The most recent inspection on October 9, 2025, found no deficiencies during a complaint investigation. Earlier inspections generally showed few issues, with one deficiency noted in June 2025 for exceeding licensed capacity by one resident in memory care. Prior reports from 2019 to 2021 included deficiencies related mainly to resident supervision and safety, particularly involving elopement incidents and a fall injury, as well as pest control and staffing concerns. Complaint investigations since 2024 have been unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history suggests improvement over time, with recent inspections showing fewer deficiencies and no substantiated complaints.
Deficiencies (last 5 years)
Deficiencies (over 5 years)4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% better than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
86420
2019
2020
2021
2024
2025
Census
Latest occupancy rate103% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
The purpose of this visit was to conduct a monitoring inspection and investigate intake #GA00214910 and #GA00215112.
Findings
The facility failed to provide protective care and watchful oversight for one resident, resulting in an injury from a fall during a transfer that was not properly witnessed or managed. The resident sustained a left femoral shaft fracture and required two-person assist for transfers, but was dropped by staff during a transfer.
Complaint Details
The visit was complaint-related, investigating intake #GA00214910 and #GA00215112. Resident #1 reported being dropped by staff during transfer, resulting in injury. Staff interviews revealed lack of investigation and that the responsible staff had left the facility.
Deficiencies (1)
Description
Failed to provide protective care and watchful oversight for Resident #1, resulting in injury from a fall during transfer.
Report Facts
Date of injury report: Jun 10, 2021Date of X-ray: Jun 8, 2021Admission date: Jun 13, 2016Hospice start date: Feb 26, 2021Care plan revision date: Jun 8, 2021
Employees Mentioned
Name
Title
Context
Staff B
Interviewed about Resident #1's fall and injury; reported hospice notification and X-ray ordering
Staff E
Reported by Resident #1 as dropping the resident during transfer; no memory of fall; no longer employed
Staff D
Heard about Resident #1's pain; did not investigate incident further; stated Staff E left facility
Staff A
Conducted reminder meeting about two-person transfer after injury; no additional training conducted
AA
Reported Resident #1's complaint of left knee pain; checked swollen knee; stated incident was accident
The purpose of this visit was to investigate intake #GA00211842 and #GA00212190, which involved an elopement incident of Resident #1 from the facility.
Findings
The facility failed to ensure effective supervision and safety measures for Resident #1, who eloped from the facility and was found 1.6 miles away at a family member's home. The exit gate alarm malfunctioned due to cold weather, and the facility did not have adequate security devices or timely response to prevent the elopement. The incident was previously cited in November 2020.
Complaint Details
The investigation was initiated due to complaints regarding Resident #1 eloping from the facility on 2/13/21. The resident was found approximately 1.6 miles away at a family member's home. The facility's supervision and safety protocols were found deficient, including malfunctioning exit gate alarms and inadequate staff response.
Severity Breakdown
E: 1K: 3
Deficiencies (4)
Description
Severity
Failed to ensure policies and procedures were effective and enforced for staff compliance.
E
Failed to ensure Resident #1 was supervised consistent with his/her needs; exit doors lacked security devices or audible alarms.
K
Failed to ensure appropriate effective safety devices were utilized to protect Resident #1 at risk of eloping; gate alarm malfunctioned and did not alert staff timely.
K
Failed to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations.
The purpose of this visit was to investigate intake #GA00208262, which started on 2020-10-20 and was completed on 2020-11-13.
Findings
The facility failed to ensure adequate supervision and safety measures for Resident #3, who eloped from the facility on 2020-09-11. The facility also failed to report the incident to the Department within 24 hours and had staffing gaps contributing to the incident.
Complaint Details
The investigation was initiated due to intake #GA00208262 concerning Resident #3's elopement on 2020-09-11. The complaint was substantiated based on record review, interviews, and video evidence showing Resident #3 leaving the facility unattended. The facility was unaware of the elopement for several hours and failed to report the incident timely.
Severity Breakdown
D: 2J: 3
Deficiencies (5)
Description
Severity
The administrator failed to ensure that policies and procedures were effective and enforced to ensure compliance with rules and community policies.
D
The facility failed to ensure that Resident #3 was supervised consistent with his/her needs, resulting in elopement.
J
The facility failed to ensure that appropriate effective safety devices were utilized to protect residents at risk of eloping.
J
The facility failed to provide adequate care and services in compliance with state law for Resident #3.
J
The facility failed to report to the Department within 24 hours after a serious incident involving Resident #3.
D
Report Facts
Elopement incident date: Sep 11, 2020Staffing gap hours: 3Distance walked by resident: 1.2Delay in reporting to Department: 4Time resident missing: 5
Employees Mentioned
Name
Title
Context
Staff D
Interviewed multiple times regarding Resident #3 elopement and facility policies.
Staff F
Last staff to see Resident #3 before elopement.
AA
Contacted by facility regarding Resident #3 elopement and hospital transport.
BB
Contacted by facility regarding Resident #3 elopement and hospital transport.
CC
Law enforcement officer responding to call about Resident #3 wandering.
DD
Superior law enforcement officer who notified facility about missing resident.
The purpose of this visit was to investigate intake #GA00200296 with an on-site visit made on 10/30/19 and investigation completed on 11/14/19.
Findings
The facility failed to maintain adequate staffing levels to meet residents' ongoing health and safety needs, had ongoing pest control issues with cockroach infestations in the kitchen, and failed to provide adequate care and services to residents, including timely assistance with transfers, toileting, feeding, and bathing.
Complaint Details
The investigation was initiated due to intake #GA00200296. The complaint involved inadequate staffing levels leading to delayed resident assistance, pest infestation in the kitchen, and failure to provide adequate resident care and services. The complaint was substantiated based on observations, record reviews, and staff and resident interviews.
Severity Breakdown
D: 2E: 1
Deficiencies (3)
Description
Severity
Failed to staff above the minimum on-site staff to resident ratio to meet residents' ongoing health, safety, and care needs.
D
Failed to maintain an adequate insect, rodent, and pest control program which continually protects the health of residents.
E
Failed to provide each resident care and services which were adequate, appropriate, and in compliance with state law and regulations.
The purpose of this visit was to conduct a follow-up to the 7/22/19 compliance inspection and investigation.
Findings
No rule violations were cited as a result of this follow-up inspection and investigation.
Inspection Report Original LicensingDeficiencies: 6Jul 22, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection and investigate intake #GA00198067.
Findings
The facility failed to maintain the interior and exterior in a clean, safe, and sanitary condition, with multiple observations of live and dead roaches in the kitchen and resident areas, missing ceiling tiles, and broken fixtures. The pest control program was inadequate as roaches and ants persisted despite recent treatments.
Severity Breakdown
SS= D: 6
Deficiencies (6)
Description
Severity
At least five live small roaches were observed crawling underneath and on the side of the steam table and on the bulletin board in the kitchen.
SS= D
Two roach traps under the steam table had at least 10 dead roaches each; the base under the steam table was greasy and unsanitary.
SS= D
Two more small dead bugs, possibly roaches, found on the window sill inside the room of Resident #7.
SS= D
Missing removable tile ceiling about 3' x 3' and uneven patch and paint on a hole at the nursing station in the memory care unit.
SS= D
Broken toilet paper holder in the room of Resident #6.
SS= D
Pest control program failed to continually protect the health of residents as roaches and ants were still present despite recent pest control services.
SS= D
Report Facts
Live roaches observed: 5Dead roaches on traps: 20Missing ceiling tile size: 9Pest control service dates: 2
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