The most recent inspection on October 21, 2025, found no deficiencies during complaint investigations. Earlier inspections showed a generally clean record with most complaint investigations resulting in no violations cited. Deficiencies that did occur primarily involved issues with following residents’ care plans and medication management, including a substantiated medication error in April 2024 and a failure to provide timely written notice of charge increases in May 2025. Complaint investigations were mostly unsubstantiated, with one substantiated case related to care plan adherence. The inspection history indicates improvement over time, with recent inspections showing no cited deficiencies.
Deficiencies (last 9 years)
Deficiencies (over 9 years)2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to conduct a re-licensure inspection and to investigate intake #GA50002105.
Findings
The facility failed to ensure that residents and their representatives were informed in writing at least 30 days prior to any increase in established charges related to personal services and at least 60 days prior to any increase in charges for room and board for 1 of 5 sampled residents. Documentation of notice to the responsible party for change in billing was not provided.
Complaint Details
Investigation of intake #GA50002105 was conducted during this visit.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failed to provide written notice at least 30 days prior to any increase in charges related to personal services and at least 60 days prior to any increase in charges for room and board for 1 of 5 sampled residents.
The purpose of this visit was to investigate intake # GA00249251. An on-site visit was made on 8/20/2024, with the investigation completed on 8/23/2024.
Findings
The facility failed to ensure that staff followed the resident's written care plan as a guide for care and services for 1 of 3 sampled residents. Specifically, Resident #1 was not checked every two hours at night as required, despite documented needs for visual, hourly, and nightly checks.
Complaint Details
Investigation was initiated due to intake # GA00249251. The complaint was substantiated based on record review and staff interviews indicating failure to follow the care plan for Resident #1.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure staff followed the care plan as a guide for care and services to Resident #1, who required visual, hourly, and nightly checks but was not checked every two hours at night.
The purpose of this visit was to investigate intake #GA00245251. An onsite visit was made to the facility on 4/10/24, with the investigation completed on 4/15/24.
Findings
The facility failed to maintain personnel files for agency staff, did not verify certified medication aide registry status for Staff D, and a medication error occurred where Staff D administered 24 units of insulin instead of 2 units to Resident #1. The Medication Assistance Record was not updated to reflect this error, and the resident received inadequate care resulting in a low blood sugar emergency. Staff D's services were terminated after the incident.
Complaint Details
Investigation of intake #GA00245251 regarding a medication error where Staff D administered 24 units of insulin instead of 2 units to Resident #1, resulting in a low blood sugar emergency. Staff D was an agency employee whose registry status was not verified and whose personnel file was not maintained. Staff D's services were terminated after the incident.
Severity Breakdown
D: 4
Deficiencies (4)
Description
Severity
Failed to maintain staff personnel files for agency employee (Staff D).
D
Failed to ensure certified medication aide (Staff D) was listed in good standing on the Georgia Certified Medication Aide Registry before administering medications.
D
Failed to update the Medication Assistance Record (MAR) after a medication error where 24 units of insulin were administered instead of 2 units to Resident #1.
D
Failed to provide adequate and appropriate care to Resident #1, resulting in a medication error and low blood sugar emergency.
D
Report Facts
Units of insulin administered: 24Units of insulin prescribed/administered correctly: 2Blood sugar reading: 35Date of incident: Mar 26, 2024
Employees Mentioned
Name
Title
Context
Staff D
Certified Medication Aide (agency employee)
Named in medication error involving incorrect insulin administration and failure to maintain personnel file or registry verification.
Staff B
Interviewed regarding the medication error and failure to update MAR.
Staff C
Interviewed regarding Staff D's agency status and registry check.
Staff E
Interviewed regarding blood sugar measurement and medication assistance on day of incident.
The visit was conducted to investigate complaint intakes #GA00243923 and #GA00244624 with an onsite visit on 2024-03-08, and the investigation was completed on 2024-03-21.
Findings
No violations or deficiencies were cited as a result of this complaint investigation.
Complaint Details
Investigation of complaint intakes #GA00243923 and #GA00244624 resulted in no violations cited.
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00226066. An onsite visit was made on 08/04/2022, and the inspection was completed on 08/15/2022.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00226066 with no violations found.
The purpose of this visit was to investigate intake #GA00210307 regarding alleged abuse of a resident.
Findings
Based on record review and interviews, the facility failed to prevent verbal and physical abuse of Resident #1 by Staff B and Staff C, failed to implement safeguards during the internal investigation, and failed to report alleged abuse to the Department and local law enforcement within 24 hours as required.
Complaint Details
The complaint investigation was triggered by intake #GA00210307. Allegations included Staff B and Staff C yelling at Resident #1, speaking hatefully, physically jerking Resident #1, not providing incontinent care, and allowing the resident to sit in dirty clothes. The internal investigation did not substantiate the allegations due to lack of specific incident timing and observation of acceptable staff behavior after the allegation. Resident #1's family reported elder abuse to police on 12/07/2020.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Facility failed to implement policies and practices supporting dignity and respect of residents in a safe environment.
SS= D
Facility failed to ensure residents' right to be free from mental, verbal, and physical abuse.
SS= D
Facility failed to report alleged abuse to the Department and local law enforcement within 24 hours.
SS= D
Report Facts
Incident Report Date: Dec 4, 2020Staff Hire Date: Sep 24, 2020Staff Resignation Date: Jan 18, 2021Resident Care Plan Date: Dec 3, 2020
Employees Mentioned
Name
Title
Context
Staff B
Named in findings related to verbal and physical abuse of Resident #1
Staff C
Named in findings related to verbal and physical abuse of Resident #1
Staff A
Received abuse reports and interviewed during investigation
Staff D
Witnessed Staff B's stern tone and rough handling of Resident #1
Staff E
Witnessed Staff B and Staff C's rough handling of Resident #1
The purpose of this visit was to investigate complaint GA 00190048.
Findings
The facility failed to ensure Certified Medication Aides were listed in good standing on the Georgia Certified Medication Aide Registry before administering medications, resulting in a medication error where Resident #2 received Resident #1's medications. Additionally, medications were not kept in original containers with original labels intact, contributing to the medication error.
Complaint Details
The visit was complaint-related for complaint GA 00190048. The complaint was substantiated by findings that Staff C administered the wrong resident's medications and had an expired Certified Medication Aide Registry status.
Severity Breakdown
Level D: 2
Deficiencies (2)
Description
Severity
Failed to check the Georgia Certified Medication Aide Registry to ensure Certified Medication Aides were in good standing before permitting medication administration.
Level D
Failed to ensure medications were kept in original containers with original labels intact for 2 of 2 sample residents.
Level D
Report Facts
Date of medication error: Jul 3, 2018Number of residents involved in medication error: 2Number of medications given in error: 9
Employees Mentioned
Name
Title
Context
Staff C
Named in medication error finding and registry expiration.
Staff A
Interviewed regarding medication error and Staff C's actions.
Staff B
Interviewed regarding notification of medication error by Staff C.
The purpose of this visit was to conduct a compliance inspection and to investigate complaint #GA00184892.
Findings
The facility failed to provide protective care and watchful oversight for one resident who eloped from the facility and was found by emergency services. The resident was transferred to the hospital and returned without injury. The resident was discharged shortly after the incident.
Complaint Details
Complaint #GA00184892 was investigated and substantiated by the finding that the facility failed to provide adequate protective care and oversight for Resident #1, who eloped from the facility on 01/30/18 and required emergency services intervention.
Deficiencies (1)
Description
Facility failed to provide protective care and watchful oversight for 1 of 8 sampled residents, resulting in elopement and emergency intervention.
Report Facts
Resident sample size: 8Incident date: Jan 30, 2018Discharge notice date: Dec 4, 2017Discharge date: Feb 3, 2018
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding Resident #1's elopement and family refusal of 24/7 care
Staff B
Reported Resident #1 eloped from exit door next to resident's room
The purpose of this visit was to conduct a follow-up to the 02/21/17 complaint investigation.
Findings
No rule violations were cited as a result of this inspection. However, the facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping, as evidenced by multiple elopement incidents involving Resident #1.
Complaint Details
The follow-up was related to a complaint investigation from 02/21/17 concerning Resident #1 eloping multiple times from the facility, including incidents on 10/5/16, 10/15/16, and 01/29/17. Resident #1 was found outside the facility on these occasions and was returned by staff or police. Resident and staff interviews confirmed the incidents and awareness of the elopement risk.
Deficiencies (1)
Description
Facility failed to utilize appropriate effective safety devices to protect residents at risk of eloping from the premises.
Report Facts
Deficiency count: 1Resident #1 elopement incidents: 3Resident #1 Service Level of Care Program Review score: 8
The purpose of this visit was to investigate complaint #GA00175124. An on-site visit was made on 5/30/17 and the investigation was completed on 6/12/17.
Findings
The facility failed to ensure fire evacuation drills were conducted in compliance with fire safety standards, failed to maintain accurate and complete Medication Assistance Records (MAR) for multiple residents, and failed to obtain new prescriptions within required timeframes for one resident.
Complaint Details
Complaint #GA00175124 was investigated with an on-site visit on 5/30/17 and completed on 6/12/17.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Failed to ensure fire evacuation drills were rehearsed in compliance with fire safety standards, including not sounding the overhead alarm and not evacuating residents during a drill.
SS= D
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 4 of 5 sampled residents and failed to add required medication details for new medications for 2 of 5 sampled residents.
SS= D
Failed to obtain new prescriptions within 48 hours of receipt of notice or sooner if indicated by the physician for 1 of 5 sampled residents.
SS= D
Report Facts
Number of sampled residents with MAR documentation issues: 4Number of sampled residents with missing medication details on MAR: 2Number of sampled residents with delayed prescription procurement: 1
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding fire drill procedures and medication record keeping; stated review and corrective actions would be taken.
Staff E
Conducted fire drill on 12/28/17 without sounding alarm or evacuating residents.
The purpose of this visit was to conduct a follow-up to the 10/27/16 annual inspection.
Findings
The community failed to include an inventory of valuable personal items brought to the assisted living community for use by the resident for 3 of 3 sampled residents. This violation was previously cited on 10/27/16.
Severity Breakdown
E: 1
Deficiencies (1)
Description
Severity
Failed to include an inventory of valuable personal items brought to the assisted living community for use by the resident for 3 of 3 sampled residents.
E
Report Facts
Number of residents without inventory: 3
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding the missing inventories for Residents #1, #2, and #3.
The purpose of this visit was to investigate complaint intake #GA 00171207 regarding the facility's failure to utilize appropriate effective safety devices to protect residents at risk of eloping.
Findings
The facility failed to implement appropriate safety measures to prevent elopement of residents with cognitive deficits. Resident #1 was documented to have eloped multiple times, including incidents on 10/5/16, 10/15/16, and 01/29/17, with staff and police involvement in returning the resident to the facility.
Complaint Details
Complaint intake #GA 00171207 was investigated. Resident #1 was found to have eloped on three documented occasions, with no injuries reported but significant safety concerns. Staff interviews confirmed awareness of the elopements and police involvement in returning the resident.
Deficiencies (1)
Description
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping from the premises.
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