Inspection Report Summary
The most recent inspection on April 23, 2025, found no violations during a complaint investigation. Earlier inspections showed mostly no deficiencies, but a substantiated complaint in December 2024 cited the facility for failing to ensure one staff member had current CPR and emergency first aid certification. Prior to that, a November 2023 investigation identified deficiencies related to inadequate safety measures and monitoring after a memory-impaired resident eloped and was found with minor injuries. Complaint investigations were otherwise unsubstantiated, and there were no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s record shows some isolated issues but no clear pattern of worsening or widespread deficiencies over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 23, 2025
Visit Reason
An on-site visit was made to the facility on 4/23/25 to investigate complaint #GA50001607 and conduct a compliance inspection.
Findings
The investigation was completed on 4/23/25 with no violations cited as a result of this inspection.
Complaint Details
Investigation of complaint #GA50001607; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 11, 2024
Visit Reason
The purpose of this visit was to investigate intake GA00251880 with an onsite visit conducted on 12/11/2024 and the investigation completed on 12/12/2024.
Findings
The facility failed to ensure that one of four sampled staff (Staff D) had current certification in Cardiopulmonary Resuscitation (CPR) and emergency first aid, as required within the first sixty days of employment. Staff D's file lacked documentation of current CPR and first aid certification, confirmed by staff interview.
Complaint Details
Investigation was conducted based on intake GA00251880. The complaint was substantiated by findings that Staff D lacked required CPR and emergency first aid certifications.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure that each staff received current certification in Cardiopulmonary Resuscitation (CPR) within the first sixty days of employment for 1 of 4 sampled staff (Staff D). | D |
| Facility failed to ensure that each staff had current certification in emergency first aid except where the staff person is a currently licensed health care professional for 1 of 4 sampled staff (Staff D). | D |
Report Facts
Sampled staff count: 4
Required training hours: 24
Certification timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Staff member lacking current CPR and emergency first aid certification | |
| Staff A | Interviewed staff who confirmed Staff D did not have CPR or first aid certificates on file |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 5, 2024
Visit Reason
The visit was conducted to investigate intake #GA00249145 with an onsite visit made on 9/5/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00249145 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 6, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes # GA00246792 and GA00246656.
Findings
There were no rule violations cited as a result of this investigation.
Complaint Details
Investigation was conducted onsite on 2024-06-06 and completed on 2024-06-10 with no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 9, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245117.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation started on 2024-04-04 and completed on 2024-04-09 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00241991.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00241991; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Nov 14, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240265 regarding a missing resident incident.
Findings
The facility failed to implement policies and safety measures to prevent elopement of a memory-impaired resident. Resident #1 eloped from the memory care unit through an unsecured window, was missing for approximately 30-45 minutes, and was found about 1.3 miles away with minor injuries. The facility lacked effective safety devices such as alarms on windows, and staff failed to monitor the resident adequately.
Complaint Details
The investigation was triggered by a complaint intake #GA00240265 concerning Resident #1 who eloped from the facility on 10/12/2023. The resident was missing for about 30-45 minutes, found 1.3 miles away with minor injuries, and the facility failed to have alarms on windows or adequate monitoring. Law enforcement was involved but not immediately called by staff.
Severity Breakdown
J: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement policies, procedures, and practices supporting memory impaired residents in a safe environment. | J |
| Failure to utilize appropriate effective safety devices to prevent residents at risk of elopement from leaving the premises. | J |
| Failure to provide adequate, appropriate care and services in compliance with state law and regulations. | J |
Report Facts
Resident missing duration: 30
Fence height: 12
Distance walked: 1.3
Wall height: 8
Date of incident: Oct 12, 2023
Date of report: Nov 14, 2023
Resident #1 admission date: Sep 28, 2023
Care plan date: Sep 29, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Notified about elopement, searched for Resident #1, initiated investigation, stated no alarm on window. | |
| Staff B | Last observed Resident #1 before elopement, assisted with search, stated no alarm sounded. | |
| Staff C | Observed open window, noted bench used to climb fence, stated no alarm sounded. | |
| Staff D | Did not hear alarm, spoke with Resident #1 after elopement, described resident's confused state. | |
| EE | Interviewed regarding elopement, declined evaluation for Resident #1, discharged resident home. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 10, 2023
Visit Reason
The visit was conducted to investigate complaint intakes #GA00238863 and #GA00239417 with an onsite visit on 10/10/2023.
Findings
No violations were cited as a result of this complaint investigation.
Complaint Details
Investigation of complaint intakes #GA00238863 and #GA00239417 was completed with no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00236681 and #GA00236946. The onsite visit was made on 7/26/23, with the investigation starting on 7/25/23 and completing on 8/9/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes #GA00236681 and #GA00236946 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00235983.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00235983 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 23, 2023
Visit Reason
The visit was conducted to investigate intake #GA00232982 with an onsite visit made on 3/23/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00232982 was completed with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 13, 2022
Visit Reason
The visit was conducted to investigate intake #GA00225155, with the onsite visit made on 07/13/2022.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00225155 with no rule violations found.
Inspection Report
Original Licensing
Deficiencies: 0
Feb 11, 2022
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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