Inspection Report Summary
The most recent inspection on July 18, 2025, cited a deficiency for failing to report a serious incident involving a resident within the required 24-hour timeframe. Earlier inspections mostly found no deficiencies, though prior reports noted issues related to resident abuse, failure to notify legal surrogates of changes in condition, and incomplete background checks for staff. The main themes of deficiencies involved incident reporting, resident safety, and communication with legal representatives. Several complaint investigations were unsubstantiated, but substantiated complaints included staff physical abuse of a resident and failure to notify family after an injury. The facility’s inspection history shows some recurring challenges with incident handling and resident protection, with no clear pattern of consistent improvement or worsening over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 18, 2025
Visit Reason
The visit was conducted to complete a compliance inspection and investigate intake #GA50003484, which involved a complaint regarding the facility.
Complaint Details
Investigation of intake #GA50003484 regarding failure to timely report a serious incident involving Resident #1. The report was substantiated as the facility did not submit the report within 24 hours.
Findings
The facility failed to report a serious incident involving a resident (Resident #1) to the Department within the required 24-hour timeframe. The incident report was dated 5/5/25 but was not submitted until 5/9/25, and the Department received it on 5/12/25.
Deficiencies (1)
Facility failed to report to the Department a serious incident involving a resident within 24 hours for 1 of 3 sampled residents (Resident #1).
Report Facts
Incident report date: May 5, 2025
Report submission date: May 9, 2025
Report received date: May 12, 2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 6, 2024
Visit Reason
The purpose of the visit was to investigate intake #GA00251424.
Complaint Details
Investigation of intake #GA00251424 found no rule violations.
Findings
The investigation was completed on 11/6/2024 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00248763 with an onsite visit conducted on 8/21/2024.
Complaint Details
Investigation of complaint #GA00248763 found no rule violations.
Findings
The investigation was completed on 8/21/2024 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 7, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00246196.
Complaint Details
Investigation of intake #GA00246196; no violations found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 15, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00243225.
Complaint Details
Investigation of intake GA00243225; no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 5, 2023
Visit Reason
The purpose of this visit was to investigate intake # GA00240940.
Complaint Details
Investigation of intake # GA00240940 with no rule violations cited.
Findings
No rule violation was cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238920 with an onsite visit made and inspection completed on 9/27/2023.
Complaint Details
Investigation of intake #GA00238920; no rule violations found.
Findings
No rule violations were cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237048, #GA00236993, and #GA00236923.
Complaint Details
Investigation of intake #GA00237048, #GA00236993, and #GA00236923 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 5, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00236033.
Complaint Details
Investigation of intake GA00236033; no rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The purpose of this visit was to investigate multiple complaint intakes (#GA00234274, #GA00234392, #GA00234573, #GA00234653) concerning alleged abuse of Resident #1. An onsite visit was made on 5/3/23 and the investigation was completed on 5/12/23.
Complaint Details
The investigation was triggered by multiple complaint intakes alleging staff assault on Resident #1. The complaint was substantiated by observations, interviews, and record reviews indicating failure to notify the legal surrogate and improper handling of the incident by staff.
Findings
The facility failed to notify the legal surrogate of a change in Resident #1's condition after an incident where the resident's fingernail was torn off and minor bleeding occurred. Interviews and record reviews revealed conflicting accounts of the incident involving staff and Resident #1, with Staff E being terminated following the investigation. The facility did not promptly notify the legal surrogate or emergency services as required.
Deficiencies (1)
Failure to notify the legal surrogate of a change in the resident's condition or adjustment for Resident #1 after an incident involving injury.
Report Facts
Complaint intakes investigated: 4
Date of incident: Apr 12, 2023
Date of care plan: Apr 10, 2023
Date of incident report: Apr 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named in incident involving Resident #1; terminated after investigation | |
| Staff B | Notified about incident; involved in communication regarding incident | |
| Staff A | Notified Department of incident on 4/13/23 | |
| Staff D | Reported incident to legal surrogate AA on 4/12/23 | |
| AA | Legal surrogate for Resident #1; received delayed and incomplete notifications | |
| GG | Witnessed blood and upset resident on 4/12/23 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 14, 2023
Visit Reason
The visit was conducted to investigate multiple complaint intakes (#GA00233605, #GA232560, #GA231465, #GA00234200, and #GA00231153) with onsite visits on 2023-03-16 and 2023-04-12.
Complaint Details
Investigation was initiated based on multiple complaint intakes and completed after onsite visits; no violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00233280.
Complaint Details
Investigation of intake GA00233280 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00221183 and #GA00221209 with an onsite visit made on 2022-02-09 and the investigation completed on 2022-02-18.
Complaint Details
Investigation of two intakes (#GA00221183 and #GA00221209) was completed with no rule violations cited.
Findings
No rule violations were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00218332. An on-site visit was conducted on 11/5/2021, with the inspection started on 11/2/2021 and completed on 1/31/2022.
Complaint Details
Investigation of intake #GA00218332 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 2, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00215041. An onsite visit was made on 6/29/2021 and the investigation was completed on 7/2/2021.
Complaint Details
Investigation was complaint-related based on intake #GA00215041. The complaint was substantiated by witness statements from Staff C and Staff D, and Resident #1's own statement. Staff E was suspended and resigned before the investigation was completed.
Findings
The facility failed to keep residents free from physical abuse for 1 of 3 sampled residents (Resident #1). Staff E was witnessed pushing Resident #1 onto an elevator and pulling the resident's arm very hard. The incident was reported, Staff E was suspended and later resigned before the investigation was completed.
Deficiencies (1)
Facility failed to keep residents free from physical abuse for 1 of 3 sampled residents (Resident #1) involving Staff E pushing Resident #1 onto the elevator and pulling the resident's arm.
Report Facts
Number of sampled residents: 3
Date of incident: Jun 7, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Named as the staff who pushed Resident #1 onto the elevator and was suspended and resigned | |
| Staff C | Witnessed Staff E push Resident #1 and reported the incident | |
| Staff D | Witnessed Staff E push Resident #1 and reported the incident | |
| Staff B | Executive Director | Received report of incident, stated Staff E was suspended and resigned |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 5, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00213741.
Complaint Details
Investigation was completed on 2021-05-14 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA0021.0040, which started on 2020-12-15 and was completed on 2021-01-05.
Complaint Details
Investigation of intake #GA0021.0040 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00203586.
Complaint Details
Investigation of intake #GA00203586 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 16, 2020
Visit Reason
The purpose of this inspection was to conduct the compliance inspection and investigate intake #GA00202988.
Complaint Details
Investigation of intake #GA00202988 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 17, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00201259.
Complaint Details
Investigation of intake #GA00201259 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198101.
Complaint Details
Investigation of intake #GA00198101 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Deficiencies: 1
Date: Jun 3, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
The community failed to obtain criminal history background checks in compliance with O.C.G.A. 31-7-250 et seq. for 4 of 6 sampled staff members, as no documentation was found that the checks were conducted through the Georgia Crime Information Center.
Deficiencies (1)
Failed to obtain criminal history background checks for 4 of 6 sampled staff in compliance with O.C.G.A. 31-7-250 et seq.
Report Facts
Number of sampled staff without criminal background checks: 4
Number of sampled staff: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in deficiency for missing criminal background check | |
| Staff D | Named in deficiency for missing criminal background check | |
| Staff E | Named in deficiency for missing criminal background check | |
| Staff F | Named in deficiency for missing criminal background check | |
| Staff A | Interviewed regarding criminal background check process |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 23, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate a self-reported incident #GA00184299. Onsite visits were made on 2018-02-13 and 2018-02-14, with the investigation completed on 2018-02-23.
Findings
The facility failed to ensure that an immediate investigation of the cause of an accident, injury, or death involving a resident was conducted and that a report was made to the representative or legal surrogate with a copy maintained in the resident's file and a central file for quality assurance review for one sampled resident (Resident #1).
Deficiencies (1)
Failure to conduct an immediate investigation of the cause of an accident, injury, or death involving a resident and to maintain the report in the resident's file and a central file for quality assurance review.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 31, 2017
Visit Reason
The visit was conducted to investigate complaint #GA00177619, with an on-site visit made on 7/31/17 and the investigation completed on 10/12/17.
Complaint Details
Complaint #GA00177619 was investigated; the visit was complaint-related.
Findings
The facility failed to clean a resident's private living space periodically and as needed, resulting in a strong smell of urine and a carpet stain in Resident #1's room, posing a health hazard.
Deficiencies (1)
Failure to clean the resident's living spaces periodically and as needed to ensure the space did not pose a health hazard.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 10, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate facility reported incident #GA00173452. The violations cited were related to the annual inspection.
Complaint Details
The visit included investigation of facility reported incident #GA00173452, but the violations cited were related to the annual inspection.
Findings
The facility failed to post required house rules, ensure all staff had current first aid and CPR training, comply with fire safety inspection requirements, and securely store and inventory medications to prevent loss and unauthorized use.
Deficiencies (5)
Facility failed to post required house rules including telephone usage, use of personal property, pets, and elopement.
Facility failed to ensure that all staff had current first aid training for 1 of 6 files sampled (staff D).
Facility failed to ensure that all staff had current CPR training for 1 of 6 staff sampled (staff D).
Facility failed to ensure compliance with fire and safety rules; sprinkler system was not completely green-tagged due to front canopy dry riser being yellow-tagged.
Facility failed to ensure medications were stored securely under lock and key and inventoried appropriately to prevent loss and unauthorized use; resident #4 was found keeping medications unsecured in his/her room.
Report Facts
Staff files sampled: 6
Staff with training deficiencies: 1
Inspection date: Apr 10, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Interviewed regarding house rules, staff training, fire safety, and medication storage deficiencies | |
| Staff D | Staff member lacking current first aid and CPR training |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00170213 and facility reported incident #GA00170908.
Complaint Details
Investigation of complaints #GA00170213 and facility reported incident #GA00170908 with no rule violations cited.
Findings
No rule violations were cited as a result of these investigations.
Viewing
Loading inspection reports...
