Inspection Reports for Bethel Gardens
3805 JACKSON WAY EXT, POWDER SPRINGS, GA, 30127
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 12, 2025, identified deficiencies following an onsite investigation. Earlier inspections showed a pattern of issues related mainly to physical plant maintenance, governing body oversight, staffing levels, and pest control, with several complaint investigations substantiating these concerns. Deficiencies frequently involved unclean or disrepair conditions such as lifted floor tiles and rodent presence, insufficient staffing to meet resident needs, and incomplete documentation including medication administration records. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved delayed staff responses and inadequate resident activities. The inspection history shows ongoing challenges with facility maintenance and staffing, with no clear improvement trend evident.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
26 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Date: Dec 12, 2025
Visit Reason
An onsite visit was made to the facility on 12/12/2025 to conduct an investigation including observation, record review, and interviews.
Findings
The report contains a statement of deficiencies and plan of correction following the onsite visit and investigation.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Date: Oct 15, 2025
Visit Reason
The purpose of this visit was to investigate complaint intakes GA50005941 and GA50006030 through an unannounced on-site visit conducted on 10/15/2025.
Complaint Details
The visit was complaint-related, investigating intake numbers GA50005941 and GA50006030. The elevator was inoperable, pest control was inadequate, and activities were insufficient as reported by residents and staff.
Findings
The facility failed to ensure corridors accommodated mobility devices due to an inoperable elevator, lacked an effective pest control program as evidenced by rodent droppings and untreated resident rooms, and did not provide sufficient activities to promote residents' physical, mental, and social well-being.
Deficiencies (3)
Facility failed to ensure corridors accommodated mobility devices such as walkers and wheelchairs due to an inoperable elevator.
Facility failed to maintain an insect, rodent or pest control program that continually protects the health of residents; rodent droppings found in an unoccupied room and no treatment in resident rooms.
Facility failed to provide sufficient activities to promote the physical, mental, and social well-being of each resident; no activities observed and residents reported lack of activities.
Report Facts
Resident census: 26
Exterminator visits: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding elevator inoperability and inability to conduct scheduled activities |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 27, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA 50005138 and GA 50004988.
Complaint Details
Investigation of complaint intakes GA 50005138 and GA 50004988 with no deficiencies cited.
Findings
No rules were cited as a result of this inspection and investigations.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Aug 13, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up inspection related to intake# 45917.
Findings
No rule violations were cited as a result of this inspection. However, several requirements were noted as not met, including governing body oversight, physical plant health and safety standards, and staffing requirements.
Deficiencies (3)
Governing body failed to provide necessary oversight to ensure compliance with applicable requirements.
Floors, walls, and ceilings were not kept clean and in good repair.
Staffing requirements were not met; the home was not staffed at all times with sufficient specially trained staff to meet residents' unique needs.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 27, 2025
Visit Reason
The purpose of this visit was to investigate complaint intake numbers GA50002691 and GA50003320 through an unannounced onsite visit conducted on 5/27/25, with the investigation completed on 6/18/25.
Complaint Details
Investigation of complaint intake numbers GA50002691 and GA50003320. The deficiencies related to physical plant conditions and governing body oversight were substantiated.
Findings
The facility failed to keep floors, walls, and ceilings in good repair, specifically with lifted floor tiles in the entry area and corridor to the elevator posing a tripping hazard. This deficiency was previously cited on 1/28/25.
Deficiencies (2)
The governing body failed to provide the oversight necessary to ensure the home operates in compliance with state rules and regulations, including maintaining floors, walls, and ceilings in good repair.
The facility failed to keep floors clean and in good repair, with lifted floor tiles observed creating a tripping hazard.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A interviewed regarding floor disrepair and awaiting contractor for repairs. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 20, 2025
Visit Reason
The purpose of this visit was to investigate intake numbers GA50001583 and GA50001849.
Complaint Details
Investigation of complaint intakes GA50001583 and GA50001849 found no rule violations.
Findings
The inspection was started on 2025-04-23 and completed on 2025-05-20. No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 20, 2025
Visit Reason
The purpose of this visit was to investigate intakes GA5000022 and GA50000418. The investigation began on 2025-01-29 and was completed on 2025-02-19.
Complaint Details
Investigation was initiated based on intakes GA5000022 and GA50000418. The investigation was conducted from 2025-01-29 to 2025-02-19.
Findings
The facility failed to maintain physical plant health and safety standards, including floors, walls, and ceilings in disrepair, and housekeeping standards resulting in unclean and disorderly conditions throughout multiple rooms.
Deficiencies (2)
Facility failed to keep ceilings clean and in good repair; floor tiles lifted causing tripping hazard; missing vent in memory care unit wall; holes in vinyl floors in kitchen.
Facility failed to maintain housekeeping standards presenting unclean and disorderly appearance including dirty floors, unbagged laundry on shower floor, odor and open food items with live roach, brown stains on curtains and toilet seats, inoperable toilet, missing shower curtain, toilet handle in disrepair, and water leak in tub/shower.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding facility maintenance and housekeeping issues. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249475.
Complaint Details
Investigation of intake #GA00249475 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 30, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA002488895 and GA00248603.
Complaint Details
Investigation of complaint intakes GA002488895 and GA00248603 with no rule violations found.
Findings
No rule violations were cited during the investigation completed on 08/30/2024.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00246476 with an onsite visit made on 6/27/24 and the investigation completed on 7/2/24.
Complaint Details
Investigation of intake # GA00246476 with no rule violations cited.
Findings
There were no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 2, 2024
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00245687.
Complaint Details
Investigation of intake #GA00245687; no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 15, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244078. The onsite visit was made on 3/15/24, with the inspection started on 3/15/24 and completed on 4/2/24.
Complaint Details
The visit was complaint-related, investigating intake #GA00244078. The complaint involved failure to maintain records, medication administration documentation, resident file availability, and failure to report a serious incident involving Resident #1 who fell and was hospitalized.
Findings
The facility failed to maintain employee files available for inspection, failed to update medication administration records properly, did not provide resident files upon request, and failed to report a serious incident involving a resident within the required timeframe.
Deficiencies (4)
Facility failed to ensure that employee files were maintained and available for inspection for 6 of 6 sampled staff.
Staff failed to update the medication administration record (MAR) each time medication was offered or taken for 1 of 4 sampled staff.
Facility failed to make resident files available for inspection or copy for 3 of 4 sampled residents.
Facility failed to report a serious incident involving a resident within 24 hours as required.
Report Facts
Number of sampled staff with missing files: 6
Number of sampled staff with MAR documentation issues: 1
Number of sampled residents with missing files: 3
Date of serious incident: Mar 9, 2024
Duration of hospital stay: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding missing employee files, resident files, and failure to report incident | |
| Staff B | Interviewed regarding failure to update MAR |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242352 and GA00242430. The onsite visit was made on 1/16/24, with the inspection started on 1/16/24 and completed on 2/7/24.
Complaint Details
The visit was complaint-related, investigating intake #GA00242352 and GA00242430. The complaint was substantiated based on findings of missing medication administration documentation.
Findings
The facility failed to ensure that each staff member who provides assistance or administration of medication recorded initials, time, and date when medications were taken, refused, or a medication error was identified for Resident #1. Multiple instances of missing staff initials on medication administration records for Resident #3 were documented.
Deficiencies (1)
Failure to ensure staff recorded initials, time, and date when medications were administered, refused, or a medication error identified on the medication assistance record (MAR) for Resident #1 and Resident #3.
Report Facts
Dates of missed medication administration: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 2/6/24 and stated that medication had been administered but staff forgot to indicate with their initials. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The purpose of this visit was to investigate complaints GA00237704 and GA00237906.
Complaint Details
The inspection was complaint-related, investigating GA00237704 and GA00237906, with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
The purpose of this visit was to investigate intake # GA00228646 with an on-site visit made to the facility from 11/1/22 to 11/4/22.
Complaint Details
Investigation of intake # GA00228646 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225260. An on-site visit was made to the facility on 8/4/22 and the investigation was completed on 8/10/22.
Complaint Details
Investigation of intake #GA00225260 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217179. An on-site visit was made on 9/14/2021.
Complaint Details
Investigation of intake #GA00217179 with no rule violations cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212334 and #GA00212398.
Complaint Details
Investigation of complaint intakes #GA00212334 and #GA00212398; no violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 16, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00211837.
Complaint Details
Investigation of intake GA00211837 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00211573, GA0211583, GA0211837, GA0211639.
Complaint Details
Investigation of complaint intakes GA00211573, GA0211583, GA0211837, GA0211639 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
The purpose of this visit was to investigate intakes GA00210359, GA00211254, GA00211283, GA00211372, GA00211373.
Complaint Details
Investigation of multiple complaint intakes with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA00209603 and #GA00209474.
Complaint Details
Investigation began on 2020-11-16 and was completed on 2020-11-20. The complainant was contacted on 2020-11-16 at 9:00 a.m.
Findings
No rule violation was cited as a result of this inspection. The investigation included a tour of the facility, observation, staff and resident interviews.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
The purpose of this inspection was to investigate intake GA00205423.
Complaint Details
Investigation of intake GA00205423; no violations found.
Findings
No rules violation were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Apr 8, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00202848 and intake #GA00202972 regarding staffing and resident care concerns.
Complaint Details
The investigation was triggered by complaints regarding inadequate staffing and delayed response to call lights. The complaint was substantiated by interviews and record reviews showing delayed staff response times ranging from 16 to 1283 minutes and residents experiencing unmet care needs.
Findings
The facility failed to maintain sufficient staffing to meet the specific safety, health, and care needs of residents, resulting in delayed responses to call lights and inadequate assistance for residents, including incontinent care and wheelchair-dependent residents.
Deficiencies (1)
Failed to ensure sufficient staff to meet the specific safety, health, and care needs of residents, resulting in delayed response to call lights and unmet resident needs.
Report Facts
Residents present on 2/10/20: 32
Residents present on 3/3/20: 27
Staff on 1/16/2020 at 2:15 p.m.: 4
Staff on 2/8/2020 at 2:20 a.m.: 3
Residents who pushed call light 16 minutes or greater: 18
Call light pushes per resident: 92
Staff response time range: 1283
Residents requiring incontinent care: 6
Residents wheelchair dependent: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in interviews regarding delayed response to call lights and complaints | |
| BB | Interviewed about delayed call light response and complaints to Staff A | |
| CC | Interviewed about call light response and complaints to Staff A | |
| DD | Interviewed about call light response and resident assistance | |
| AA | Interviewed about resident care concerns including soiled clothing |
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 25, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00203502, initiated on 2020-03-23 and completed on 2020-03-25.
Complaint Details
Investigation of intake #GA00203502 was completed with no violations cited.
Findings
No violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 21, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00201621.
Complaint Details
Investigation of intake #GA00201621 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 18, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00200779.
Complaint Details
Investigation of intake #GA00200779 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00200391.
Complaint Details
Investigation of intake #GA00200391 with no violations cited.
Findings
No violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jan 10, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/28/17 initial inspection and complaint investigation.
Complaint Details
This visit was a follow-up to the initial inspection and complaint investigation conducted on 9/28/17.
Findings
The facility failed to develop policies and procedures for the specific use and oversight of proxy caregivers as required by Georgia law, and admitted and retained two non-ambulatory residents not capable of self-preservation with minimal assistance, contrary to regulations. Waiver applications for these residents were sent and received by the Department.
Deficiencies (2)
Failed to develop policies and procedures for the specific use and oversight of proxy caregivers as required by Georgia law.
Failed to ensure the home admitted and retained only ambulatory residents capable of self-preservation with minimal assistance for 2 of 2 residents.
Report Facts
Number of proxy caregivers trained: 9
Number of residents not ambulatory: 2
Dates waiver applications sent: Waiver applications sent by certified mail for Resident #1 on 2017-10-11 and Resident #2 on 2017-10-13.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff who stated the facility did not have written policies and procedures for proxy caregivers and confirmed waiver applications were sent for two residents. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Sep 28, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection and investigate complaint #GA00179799, with on-site visits made on 9/25/17 and 9/26/17 and investigation completed on 9/28/17.
Complaint Details
Complaint #GA00179799 was investigated during this visit. The investigation included review of policies, staff interviews, resident observations, and record reviews. The complaint was substantiated with multiple deficiencies found.
Findings
The facility failed to implement required policies and procedures supporting resident dignity, respect, and safety; failed to develop policies for proxy caregivers; did not ensure staff had current emergency first aid and CPR certifications; admitted residents not meeting ambulatory requirements under waiver conditions; failed to develop an accurate written description of the memory care unit; and did not provide specialized training to memory care staff. Additionally, the facility failed to adhere to waiver conditions related to change of ownership.
Deficiencies (9)
Governing body failed to implement policies and procedures supporting dignity, respect, choice, independence, and privacy of residents.
Facility failed to develop policies and procedures for the specific use and oversight of proxy caregivers.
Facility failed to ensure staff received current certification in emergency first aid within first 60 days of employment for 1 of 5 sampled staff.
Facility failed to ensure staff received current certification in CPR within first 60 days of employment for 1 of 5 sampled staff.
Facility failed to maintain recertification for first aid and CPR for 1 of 5 sampled staff.
Facility admitted and retained ambulatory residents not capable of self-preservation with minimal assistance for 2 of 37 residents, violating waiver conditions.
Facility failed to develop an accurate written description of the memory care unit including staffing, assessment protocols, physical environment, activities, fees, discharge criteria, family involvement, disclosures, and service plans.
Facility failed to provide specialized training to memory care staff on Alzheimer's disease, behavior management, communication skills, therapeutic interventions, family role, environmental modifications, service plans, new developments, recognition of changes, and safety.
Facility failed to adhere to waiver conditions related to change of ownership for Resident #2, who was observed in a hospital bed with half bed rails in place.
Report Facts
Number of staff trained as proxy caregivers: 9
Sampled staff count: 5
Residents not ambulatory as required: 2
Resident waiver granted date: Feb 13, 2017
Facility ownership change date: Jun 15, 2017
Resident waiver application date: Jun 28, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed multiple times regarding policies, certifications, waiver awareness, and training. | |
| Staff D | Sampled staff lacking current emergency first aid and CPR certification and specialized memory care training. | |
| Staff A | Sampled staff with expired first aid and CPR certifications. | |
| Staff E | Sampled staff lacking specialized memory care training. |
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