Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 22, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA50003616. An on-site visit was made to the facility on 07/22/2025.
Findings
No rule violations were cited as a result of this inspection and investigation.
Complaint Details
Investigation of intake #GA50003616 was conducted and completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00233576. The investigation was started on 2023-05-15, with an on-site visit on 2023-05-24, and completed on 2023-06-12.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00233576 was conducted with no rule violations found.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 10, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232847 and conduct the annual inspection.
Findings
No rule violations were cited as a result of this investigation and inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 22, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00229088. An on-site visit was made to the facility on 11/22/22, with the investigation completed on 11/23/22.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00229088 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 12, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00227037 with an on-site visit made on 10/12/22. The investigation started on 10/4/22 and was completed on 10/18/22.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00227037 was conducted with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 28, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00221441 with an on-site visit made to the facility on 2022-02-28 and the investigation completed on 2022-03-10.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00221441; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00219733 and conduct the compliance inspection.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2021-12-09 and was completed on 2021-12-17. No rule violations were cited.
Inspection Report
Monitoring
Deficiencies: 0
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
Routine
Deficiencies: 6
Mar 10, 2020
Visit Reason
The purpose of this visit was to conduct a compliance inspection at the facility on 3/10/20, completed on 3/11/20.
Findings
The facility failed to meet multiple workforce training requirements including emergency first aid certification, abuse reporting training, and annual training hours for several staff members. Additionally, the facility did not conduct required fire drills during sleeping hours, failed to report a serious injury to the Department, and did not ensure proper training and competency documentation for proxy caregivers administering insulin and glucose checks.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure 3 of 7 sampled staff had current certification in emergency first aid within the first 60 days of employment. | D |
| Failed to ensure 1 of 7 sampled staff received training on identification of abuse, neglect, exploitation and reporting requirements. | D |
| Failed to ensure 3 of 7 sampled staff had at least 16 hours of training per year. | D |
| Failed to conduct required fire drills during sleeping hours; no fire drills conducted after 3:41 p.m. in 2019. | D |
| Failed to report a serious injury requiring medical treatment for 1 of 7 sampled residents to the Department. | D |
| Failed to ensure unlicensed staff performing specialized tasks had satisfactory completion of skills competency checklists for insulin injection and glucose checks for 1 of 6 sampled residents. | D |
Report Facts
Staff sampled: 7
Fire drills required annually: 6
Fire drills conducted during sleeping hours: 0
Resident sampled: 7
Resident sampled: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding locating first aid and abuse reporting trainings | |
| Staff B | Interviewed regarding failure to report resident injury and proxy caregiver insulin administration | |
| Staff I | Interviewed regarding insulin administration to Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 16, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195782.
Findings
The facility failed to provide sufficient staff time to ensure residents received medications as prescribed for Resident #1. Staff was observed preparing to give 9:00 a.m. medications at 10:33 a.m., indicating a delay in medication administration.
Complaint Details
Investigation was initiated based on intake #GA00195782. The complaint was substantiated by observation, record review, and interview indicating delayed medication administration.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide sufficient staff time to ensure residents received medications as prescribed for Resident #1. | SS= D |
Report Facts
Medication dose count: 13
Staff clock-in time: 7.16
Medication administration time: 10.33
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 4, 2018
Visit Reason
The purpose of this visit was to investigate intake #GA 001923027 with an on-site visit made on 12/4/18 and investigation completed on 12/5/18.
Findings
The facility failed to ensure immediate initiation of cardiopulmonary resuscitation (CPR) for a resident who experienced cardiac or respiratory arrest. Staff did not initiate CPR for Resident #1 found unresponsive and without a pulse, despite facility policy requiring CPR initiation when no Do Not Resuscitate (DNR) order was present or known.
Complaint Details
The investigation was triggered by intake #GA 001923027 regarding the unexpected death of Resident #1 on 11/19/18. The complaint alleged failure to initiate CPR when the resident was found unresponsive without a pulse or respirations. Staff interviews and record reviews confirmed CPR was not initiated and the resident had no advance directive or DNR on file.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who experienced cardiac or respiratory arrest. | J |
Report Facts
Number of sampled residents with deficiency: 1
Date of incident: Nov 19, 2018
Date of last observation: Nov 18, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | CPR certified staff who did not initiate CPR for Resident #1 | |
| Staff C | Staff present when Resident #1 was found unresponsive | |
| Staff A | Assessed Resident #1 and confirmed no CPR was initiated | |
| Staff E | Interviewed regarding CPR policy and procedures | |
| AA | Responsible party for Resident #1, not informed of breathing difficulties |
Inspection Report
Routine
Deficiencies: 5
Sep 27, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
The facility was found deficient in multiple areas including workforce qualifications where 2 of 7 staff did not have proper CPR certification, failure to update medication administration records for 2 of 6 residents, improper disposal of expired medications for 1 resident, failure to maintain personal inventory records for 3 residents, and missing signed medical orders impacting end of life care for 2 residents.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure that each staff received current certification in cardiopulmonary resuscitation (CPR) with return demonstration of competency for 2 of 7 sampled staff. | SS= D |
| Facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 6 sampled residents. | SS= D |
| Facility failed to properly dispose of expired medications for 1 of 6 sampled residents. | SS= D |
| Facility failed to maintain an inventory of personal items brought to the home by residents for 3 of 6 sampled residents. | SS= D |
| Facility failed to maintain signed medical orders impacting end of life care (DNR) for 2 of 6 sampled residents. | SS= D |
Report Facts
Sampled staff: 7
Staff with deficient CPR certification: 2
Sampled residents: 6
Residents with MAR documentation issues: 2
Residents with expired medication disposal issues: 1
Residents with missing personal inventory: 3
Residents with missing signed medical orders: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in CPR certification deficiency | |
| Staff E | Named in CPR certification deficiency | |
| Staff A | Interviewed regarding CPR certification and personal inventory lists | |
| Staff G | Interviewed regarding medication administration and expired medication disposal | |
| Staff B | Interviewed regarding missing signed medical orders |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 23, 2018
Visit Reason
The visit was conducted to investigate a facility reported incident #GA00188237.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of facility reported incident #GA00188237 with no rule violations found.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 26, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 11/8/18 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up inspection to the 11/8/18 complaint investigation; no rule violations found.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 26, 2018
Visit Reason
The purpose of this visit was to conduct the follow-up inspection to the 12/11/18 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up inspection to the 12/11/18 complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 11, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00182455.
Findings
The facility failed to ensure unlicensed staff providing medication assistance had current annual medication training, failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for multiple residents, and failed to obtain timely refills of prescribed medications resulting in interruptions in routine dosing for several residents.
Complaint Details
The visit was complaint-related to complaint #GA00182455. The complaint was substantiated by findings of medication training deficiencies, MAR documentation errors, and medication refill delays.
Severity Breakdown
SS= D: 2
SS= J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Unlicensed staff providing assistance with or supervision of self-administered medications did not demonstrate necessary skills to perform medication tasks competently for 4 of 10 sampled staff. | SS= D |
| Failure to update the Medication Assistance Record (MAR) each time medication was offered or taken for 5 of 6 sampled residents. | SS= D |
| Failure to obtain timely refills of prescribed medications causing interruptions in routine dosing for 5 of 6 sampled residents. | SS= J |
Report Facts
Staff medication training deficiencies: 4
Residents with MAR documentation errors: 5
Residents with medication refill delays: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named as unlicensed staff lacking current medication training. | |
| Staff H | Named as unlicensed staff lacking current medication training. | |
| Staff I | Named as unlicensed staff lacking current medication training. | |
| Staff J | Named as unlicensed staff lacking current medication training. | |
| Staff C | Interviewed staff who confirmed medication training deficiencies. | |
| Staff D | Interviewed staff who acknowledged MAR documentation errors and medication refill issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 1, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00181092 and #GA00181057.
Findings
The facility failed to operate in a manner that respected the personal dignity and human rights of one sampled resident, as evidenced by an incident where a staff member was reported to have pinched the resident. The facility conducted an internal investigation but did not notify the local police department of the possible abuse.
Complaint Details
The visit was complaint-related, investigating complaints #GA00181092 and #GA00181057. The complaint was substantiated by findings of staff misconduct and failure to report to police.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to operate in a manner that respected the personal dignity and human rights of a resident, with an incident involving staff pinching a resident and failure to notify police. | D |
Report Facts
Complaint numbers: 2
Date of incident: Oct 18, 2017
Date of observation: 201708
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Conducted internal investigation and reported incident to Department but not police | |
| Staff B | Witnessed pinching resident | |
| Staff C | Reported observing Staff B pinching resident |
Inspection Report
Follow-Up
Deficiencies: 1
Jul 17, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/18/17 annual inspection.
Findings
The facility failed to obtain a satisfactory fingerprint records check determination prior to employment for the facility administrator, which was a previously cited violation.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain a satisfactory fingerprint records check determination prior to employment for the facility administrator. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | facility administrator | Named in deficiency for failure to complete fingerprint records check prior to employment. |
Inspection Report
Annual Inspection
Deficiencies: 5
Apr 18, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The facility failed to meet several workforce qualifications and training requirements, including insufficient continuing education hours for some staff, lack of required physical examinations and tuberculosis screenings prior to employment, missing fingerprint background checks for the administrator, expired CPR and First Aid training for one staff member, and failure to conduct required bi-monthly fire drills on different shifts.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure all staff had 16 hours of continuing education in the past year for 2 of 8 sampled staff. | SS= D |
| Facility failed to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 2 of 8 sampled staff. | SS= D |
| Facility failed to obtain a satisfactory fingerprint records check prior to employment for the administrator. | SS= D |
| Personnel files lacked evidence of trainings, skill competency determinations and recertifications as required for 1 of 8 staff; CPR and First Aid training expired. | SS= D |
| Facility failed to comply with fire and safety rules requiring bi-monthly fire drills on different shifts; no documentation of fire drills from January 2016 through August 2016. | SS= D |
Report Facts
Sampled staff: 8
Staff with insufficient continuing education hours: 2
Staff without physical exam and TB screening prior to employment: 2
Staff with expired CPR and First Aid training: 1
Fire drills missing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff who provided information about training and documentation deficiencies | |
| Staff C | Had only 7 hours of annual training in 2016 | |
| Staff D | Had only 8 hours of annual training in 2016 | |
| Staff E | CPR and First Aid training expired as of 2/28/17 | |
| Staff G | No documentation of physical exam and TB screening prior to employment | |
| Staff H | No documentation of physical exam and TB screening prior to employment |
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