The most recent inspection on October 1, 2025, found no deficiencies. Earlier inspections showed a generally clean record with isolated issues related primarily to medication management and staff background checks. Prior deficiencies included delays in medication refills causing interruptions in dosing and incomplete fingerprint background checks for some staff members. A substantiated complaint in June 2023 involved medication administration errors affecting 14 memory care residents, but no enforcement actions or fines were listed in the available reports. The facility’s inspection history suggests improvement over time, with recent investigations consistently finding no rule violations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake #GA50004892.
Findings
An on-site visit was conducted on 10/1/25, and the investigation was completed on 10/1/25. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA50004892 found no rule violations.
The purpose of this visit was to conduct a complaint inspection related to allegations identified by complaint numbers GA50004010 and GA50004336.
Findings
The facility failed to obtain a satisfactory fingerprint records check for one of three sampled staff and failed to obtain timely refills of prescribed medications for two of three sampled residents, resulting in interruptions in routine dosing.
Complaint Details
This inspection was complaint-related, triggered by complaints GA50004010 and GA50004336. The report does not explicitly state substantiation status.
Severity Breakdown
Level D: 2
Deficiencies (2)
Description
Severity
Failure to obtain a satisfactory fingerprint records check determination for one of three sampled staff (Staff D) as required by criminal background check regulations.
Level D
Failure to obtain refills of prescribed medication timely, causing interruptions in routine dosing for two of three sampled residents (Resident #1 and Resident #2).
Level D
Report Facts
Number of sampled staff with fingerprint check deficiency: 1Number of sampled residents with medication refill deficiency: 2Dates of inspection: 2025-08-20 to 2025-08-27
Employees Mentioned
Name
Title
Context
Staff D
Staff member lacking satisfactory fingerprint records check
Staff B
Interviewed regarding fingerprint check and medication issues
The visit was conducted to investigate intake #GA00238039 with an onsite visit made on 2023-08-23. The investigation started on 2023-08-23 and was completed on 2023-09-05.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00238039 was conducted with no rule violations found.
The purpose of this visit was to investigate complaint intakes #GA00235071 and #GA00235257, with an onsite visit made on 6/21/2023 and the investigation completed on 7/18/2023.
Findings
The facility failed to ensure that all 14 memory care residents received adequate and appropriate care and services in compliance with state law and regulation. Specifically, on May 7, 2023, 14 residents did not receive their morning medications because Staff C only passed medications from one medication cart instead of both. All families and physicians were notified, residents were placed on a 72-hour close watch protocol, and no adverse effects were observed. Staff C was terminated on 5/8/2023.
Complaint Details
Investigation was initiated based on complaint intakes #GA00235071 and #GA00235257. The complaint was substantiated as the facility failed to administer medications properly to 14 residents on May 7, 2023.
Severity Breakdown
Level D: 1
Deficiencies (1)
Description
Severity
Failure to ensure each resident received adequate and appropriate care and services, specifically medication administration errors affecting 14 memory care residents.
Level D
Report Facts
Residents affected: 14Close watch protocol duration: 72Staff C hire date: Nov 4, 2022Staff C termination date: May 8, 2023
Employees Mentioned
Name
Title
Context
Staff C
Certified Nurse Assistant and Certified Medication Aid
Named in medication administration error and subsequent termination
Staff A
Reported the medication error and actions taken
Staff B
Notified Staff A about the medication error
Inspection Report Original LicensingDeficiencies: 0May 3, 2023
Visit Reason
The purpose of this visit was to conduct an initial inspection for a change of ownership.
Findings
No violations were cited as a result of this inspection.
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00223511. An onsite visit was made to the facility on 5/11/2022 and the investigation was completed on 5/18/2022.
Findings
The facility failed to ensure that refills of prescribed medications were obtained timely, resulting in an interruption in routine dosing for 1 of 1 sampled residents (Resident #1). Resident #1 did not sustain any injuries.
Complaint Details
Investigation was complaint-related intake GA00223511. The medication for Resident #1 was not started timely after hospital discharge paperwork and medication were left on staff desk. Staff A received corrective action. Resident #1's family, physician, and nurse practitioner were contacted and medication was started on 4/21/22.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to ensure timely refills of prescribed medications resulting in interruption of routine dosing for Resident #1.
SS= D
Report Facts
Date of medication error: Feb 25, 2022Date medication started: Apr 21, 2022
Employees Mentioned
Name
Title
Context
Staff A
Received corrective action related to medication error.
Staff B
Interviewed regarding medication error and corrective action.
The purpose of this review is to monitor COVID-19 cases and assess the infection control process.
Findings
The report focuses on monitoring COVID-19 cases and evaluating the facility's infection control procedures. No specific deficiencies or severity levels are detailed.
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00200712.
Findings
The facility failed to obtain satisfactory criminal history background checks for 5 of 6 sampled staff. The facility also failed to have an effective automated alert system for the memory care unit exits, resulting in Resident #1 eloping. Additionally, the facility failed to provide watchful oversight consistent with residents' needs and failed to ensure residents were free from physical restraints, as bedrails were used on 4 sampled residents in the memory care unit.
Complaint Details
The visit was triggered by intake #GA00200712, which involved investigation of Resident #1 eloping from the memory care unit due to ineffective alarm systems and inadequate staff oversight.
Severity Breakdown
D: 1J: 3
Deficiencies (4)
Description
Severity
Failed to obtain satisfactory Criminal Records Check (CRC) determination for 5 of 6 sampled staff.
D
Failed to have an effective automated device or system to alert staff to individuals entering or leaving the memory care unit in an unauthorized manner.
J
Failed to provide watchful oversight consistent with the residents' needs, resulting in Resident #1 eloping from the memory care unit.
J
Failed to ensure each resident is given the right to be free from physical restraints; bedrails were used on 4 sampled residents in the memory care unit.
J
Report Facts
Number of staff without satisfactory CRC: 5Number of residents with bedrails used: 4Date of Resident #1 elopement incident: Oct 28, 2019
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding criminal record checks, alarm system failure, and use of bedrails in memory care unit.
Staff B
Sampled staff without satisfactory criminal records check.
Staff C
Sampled staff without satisfactory criminal records check.
Staff D
Sampled staff without satisfactory criminal records check.
Staff E
Sampled staff without satisfactory criminal records check.
Staff F
Sampled staff without satisfactory criminal records check.
Inspection Report Original LicensingDeficiencies: 0Feb 28, 2018
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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