Inspection Reports for Brookside Commerce
199 WEST W GARY ROAD, COMMERCE, GA, 30529
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 8, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a mixed history with several deficiencies related mainly to medication management, resident physical examinations, individual service plan updates, and staffing levels. Prior reports also noted issues with pest control, staff training, and admission of residents not capable of self-preservation. Complaint investigations since 2018 have been mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. The facility appears to have addressed many earlier concerns, as recent investigations have not identified rule violations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
42 residents
Based on a December 2019 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
The purpose of this visit was to investigate complaint #GA50001576.
Complaint Details
Investigation of complaint #GA50001576 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 27, 2025
Visit Reason
The purpose of this survey was to investigate complaint #GA50000970 with an onsite visit conducted on 2/27/25 and investigation completed on 2/28/25.
Complaint Details
Investigation of complaint #GA50000970; no rule violations found.
Findings
No rule violations were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249601.
Complaint Details
Investigation of intake #GA00249601 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 17, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239739 and conduct the compliance inspection.
Complaint Details
The visit was complaint-related, investigating intake #GA00239739.
Findings
The facility was found deficient in several areas including failure to ensure annual checks of fire extinguishers, incomplete physical examinations for residents prior to admission, failure to update individual service plans quarterly, and failure to obtain timely medication refills for residents.
Deficiencies (4)
Facility failed to ensure that fire extinguishers were checked annually and remained in operable condition; all fire extinguishers had not been checked since June 2022.
Facility failed to ensure residents had a physical examination by a licensed provider dated within 30 days prior to admission and that the physical examination form was completed in its entirety including tuberculosis screening results for 2 of 5 residents (Resident #2 and Resident #5).
Facility failed to ensure individual service plans were updated at least quarterly or more frequently if resident needs changed substantially for 1 of 5 residents (Resident #3).
Facility failed to ensure refills of prescribed medications were obtained timely to avoid interruption in routine dosing for 2 of 5 residents (Resident #2 and Resident #3).
Report Facts
Date of inspection: Oct 17, 2023
Residents reviewed: 5
Medication unavailability dates: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Aware of findings related to physical exams, service plan updates, and medication refill issues | |
| Staff C | Described medication reorder and follow-up process | |
| AA | Stated belief that Resident #2 had been out of some medications | |
| Staff B | Mentioned as person responsible for following up on medication orders |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00224824.
Complaint Details
Investigation of intake #GA00224824 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
The purpose of this visit was to conduct the monitoring inspection to increase capacity.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Date: Dec 16, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00201381 regarding staffing and care concerns at the facility.
Complaint Details
Investigation of complaint #GA00201381 found substantiated issues with staffing shortages, high turnover, delayed medication administration, and insufficient assistance for residents requiring two-person support.
Findings
The facility failed to maintain adequate staffing levels to meet the specific safety, health, and care needs of residents, as evidenced by staff shortages, delayed medication administration, and residents requiring two-person assistance not consistently met.
Deficiencies (1)
The home failed to maintain minimum on-site staff to resident ratios to meet residents' ongoing health, safety, and care needs.
Report Facts
Facility census: 42
Staffing hours: 1
Medication administration time: 2
Dates of staff quitting: 3
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Nov 22, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00200404. On-site visits were made on 11/5/19, 11/6/19, and the inspection was completed on 11/22/19.
Complaint Details
The inspection was conducted to investigate intake #GA00200404.
Findings
The facility was found deficient in multiple areas including workforce qualifications and training, failure to maintain an adequate pest control program, admission of residents not capable of self-preservation, failure to obtain required physical examinations and admission agreements, failure to update individual service plans, medication management issues including untimely refills and improper storage, and failure to conduct required criminal background checks for staff.
Deficiencies (12)
Failed to ensure 2 of 12 sampled staff had current certification in emergency first aid within 60 days of employment.
Failed to ensure 2 of 12 staff received current certification in CPR with return demonstration of competency.
Failed to ensure employees received training in general infection control principles within 60 days of employment for 5 of 12 sampled staff.
Failed to obtain a satisfactory fingerprint records check determination for the director, administrator or manager prior to employment for 1 of 12 sampled staff.
Failed to maintain an adequate insect, rodent and pest control program protecting the health of residents for 2 of 6 residents.
Admitted and retained a non-ambulatory resident not capable of self-preservation with minimal assistance for 1 of 6 sampled residents.
Failed to obtain a physical examination by a licensed provider within 30 days prior to admission for 3 of 6 residents.
Failed to enter into a written admission agreement between the governing body and the resident for 1 of 6 residents.
Failed to update the resident's individual service plan at least quarterly or more frequently if needs changed for 1 of 6 residents.
Failed to ensure timely refills of prescribed medications resulting in interruptions in routine dosing for 2 of 6 residents.
Failed to have an effective system to manage medications including storing medications under lock and key for 1 of 6 residents.
Failed to ensure direct care staff hired after October 1, 2019 had required criminal background checks prior to employment for 2 of 12 sampled staff.
Report Facts
Staff sampled: 12
Residents sampled: 6
Dates of on-site visits: 3
Residents with pest control issues: 2
Residents with admission physical exam issues: 3
Residents with medication refill issues: 2
Staff without criminal background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director | Acknowledged multiple findings including lack of training, fingerprint check, and background checks |
| Staff F | Failed to obtain emergency first aid and CPR certification | |
| Staff J | Failed to obtain emergency first aid and CPR certification | |
| Staff C | Provided information about Resident #1 being bedbound | |
| Staff K | Provided information about medication issues and pharmacy communication | |
| EE | Reported sending back medication to pharmacy due to packaging issues | |
| CC | Reported observation of medication on floor and concerns about residents spitting pills |
Inspection Report
Follow-Up
Census: 12
Deficiencies: 5
Date: Sep 26, 2018
Visit Reason
The visit was conducted as a follow-up to the 5/18/18 compliance inspection and to investigate intake #GA00191320.
Findings
The facility failed to provide sufficient staff time to ensure residents received medications as prescribed, maintain an adequate pest control program, uphold housekeeping standards, admit only ambulatory residents capable of self-preservation, and ensure residents received adequate and appropriate care and services. Multiple medication administration deficiencies were documented for several residents.
Deficiencies (5)
Failed to provide sufficient staff time to ensure residents received medications as prescribed for 1 of 6 sampled residents.
Failed to maintain an adequate insect, rodent and pest control program which continually protects the health of residents.
Failed to maintain housekeeping standards so that the home presented a clean and orderly appearance.
Failed to admit and retain only ambulatory residents capable of self-preservation with minimal assistance for 2 of 6 sampled residents.
Failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with applicable federal and state law and regulations for 4 of 5 sampled residents.
Report Facts
Census in Memory Care Unit: 12
Staff scheduled for 8:00 a.m. to 6:00 p.m. shift: 6
Medication doses not given: 7
Medication doses not given: 2
Medication doses not given: 2
Medication doses not given: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed passing medications and interviewed regarding medication administration and resident care | |
| Staff C | Observed passing medications and interviewed regarding staffing and resident care | |
| Staff A | Interviewed regarding staffing, resident care, and medication refill issues | |
| Staff F | Scheduled staff member terminated on 9/24/18, mentioned in relation to staffing shortages and medication refill responsibilities |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 26, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00191320 and to conduct a follow-up to the 5/18/18 compliance inspection.
Complaint Details
Investigation of complaint #GA00191320.
Findings
Rule violations related to this inspection are listed in the follow-up report.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 18, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection.
Findings
The facility failed to ensure that staff updated the Medication Administration Record (MAR) each time medication was offered or taken for 1 of 6 sampled residents, specifically Resident #1 had missing documentation for a prescribed medication dose on 4/16/18.
Deficiencies (1)
Staff failed to update the Medication Administration Record (MAR) each time medication was offered or taken for Resident #1.
Report Facts
Sampled residents: 6
Date of missing documentation: Apr 16, 2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 7, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00184404. The investigation began on 2018-01-29 and ended on 2018-02-07.
Complaint Details
Investigation of complaint GA00184404 found no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 18, 2017
Visit Reason
The purpose of this visit was to conduct a follow up to the 1/25/17 initial inspection and to investigate complaint GA00178172.
Complaint Details
Complaint GA00178172 was investigated during this follow-up visit.
Findings
No rule violations were cited as a result of the follow-up inspection conducted from 2017-08-15 to 2017-08-18.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 18, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA0 and to conduct a follow up to the initial inspection.
Complaint Details
Complaint #GA0 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of the complaint investigation.
Inspection Report
Original Licensing
Deficiencies: 8
Date: Jan 25, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
The facility failed to meet several regulatory requirements including ensuring employees had timely physical examinations and TB screenings prior to employment, residents had physical examinations within 30 days prior to admission, development of individual service plans within 14 days of admission, possession of a valid food service permit, maintenance of personal item inventories for residents, reporting serious injuries to the Department, execution of informed consent for proxy caregivers, and development of plans of care for proxy caregiver services.
Deficiencies (8)
Facility failed to ensure each employee received a physical examination and TB screening within 12 months prior to employment for 1 of 4 staff (Staff C).
Facility failed to ensure residents had a physical examination dated within 30 days prior to admission and that the PE form was completed in its entirety for 2 of 5 residents (Resident #1 and Resident #2).
Facility failed to ensure resident individual service plans were developed within 14 days of admission for 2 of 5 residents (Resident #1 and Resident #3).
Facility failed to possess a valid food service permit for a home serving 25 or more residents.
Facility failed to maintain an inventory of personal items brought to the home by residents for 5 of 5 sampled residents.
Facility failed to report to the Department a serious injury to a resident that required medical treatment for 1 of 6 sampled residents (Resident #6).
Facility failed to execute an informed consent for a proxy caregiver to provide health maintenance activities for 2 of 5 residents sampled (Resident #3).
Facility failed to ensure a plan of care for proxy caregiver services was written for 3 of 5 sampled residents (Resident #1, Resident #3, and Resident #5).
Report Facts
Staff: 4
Residents: 5
Residents: 6
Residents: 5
Residents: 5
Residents: 2
Residents: 2
Residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Failed to have physical examination and TB screening within 12 months prior to employment | |
| Staff A | Interviewed and aware that Staff C's PE/TB results were completed after hire | |
| Staff B | Interviewed multiple times regarding physical examination forms, individual service plans, food service permit, incident reporting, informed consent, and proxy caregiver plans of care |
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