Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2025
Visit Reason
The purpose of this survey was to investigate complaint #GA50003923 with an onsite visit conducted on 2025-08-07.
Findings
The investigation was completed on 2025-08-07 and no rule violations were cited.
Complaint Details
Investigation of complaint #GA50003923 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 4, 2025
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaint #GA50001937.
Findings
The survey was completed on 4/4/2025 with no rule violations cited.
Complaint Details
Investigation of complaint #GA50001937 resulted in no rule violations.
Inspection Report
Routine
Deficiencies: 4
Oct 11, 2023
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
The facility was found deficient in workforce qualifications and training, specifically lacking current certification in emergency first aid for 2 of 6 staff and CPR with return demonstration for 1 of 6 staff. Additionally, the facility failed to ensure sufficient staff time for medication administration for 1 of 3 residents and had an inadequate hot water system with water temperature exceeding 120 degrees Fahrenheit.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure that any person working in the home received work-related training within the first sixty days of employment including current certification in emergency first aid for 2 of 6 staff (Staff B and Staff C). | D |
| Failed to ensure that each staff received current certification in cardiopulmonary resuscitation (CPR) with return demonstration of competency within the first sixty days of employment for 1 of 6 staff (Staff D). | D |
| Failed to ensure sufficient staff time was provided to ensure that each resident received medications as prescribed for 1 of 3 residents (Resident #3). | D |
| Failed to ensure the home had an adequate hot water system supplying heated water not exceeding 120 degrees Fahrenheit; water temperature measured at 127.8 degrees Fahrenheit in a resident's bathroom sink. | D |
Report Facts
Staff without emergency first aid certification: 2
Staff without CPR certification with return demonstration: 1
Residents with medication administration issues: 1
Water temperature: 127.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Lacked emergency first aid certification | |
| Staff C | Lacked emergency first aid certification | |
| Staff D | Lacked CPR certification with return demonstration | |
| Staff F | Documented medication administration in error | |
| Staff G | Interviewed regarding hot water temperature | |
| Staff A | Interviewed and aware of multiple findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2023
Visit Reason
The purpose of this visit was to investigate complaint #GA00238462.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00238462 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235035 regarding medication management concerns at the facility.
Findings
The facility failed to have an effective system to manage medications, including secure storage and proper logging of controlled substances, resulting in tampering and unauthorized access to Hydrocodone medication for one resident. Staff misconduct related to medication handling was identified and led to termination.
Complaint Details
Investigation was triggered by intake #GA00235035. The complaint was substantiated as tampering with controlled substances was confirmed, and Staff D was terminated for violating medication policies.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to have an effective system to manage medications including secure storage and daily updated logs for controlled substances, leading to tampering of Hydrocodone medication for Resident #1. | D |
Report Facts
Medication packs tampered: 3
Hydrocodone pills delivered: 120
Hydrocodone doses given: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Terminated for violating medication policy by giving narcotics to a family member and admitting to policy violation | |
| Staff A | Interviewed and provided information about Staff D's misconduct and medication delivery | |
| Staff C | Observed tampering with medication packs and reported findings | |
| Staff B | Confirmed medication tampering with Staff C | |
| Staff F | Mentioned by Staff C regarding noticing taped medication packs |
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 6
Oct 6, 2021
Visit Reason
The purpose of the visit was to conduct a compliance inspection and investigate intake #GA00217428 following a complaint about Resident #1 eloping from the Memory Care Unit.
Findings
The facility failed to implement policies and procedures to support residents' dignity and safety, failed to provide adequate supervision for Resident #1 who eloped, failed to utilize effective safety devices to prevent elopement, and failed to report the elopement to police within the required 30 minutes. Resident #1 was found by police about 0.8 miles from the facility and taken to the hospital with no injuries.
Complaint Details
The investigation was triggered by intake #GA00217428 concerning Resident #1 eloping from the Memory Care Unit on 9/3/21. The resident was missing from 10:40 p.m. until found by police around 11:45 p.m. The facility delayed notifying police beyond the required 30 minutes.
Severity Breakdown
D: 3
K: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement policies, procedures, and practices supporting dignity, respect, choice, independence, and privacy for Resident #1. | D |
| Failed to provide supervision consistent with residents' needs; Resident #1 eloped from Memory Care Unit. | K |
| Failed to utilize appropriate effective safety devices to protect residents at risk of eloping; non-electronic keyed locks were used and exit doors were malfunctioning due to lightning strike. | K |
| Failed to ensure entrance and exit doors did not have non-electronic keyed locks or keyed locks placed between resident and exit. | D |
| Failed to provide adequate care and services in compliance with applicable laws for Resident #1 who eloped. | K |
| Failed to report elopement to local police within 30 minutes as required by Mattie's Call Act. | D |
Report Facts
Resident census: 11
Staff shift hours: 11
Distance: 0.8
Temperature: 79
Time delay: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding delay in police notification and instructions to call police | |
| Staff B | Worked second shift, gave Resident #1 medication, searched for resident, and reported observations | |
| Staff C | Observed Resident #1 missing during rounds and participated in search | |
| Staff D | Reported lightning strike damage to exit doors and manual locking procedures | |
| Staff E | Confirmed timing of lightning strike and door issues | |
| Staff F | Reported use of keyed locks due to door malfunction | |
| Staff G | Reported use of keyed locks due to door malfunction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 27, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206596.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00206596 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jul 17, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205492 and #GA00205692, which involved allegations related to resident supervision and safety.
Findings
The facility failed to provide adequate supervision and protective care for Resident #2, who eloped from the facility multiple times. The facility also failed to utilize effective safety devices to prevent elopement and lacked alarm systems and security cameras. Resident #2 had a diagnosis of vascular dementia and required placement in a specialized memory care unit. The incident occurred on 5/30/2020, and the resident was found approximately 0.8 miles from the facility.
Complaint Details
The investigation was initiated due to complaints alleging failure to provide protective care and watchful oversight for Resident #2, who eloped from the facility on 5/30/2020. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
J: 2
K: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide supervision consistent with residents' needs for Resident #2. | J |
| Failed to utilize effective safety devices to protect residents at risk of eloping. | J |
| Failed to ensure each resident received adequate and appropriate care and services for Resident #2. | K |
Report Facts
Incident date: May 30, 2020
Distance eloped: 0.8
Temperature: 84
Resident #2 admission date: Dec 18, 2018
Physical exam date: Jun 1, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #2's elopement and cognitive decline. | |
| Staff D | Interviewed about Resident #2's whereabouts and routine on day of elopement. | |
| Staff C | Interviewed about Resident #2's elopement and search efforts. | |
| Staff E | Interviewed about finding and returning Resident #2 to the facility. | |
| DD | Found Resident #2 near apartments and notified facility. | |
| CC | Received calls about Resident #2's elopement and location. | |
| EE | Received call from facility about Resident #2 and spoke with resident. |
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 process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 10, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00201192 with an onsite visit made on 12/10/19 and the investigation completed on 12/19/19.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00201192 with no rule violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 27, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 11/27/18 compliance inspection and investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 11, 2019
Visit Reason
The purpose of this visit was to investigate intake # GA00197032 with an on-site visit made on 6/11/19 and the investigation completed on 6/14/19.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake # GA00197032 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 4, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00193397, with the investigation beginning on 2018-12-18 and completed on 2019-01-04.
Findings
No rule violations were cited as a result of this complaint investigation.
Complaint Details
Investigation of complaint GA00193397 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 27, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00192287 and #GA00192278, with the investigation starting on 2018-11-01, an on-site visit on 2018-11-06, and completion on 2018-11-27.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by Resident #2 who was not capable of self-preservation. Additionally, the facility failed to ensure adequate and appropriate care and services for Resident #1, who was missing from the facility and found at another healthcare facility after wandering off.
Complaint Details
The investigation was initiated based on intake complaints #GA00192287 and #GA00192278. Resident #1 was reported missing from the facility on 10/15/18 and was found at another healthcare facility after crossing a busy street. Resident #2 was observed unable to self-propel his/her wheelchair and follow commands, indicating failure to meet admission criteria.
Severity Breakdown
D: 1
J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The home admitted and retained a resident (Resident #2) who was not capable of self-preservation with minimal assistance and unable to follow commands. | D |
| The facility failed to ensure each resident received adequate, appropriate care and services in compliance with applicable laws, as Resident #1 was missing from the facility and found at another healthcare facility. | J |
Report Facts
Resident sample size: 5
Incident time: 615
Incident time: 720
Incident time: 800
Distance: 0.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Observed Resident #1 at front porch and interviewed about incident | |
| Staff B | Observed Resident #1 at front porch and interviewed about incident | |
| Staff C | Worked with Staff D on day of incident, called police, interviewed about Resident #1 | |
| Staff D | Interviewed about Resident #2's condition and assisted on day of Resident #1 incident | |
| Staff E | Received call about Resident #1 from nearby healthcare facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00184636.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Complaint GA00184636 was investigated and found to have no violations.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 22, 2018
Visit Reason
The purpose of this visit was to conduct a follow up to the 10/13/17 annual inspection.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Annual Inspection
Deficiencies: 1
Oct 13, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection from 10/13/17 to 10/16/17.
Findings
The facility failed to maintain documentation of competency-based skills checklists for catheter care completed by a licensed healthcare professional for 3 of 3 sampled staff for 1 of 5 sampled residents.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain documentation of the competency-based skills checklist for catheter care completed by a licensed healthcare professional for 3 of 3 sampled staff for 1 of 5 sampled residents. | SS= D |
Report Facts
Number of sampled staff missing competency checklists: 3
Number of sampled residents affected: 1
Date of resident admission: May 12, 2017
Date of proxy caregiver plan of care: May 15, 2017
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