Inspection Reports for Cedarhurst of Oakwood
4251 HUDSON DRIVE, OAKWOOD, GA, 30566.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 17, 2025, identified a deficiency related to late medication administration for one resident. Earlier inspections showed a pattern of issues primarily involving medication management, staff training and certification, resident care monitoring, and timely communication with representatives. Complaint investigations substantiated problems such as delayed medication delivery, insufficient staff training in emergency and dementia care, inadequate monitoring leading to resident injury, and incomplete incident reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history suggests ongoing challenges with medication timing and staff qualifications, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50005561, #GA50005762, and #GA50005574 with an onsite visit on 10/17/2025 and investigation completion on 10/29/2025.
Complaint Details
Investigation was complaint-related for complaints #GA50005561, #GA50005762, and #GA50005574. Resident #5 confirmed medications were administered late on 10/17/25. Staff A was made aware of the findings on 10/29/25.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5). Specifically, medications scheduled for 8:00 a.m. were administered at 9:19 a.m., more than one hour late.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5, administering medications more than one hour late.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff made aware of medication administration findings on 10/29/25 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaint numbers #GA50005561, #GA50005762, and #GA50005574. The onsite visit was conducted on 10/17/2025 with the investigation completed on 10/29/2025.
Complaint Details
Investigation was conducted based on complaints #GA50005561, #GA50005762, and #GA50005574. Resident #5 confirmed medications were administered late on 10/17/2025.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5). Specifically, medications scheduled for 8:00 a.m. were administered more than one hour late at 9:19 a.m. on 10/17/2025.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5, administering medications more than one hour late.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Made aware of the findings during interview on 10/29/2025 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50005561, #GA50005762, and #GA50005574, with the onsite visit conducted on 2025-10-17 and the investigation completed on 2025-10-29.
Complaint Details
Investigation was conducted based on complaints #GA50005561, #GA50005762, and #GA50005574. Resident #5 confirmed medications were administered late on 10/17/25. Staff A was made aware of the findings on 10/29/25.
Findings
Staff failed to provide medications at the right time for one of five sampled residents (Resident #5), administering medications more than one hour late at 9:19 a.m. instead of the scheduled 8:00 a.m. time.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5, administering medications more than one hour late.
Report Facts
Deficiencies cited: 1
Medication administration time: 9.19
Scheduled medication time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Made aware of medication timing findings on 10/29/25 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50005561, #GA50005762, and #GA50005574 with an onsite visit conducted on 10/17/2025 and investigation completed on 10/29/2025.
Complaint Details
Investigation was conducted based on complaints #GA50005561, #GA50005762, and #GA50005574. Resident #5 confirmed medications were administered late on 10/17/25. Staff A was made aware of the findings on 10/29/25.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5), with medications administered more than one hour late at 9:19 a.m. instead of the scheduled 8:00 a.m.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5, administering medications more than one hour late.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff made aware of medication timing findings on 10/29/25 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaints #GA50005561, #GA50005762, and #GA50005574 with an onsite visit conducted on 10/17/2025 and investigation completed on 10/29/2025.
Complaint Details
Investigation was complaint-driven based on three complaint numbers. Resident #5 confirmed medications were administered late on 10/17/25. Staff A was made aware of the findings on 10/29/25.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5), with medications scheduled for 8:00 a.m. administered at 9:19 a.m. The resident confirmed the late administration during interview.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Made aware of medication administration findings on 10/29/25 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaint numbers #GA50005561, #GA50005762, and #GA50005574 with an onsite visit conducted on 10/17/2025 and investigation completed on 10/29/2025.
Complaint Details
Investigation was complaint-related based on complaint numbers #GA50005561, #GA50005762, and #GA50005574. Resident #5 confirmed medications were administered late on 10/17/2025.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5), with medications scheduled for 8:00 a.m. administered more than one hour late at 9:19 a.m. on 10/17/2025.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Made aware of the findings during interview on 10/29/2025 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 17, 2025
Visit Reason
The purpose of this survey was to investigate complaint numbers #GA50005561, #GA50005762, and #GA50005574 with an onsite visit conducted on 10/17/2025 and investigation completed on 10/29/2025.
Complaint Details
Investigation was conducted based on complaints #GA50005561, #GA50005762, and #GA50005574. Resident #5 substantiated the complaint by stating medications were administered late on 10/17/2025.
Findings
Staff failed to provide medications at the right time for 1 of 5 sampled residents (Resident #5), with medications scheduled for 8:00 a.m. administered at 9:19 a.m. on 10/17/2025. Resident #5 confirmed medications were administered late during an interview.
Deficiencies (1)
Staff failed to provide medications at the right time for Resident #5, with medications scheduled for 8:00 a.m. given at 9:19 a.m.
Report Facts
Medication administration delay: 79
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Made aware of the findings during interview on 10/29/2025 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 20, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002208 and conduct the compliance inspection. An onsite visit was made on 5/20/25.
Complaint Details
The visit was complaint-related, investigating intake #GA50002208.
Findings
The facility failed to ensure that staff hired to provide hands-on personal services received required training and certifications. Specifically, one of four staff (Staff C) lacked emergency first aid and CPR certification, and one of four staff (Staff D) assigned to the memory care unit did not receive required dementia-specific orientation and training within the mandated timeframes.
Deficiencies (3)
Staff C did not have current certification in emergency first aid as required within the first 60 days of employment.
Staff C did not have current certification in cardiopulmonary resuscitation (CPR) with return demonstration of competency as required within the first 60 days of employment.
Staff D assigned to the memory care unit did not receive required dementia-specific orientation and training within the first six months of employment.
Report Facts
Staff lacking required training: 1
Staff lacking required training: 1
Total staff reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings for lacking emergency first aid and CPR certification | |
| Staff D | Named in findings for lacking dementia-specific orientation and training | |
| Staff A | Interviewed and provided information about Staff C and Staff D training status |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 2, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00247918, with the investigation beginning on 2024-08-01 and ending on 2024-08-02.
Complaint Details
Investigation of intake# GA00247918; no rule violations were found.
Findings
No rule violations were cited as a result of the visit.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00246389 regarding a resident wandering out of the memory care unit and sustaining a fall with injury.
Complaint Details
Investigation of complaint #GA00246389 confirmed that Resident #1 wandered out of the memory care unit on 4/30/24 at 6:40 a.m., fell, and was transported to the emergency room. The resident was at risk for elopement and falls per care plan. Staff failed to adequately monitor the resident, leading to the incident.
Findings
The facility failed to ensure adequate and appropriate care for one resident who wandered out of the memory care unit, fell, and sustained a head injury. Staff interviews and record reviews confirmed the resident was at risk for elopement and falls, but monitoring was insufficient to prevent the incident.
Deficiencies (1)
Facility failed to provide adequate care and services to prevent a resident at risk for elopement and falls from wandering out and sustaining injury.
Report Facts
Date of incident: Apr 30, 2024
Date of onsite visit: May 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Staff member who responded to door alarm and witnessed resident wandering and fall |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The purpose of this survey was to investigate complaints #GA00243164 and #GA00243282 during an onsite visit on 3/27/24.
Complaint Details
Investigation of complaints #GA00243164 and #GA00243282 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237536. An onsite visit was made on 8/17/23 and the investigation was completed on 8/23/23.
Complaint Details
Investigation of intake #GA00237536 regarding failure to notify responsible party and complete incident report for Resident #2 after hospital transfer on 5/16/23. Substantiation status not explicitly stated.
Findings
The facility failed to ensure immediate and appropriate action was taken in case of an accident or sudden adverse change in a resident's condition, including notifying the representative or legal surrogate for Resident #2. Documentation and incident reporting were incomplete, and responsible parties were not notified timely.
Deficiencies (1)
Failed to ensure immediate action and notification to representative for Resident #2 after sudden adverse change and hospital transfer on 5/16/23.
Report Facts
Residents in sample: 2
Date of hospital event: 51623
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding notification failure for Resident #2 | |
| Staff C | Interviewed regarding notification attempts for Resident #2 | |
| AA | Unaware of hospital transfer until contacted by hospital |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00232273 during an onsite visit on 2/24/2023.
Complaint Details
Investigation of complaint #GA00232273 found Staff C administered medications without certification; substantiation status not explicitly stated.
Findings
The facility failed to ensure that a certified medication aide (CMA) administered medications to residents, as Staff C was found to have no active CMA certification or training documentation while administering medications to residents on 2/5/2023 and 2/7/2023.
Deficiencies (1)
Facility failed to ensure that a certified medication aide administered medications; Staff C had no active certification or training documentation.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in medication administration without certification finding | |
| Staff B | Interviewed and stated Staff C did not have certification medication aide training in the file | |
| Staff A | Made aware of the finding on 2/24/2023 at 4:45 p.m. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 22, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00225283. The onsite visit occurred on 2022-07-22 and was completed on 2022-07-26.
Complaint Details
Investigation was initiated due to complaint #GA00225283. The complaint was substantiated based on findings that the facility failed to provide timely medical care to Resident #1 after the injury.
Findings
Based on record review and interviews, the facility failed to ensure that a resident received appropriate medical care after an incident where one resident rolled over another resident's foot with a wheelchair, resulting in a foot fracture that was not promptly addressed.
Deficiencies (1)
Facility failed to ensure that Resident #1 received medical care as required by law or regulations after an incident involving a foot injury caused by Resident #2 rolling over Resident #1's foot with a wheelchair.
Report Facts
Incident date: May 28, 2022
X-ray order date: May 31, 2022
Swelling noted date: Jun 1, 2022
Swelling still present date: Jun 2, 2022
Fracture diagnosis date: Jun 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Observed the incident where Resident #2 rolled over Resident #1's foot and reported it | |
| Staff E | Noted that Resident #1's foot was still swollen on 6/2/2022 | |
| Staff A | Was aware of the findings during interview on 7/26/2022 | |
| Staff B | Was informed by Staff D about the incident |
Inspection Report
Original Licensing
Census: 37
Deficiencies: 12
Date: Feb 28, 2022
Visit Reason
The purpose of this visit was to conduct an initial inspection and to investigate complaint #GA00220682. Onsite visits were made on 1/26/22 and 1/27/22, with the inspection completed on 2/28/22.
Complaint Details
The inspection included an investigation of complaint #GA00220682.
Findings
The facility failed to have policies and procedures for services available, admissions, refunds, medication management, staff training, recertifications, sufficient staffing, memory care certification, quarterly drug regimen reviews, medication administration records, incident reporting, and disaster preparedness. Multiple deficiencies were noted including late medication administration, lack of staff training, missing documentation, and inadequate emergency plans.
Deficiencies (12)
No policy regarding services available in the assisted living community.
No policy regarding admissions, discharges, and immediate transfers.
No policy regarding refunds when a resident is transferred or discharged.
No policy regarding use of certified medication aides and professional oversight.
Staff providing hands-on personal services lacked required continuing education hours (2 of 11 staff).
No evidence of recertifications such as CPR and first aid for 3 of 12 sampled staff.
Insufficient staff time to ensure residents received prescribed services, treatments, medications, and diet for 3 of 5 residents.
Certificate for memory care was not obtained or observed.
Quarterly drug regimen reviews were not performed for 3 of 5 residents.
Medication assistance records did not include individual staff initials for medication administration for 3 residents.
Lack of documentation of adverse changes and facility response in resident's file for 1 of 5 residents.
Disaster preparedness plan did not address loss of air conditioning or heat.
Report Facts
Resident census: 37
Staff providing hands-on personal services: 2
Staff sampled for recertifications: 3
Residents with insufficient staff time: 3
Residents without quarterly drug reviews: 3
Residents with MAR issues: 3
Residents with missing adverse change documentation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed multiple times acknowledging findings and policies to be developed. | |
| Staff B | Staff file reviewed showing insufficient training and expired CPR/first aid. | |
| Staff J | Staff file reviewed showing no training in 2021 and expired CPR/first aid; no longer employed. | |
| Staff K | Interviewed regarding staff training and employment status of Staff J. | |
| Staff P | Observed passing medications late and interviewed about staffing shortages. | |
| Staff G | Reported staffing shortages on Christmas Eve and being the only nurse passing medications. | |
| Staff O | Interviewed about missing quarterly drug reviews and incident report documentation. | |
| Staff L | Interviewed about missing memory care certificate. | |
| AA | Family member reporting safety concerns and multiple falls of Resident #1. |
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