Deficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 6, 2025
Visit Reason
The purpose of this visit was to conduct a complaint inspection (GA50005914).
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint inspection conducted with no rule violations cited.
Inspection Report
Renewal
Deficiencies: 2
Jul 28, 2025
Visit Reason
The purpose of this visit was to conduct a re-licensure and a complaint inspection (GA50004081). The inspection started on 2025-07-22 and was completed on 2025-07-24.
Findings
The facility failed to ensure proper documentation of medication administration for one resident and timely procurement of medications for another resident, resulting in missed doses and hospitalization due to a seizure.
Complaint Details
The inspection included a complaint investigation (GA50004081) related to medication administration and procurement issues.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff record initials, time, and date when medications are taken or refused for Resident #1. | D |
| Failure to ensure timely management of medication procurement and refills for Resident #2, resulting in missed doses and hospitalization. | D |
Report Facts
Number of sampled residents with deficiencies: 3
Days medication not administered: 2
Days without medication before reporting: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding failure to sign MAR and medication procurement issues. | |
| Staff D | Responsible for medication refill for Resident #2; failed to ensure timely medication availability. | |
| Staff C | Notified Staff D about Resident #2 medication unavailability and reported hospitalization. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239639 with an onsite visit made to the facility on 10/23/23.
Findings
No violations were cited as the resident was residing in Independent Living, which is not regulated by Healthcare Facility Regulation (HFR).
Complaint Details
Investigation of intake #GA00239639; no violations found; resident was in Independent Living not regulated by HFR.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 27, 2023
Visit Reason
A visit was made to the facility on 9/27/23 to investigate intake #GA00238642 and #GA00239224.
Findings
The investigation was completed on 9/27/23 with no rule violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00238642 and #GA00239224 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2023
Visit Reason
The purpose of this visit was to investigate intake # GA00237795.
Findings
An on-site visit was made on 8/31/2023. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake # GA00237795 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 12, 2022
Visit Reason
The visit was conducted to investigate intake #GA00225226.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00225226 with no rule violations found.
Inspection Report
Annual Inspection
Deficiencies: 1
May 19, 2021
Visit Reason
The purpose of this visit was to conduct an annual inspection and investigate intake #GA00213153. An unannounced visit was made to the facility on 2021-04-30, with the investigation started on 2021-04-21 and completed on 2021-05-19.
Findings
The facility failed to ensure residents' medications were in unit dose or multi-unit dose packaging for 1 of 3 sampled residents (Resident #1). Medications for Resident #1 were found in bottles contrary to facility policy requiring unit dose or multi-dose unit packaging.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure medications were in unit dose or multi-unit dose packaging for Resident #1; medications were found in bottles. | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 18, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00211524.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2021-02-09 and was completed on 2021-02-18. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 19, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00208758.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00208758 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 4
Oct 14, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00208283, which was started on 2020-10-01 and completed on 2020-10-14.
Findings
The facility failed to implement policies and procedures to support memory impaired residents safely, failed to have enough staff to meet resident needs, failed to utilize effective safety devices to prevent elopement, and failed to ensure adequate care and services for Resident #1 who eloped from the facility on 2020-09-14 and was found approximately 0.5 miles away. The exit door was propped open preventing the alarm from activating, and staff were unaware or unable to monitor the door properly.
Complaint Details
The investigation was initiated due to intake #GA00208283 regarding Resident #1 eloping from the facility on 2020-09-14. The complaint was substantiated based on record review and staff interviews confirming the elopement and related deficiencies.
Severity Breakdown
SS= D: 1
SS= J: 1
SS= K: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement policies, procedures, and practices to support memory impaired residents in a safe environment. | SS= D |
| Failed to have enough staff to meet the specific resident ongoing health and safety needs. | SS= J |
| Failed to utilize appropriate effective safety devices to protect residents at risk of eloping. | SS= K |
| Failed to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations. | SS= K |
Report Facts
Date of elopement: Sep 14, 2020
Distance eloped: 0.5
Time last seen: 2115
Time found: 2230
Temperature: 84
Percentage of residents with dementia: 50
Number of residents with dementia: 6
Number of residents needing shower assistance: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided statements about the elopement incident, family visitation, and door security. | |
| Staff B | Last staff to see Resident #1 before elopement; described door being propped open and staff duties. | |
| Staff C | Assisted with resident care; did not observe elopement; involved in search and return of Resident #1. | |
| Staff D | Provided information about door being propped open and visitation staffing changes. |
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 2
Jul 8, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205470, which started on 2020-06-15 and was completed on 2020-07-08.
Findings
The facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping, specifically Resident #1 who eloped on 2020-05-23 and was found outside the facility. The facility also failed to ensure adequate and appropriate care and services for Resident #1, who was found outside the facility without injuries but without proper supervision or alarm systems on certain doors.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00205470. Resident #1 eloped on 2020-05-23 and was found in the parking lot of a business next door. The facility did not have an alarm on the interior door leading to the independent living side, and staff did not call law enforcement though law enforcement arrived after the business next door called. Resident #1 had diagnoses of Alzheimer and hypertension and was independent with activities of daily living.
Deficiencies (2)
| Description |
|---|
| Failed to utilize appropriate effective safety devices to protect residents at risk of eloping, specifically the interior door leading to the independent living side lacked an alarm. |
| Failed to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations, as evidenced by Resident #1 eloping and being found outside the facility. |
Report Facts
Resident census: 20
Wheelchair-bound residents: 1
Walking distance: 100
Temperature: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1 elopement and lack of alarm on interior door | |
| Staff B | Interviewed regarding Resident #1 elopement, resident's behavior, and staff response | |
| Staff C | Mentioned as staff on duty and involved in searching for Resident #1; unavailable for interview | |
| AA | Interviewed regarding Resident #1 admission and hospital evaluation |
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 measures.
Inspection Report
Original Licensing
Deficiencies: 0
Jun 24, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection and to increase the facility capacity.
Findings
No rule violations were cited as a result of this inspection.
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