Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 22, 2025
Visit Reason
The purpose of this visit was to investigate intake GA50003457 and GA50004573 with an on-site visit made on 07/22/2025.
Findings
No rule violations were cited as a result of this inspection and investigation completed on 08/25/2025.
Complaint Details
Investigation of complaint intakes GA50003457 and GA50004573 was conducted with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 2, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00246149.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00246149 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 4, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00243655 and #GA00244093 with an onsite visit made on 3/4/24 and the investigation completed on 3/8/24.
Findings
The facility was found to have unsanitary and unsafe conditions including dirty floors with dried spills, food particles, trash, and a strong urine smell in a resident's room. Additionally, medications were observed to be stored unlocked and unattended, posing a risk for unauthorized use.
Complaint Details
Investigation was triggered by two intakes (#GA00243655 and #GA00244093).
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| The interior of the community was not kept clean, with dried spills, food particles, trash on floors, dusty baseboards, and a strong urine smell in a resident's room. | D |
| Medications were not stored under lock and key at all times; an unlocked medication cart was left unattended. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding cleaning responsibilities and resident behavior related to urine incidents. | |
| Staff A | Interviewed and aware of the findings on 3/8/24. | |
| Staff G | Interviewed regarding medication administration and leaving medication cart unattended. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 30, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240978, which was initiated on 2023-11-27. An onsite visit was conducted on 2023-11-30 and the investigation was completed on 2023-12-04.
Findings
The facility failed to obtain satisfactory fingerprint records check determinations for two of four direct access employees (Staff E and Staff F) in compliance with the Rules and Regulations for Criminal Background Checks, Chapter 111-8-12.
Complaint Details
Investigation was initiated based on intake #GA00240978. The complaint was investigated onsite from 2023-11-30 to 2023-12-04. The facility was found noncompliant regarding fingerprint background checks for two staff members.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory fingerprint records check determination for two direct access employees in compliance with criminal background check regulations. | SS= D |
Report Facts
Staff with missing fingerprint records check: 2
Staff hire dates: Staff E hired 2023-09-26, Staff F hired 2023-08-16.
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 5, 2023
Visit Reason
The visit was conducted to investigate intake complaints GA00233076 and GA00234001, with an onsite visit made on 2023-04-05 and the investigation completed on 2023-04-13.
Findings
The facility failed to report the elopement and abuse of residents #1 and #3, failed to ensure adequate care and services for these residents, and failed to have effective safety devices to prevent elopement. Multiple staff interviews and record reviews confirmed residents eloped by climbing out of windows, and the incidents were not properly reported to the Department.
Complaint Details
The investigation was initiated due to complaints GA00233076 and GA00234001. The facility failed to report incidents of elopement and abuse involving residents #1 and #3. The complaints were substantiated by record reviews and staff interviews.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to report to the Department the elopement of a resident for 2 of 3 sampled residents (Resident #1 and Resident #3). | SS= D |
| Facility failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulation for 2 of 3 sampled residents (Resident #1 and Resident #3). | SS= D |
| Facility failed to have effective safety devices to prevent residents from eloping for 1 of 4 sampled residents (Resident #1). | SS= D |
| Facility failed to report to the Department the abuse of a resident for 2 of 3 sampled residents (Resident #1 and Resident #3). | SS= D |
Report Facts
Residents sampled: 3
Residents involved in elopement: 2
Residents involved in abuse reporting failure: 2
Residents involved in safety device failure: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 29, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00228999, with the investigation starting on 2022-11-08 and the onsite visit made on the same day.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00228999 was conducted starting 2022-11-08 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 22, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224581, GA00224986, GA00224709, and GA00224932. An onsite visit was made to the facility on 6/22/22, with the investigation starting on 6/22/22 and completing on 6/23/22.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of four intakes (GA00224581, GA00224986, GA00224709, GA00224932) with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224316 with an onsite visit made to the facility on 6/2/22 and 6/3/22.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00224316; no rule violations found.
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 infection control measures at the facility.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 11, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 5/9/19 compliance inspection and compliance investigation of intake #GA00196072.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 13, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00198383.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint GA00198383 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 5
May 9, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00196072, with on-site visits on 5/8/19 and 5/9/19.
Findings
The facility was found deficient in multiple areas including failure to ensure staff completed required continuing education, noncompliance with fire and safety rules including missing fire drills, failure to maintain heated water temperature below 120 degrees Fahrenheit, missing signed admission agreement for a resident, and inadequate care and reporting related to an incident where a resident sustained injuries during transport.
Complaint Details
The visit was triggered by intake #GA00196072. The investigation found substantiated deficiencies including failure to ensure staff continuing education, fire safety noncompliance, water temperature hazards, missing admission agreement, and inadequate incident reporting and resident care related to a fall and injury of Resident #1 during transport.
Severity Breakdown
D: 3
J: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure staff had 16 hours of continuing education for 1 of 6 sampled staff (Staff D). | D |
| Facility failed to comply with applicable fire and safety rules; no fire drills completed for multiple months in 2018 and only one disaster drill completed. | D |
| Facility failed to maintain heated water temperature that did not exceed 120 degrees Fahrenheit; observed temperatures of 130.1 to 132.9 degrees in resident bathroom sinks. | J |
| Facility failed to include a signed copy of the Admission Agreement in the file of 1 of 6 sampled residents (Resident #1). | D |
| Facility failed to provide adequate care and services in compliance with state law for Resident #1 who sustained injuries during transport and was not properly reported to family or hospice. | J |
Report Facts
Continuing education hours missing: 16
Fire drills missing: 4
Disaster drills completed: 1
Water temperature: 132.9
Water temperature: 130.1
Water temperature: 132
Incident date: Apr 8, 2019
Incident report submission date: Apr 11, 2019
Resident injuries: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiency for failing to complete continuing education and involved in incident where Resident #1 fell and was injured. | |
| Staff G | Interviewed regarding Staff D's continuing education and incident involving Resident #1. | |
| Staff C | Interviewed regarding fire safety policy and water temperature observations. | |
| Staff A | Interviewed regarding plans to correct water temperature issues. | |
| Staff H | Interviewed regarding missing signed admission agreement for Resident #1. | |
| Staff B | Interviewed regarding notification of Resident #1's injury and family communication. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 12, 2018
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00191064 and #GA00190942 regarding resident safety and elopement incidents at the memory care unit.
Findings
The facility failed to enforce policies and procedures to monitor residents who may wander away, resulting in two residents eloping from the memory care unit due to a malfunctioning magnetic door that did not close tightly and lacked an audible alarm.
Complaint Details
The investigation was triggered by complaints regarding two residents who eloped from the memory care unit on separate occasions due to an unlocked or malfunctioning magnetic door. Resident #1 eloped on 8/20/18 and was found walking at a busy intersection; Resident #2 was found outside the unit without his rollator on 7/23/18. Both incidents were linked to the door not closing tightly and lack of monitoring.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to enforce policies and procedures for staff to monitor residents who may wander away from the assisted living community for 2 of 3 sampled residents. | SS= D |
Report Facts
Date of incidents: Aug 20, 2018
Date of incidents: Jul 23, 2018
Resident admission date: Aug 15, 2018
Resident admission date: Aug 1, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding Resident #1 and Resident #2 elopement incidents and door monitoring | |
| Staff C | Interviewed regarding medication passing and door monitoring during elopement incidents | |
| Staff D | Telephone interview regarding malfunctioning magnetic door |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA#00181877.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint GA#00181877 found no rule violations.
Inspection Report
Original Licensing
Deficiencies: 0
Oct 17, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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