchful oversight for three residents, and failed to immediately address changes in a resident's condition including notifying representatives. Multiple incidents of neglect and inadequate staff oversight were documented.

The visit included investigation of complaint intakes #GA00202797 and GA00202894. The complaint investigation found substantiated issues including uncertified staff administering medications and failure to respond appropriately to a resident's adverse health condition.

The facility was found deficient in maintaining personnel files for employees, employing certified medication aides for medication administration, and failing to take immediate appropriate actions for a resident's adverse condition change, including notifying legal representatives. Specific deficiencies included missing personnel files, uncertified staff administering medications, and inadequate response to a resident's foot gangrene leading to hospitalization and surgery.

Complaint GA00197890 was investigated and substantiated by findings of failure to obtain criminal background checks and failure to provide medications as ordered.

The facility failed to obtain criminal background checks prior to employment for 2 of 6 sampled staff and failed to provide medications as ordered by the physician to 9 sampled residents due to lack of Certified Medication Aide on the morning of 06/12/19.

The visit was complaint-related, investigating intake #GA00195875 and #GA00195686.

The facility was found to have multiple deficiencies including failure to ensure staff received tuberculosis screening and physical examinations within twelve months, failure to obtain criminal background checks for staff, failure to ensure staff wore visible employee identification badges, and failure to employ certified medication aides for medication administration.

The facility failed to update the Medication Assistance Record (MAR) each time the medication was offered or taken for multiple residents, as evidenced by missing MAR updates on specific dates and times for residents #4, #5, #12, #19, and #24. The facility was working to correct the issue, including termination of staff.

The inspection was conducted to investigate multiple complaint intakes (#GA00190470, #GA00190762, #GA00190846, #GA00190940, and #GA00192867).

The facility was found deficient in multiple areas including failure to provide infection control training to staff, failure to provide protective care and watchful oversight for a resident resulting in injury, failure to maintain accurate medication assistance records, failure to obtain timely medication refills, improper storage and disposal of medications, and failure to ensure residents received adequate and appropriate care in compliance with state regulations.

The visit was complaint-related to investigate allegations of drug diversion and medication mismanagement at the facility. The complaint was substantiated with findings of drug diversion by staff, medication errors, and failure to follow regulatory requirements.

The investigation found multiple deficiencies including failure to investigate drug diversion, staff not wearing identification badges, medication administration errors, uncertified staff administering medications, lack of quarterly medication observations and drug regimen reviews, improper medication storage and disposal, missing resident files, failure to update medication records, and confirmed drug diversion resulting in arrests.

The facility failed to ensure that one of seven sampled staff had the required 16 hours of continuing education units (CEUs) and failed to obtain a fingerprint check for the onsite manager.

Complaint # GA00189070 was investigated and rule violations related to the complaint are listed in the report.

The facility failed to ensure that each resident was given the right to be free from physical restraints for 1 of 11 sampled residents. Specifically, Resident #1 was observed with a raised half bed rail, which was not allowed for residents with dementia.

The complaint investigation was triggered by complaint #GA00188651. The facility was found noncompliant for failing to obtain required criminal background checks for staff and failing to report a serious injury to the Department involving Resident #1, who suffered multiple injuries from falls and hospitalization.

The facility failed to obtain satisfactory fingerprint records checks for the Director and one employee, and failed to report a serious injury requiring medical care for one resident to the Department. The investigation revealed deficiencies in criminal background checks and reporting serious incidents.

Complaint #GA00187293 was investigated. The complaint involved the facility providing prohibited proxy caregiver services by administering morphine to Resident #3 based on hospice nurse instructions.

The facility failed to ensure that medical and nursing health services required on a periodic basis, or for short-term illness, were not provided as services of the assisted living community, specifically for 1 of 4 sampled residents (Resident #3). Staff administered morphine to Resident #3 based on hospice nurse instructions, which is prohibited.

The community failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 3 of 6 sampled residents, and failed to ensure adequate and appropriate care for 2 of 6 sampled residents. The violations were previously cited on 6/8/17 and involved medication documentation errors and missed medication administration.

The inspection identified multiple deficiencies including failure to ensure staff received timely tuberculosis screenings and physical exams, incomplete documentation of residents' physical exams prior to admission, medication aides not listed in good standing on the Georgia Certified Medication Aide Registry, failure to update Medication Assistance Records accurately, lack of a three-day emergency water supply, improper infection control practices by staff, and failure to provide adequate and appropriate care and services to residents as per state regulations.

The visit was complaint-related, investigating complaints #GA00173772 and #GA00174182. The investigation was closed on 5/8/17.

The facility failed to obtain criminal background checks prior to employment for 2 of 2 sampled staff and failed to ensure that all Certified Medication Aides were listed in good standing on the Georgia CMA registry before permitting medication administration for 1 of 2 CMAs.