Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002820 through an unannounced onsite visit to the facility.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation was started on 2025-06-05 and completed on 2025-06-11 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 6
Feb 11, 2025
Visit Reason
The purpose of the visit was to investigate complaint intakes GA0050001358, GA50001359, and GA50001454 with an onsite visit on 2025-02-11 and investigation period from 2025-02-10 to 2025-02-20.
Findings
The investigation found that an agency caregiver physically assaulted Resident #1 on 2025-01-05, resulting in the resident's death from blunt force trauma to the head. The facility failed to conduct proper background checks, provide required training to staff, and report the serious incident timely to the Department. The facility also failed to ensure residents were free from physical abuse and did not have sufficient specially trained staff in the memory care unit.
Complaint Details
The investigation was complaint-driven based on intakes GA0050001358, GA50001359, and GA50001454. The complaint involved physical abuse of Resident #1 by an agency caregiver on 2025-01-05, resulting in the resident's death on 2025-01-17. The facility initially misreported the incident as a fall and delayed reporting to the Department until 2025-01-30.
Severity Breakdown
J: 5
D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to implement policies and procedures supporting resident dignity, respect, and safety, including protection from harm by non-employees. | J |
| Failure to obtain criminal background checks for direct access employees. | J |
| Failure to staff memory care unit with sufficient specially trained staff to meet residents' unique needs. | J |
| Failure to provide required dementia-specific orientation and training to staff assigned to memory care unit. | J |
| Failure to ensure residents are free from physical abuse; agency caregiver physically assaulted Resident #1 causing fatal injury. | J |
| Failure to report serious injury incident involving Resident #1 to the Department within 24 hours. | D |
Report Facts
Incident date: Jan 5, 2025
Resident death date: Jan 17, 2025
Video footage length: 23
Staff AS work shifts: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AS | Agency Direct Caregiver | Named in physical abuse incident involving Resident #1 |
| Staff A | Executive Director | Notified of Resident #1's death and reviewed video footage; responsible for oversight |
| Staff C | Med Tech | Witnessed aftermath of assault; lacked proper training |
| Staff D | Staff Member | Third shift staff who responded to incident; did not witness assault |
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