The most recent inspection on August 8, 2025, found deficiencies related to food safety and sanitation practices, including staff not wearing hair nets, improperly covered food, and lack of required Serve-Safe certification. Earlier inspections showed a mixed pattern with prior deficiencies involving resident mistreatment, inadequate staffing, and housekeeping issues, but many complaint investigations found no violations. Main themes across deficiencies included resident dignity and respect, staffing levels, and food safety practices. Several substantiated complaints led to staff suspensions or terminations, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with compliance in specific areas, with no clear overall improvement or worsening trend.
Deficiencies (last 8 years)
Deficiencies (over 8 years)1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
43210
2018
2019
2020
2021
2022
2023
2024
2025
Census
Latest occupancy rate15 residents
Based on a February 2021 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The purpose of this survey was to conduct a compliance inspection and investigate intake #GA50004201, with the investigation starting on 2025-08-05 and completed on 2025-08-07.
Findings
The facility failed to ensure safe food handling, hygiene, and sanitation practices were maintained by all staff, including issues such as kitchen staff not wearing hair nets, improperly covered and dated food items, and operating a dishwasher without detergent. Staff responsible for training had not completed required Serve-Safe certification.
Complaint Details
Investigation was initiated due to intake #GA50004201. The complaint was substantiated based on observations, interviews, and record reviews revealing multiple food safety and sanitation violations.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to enforce safe food handling practices ensuring food safety, hygiene, and sanitation by all staff.
SS= D
Employees Mentioned
Name
Title
Context
Staff BB
Verified food safety violations including uncovered and undated food, operating dishwasher without detergent, and was responsible for training kitchen staff but had not completed Serve-Safe certification.
Staff A
Stated Staff BB was responsible for training kitchen staff and would be scheduled to complete Serve-Safe certification.
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00237219. An onsite visit was made to the facility on 2023-08-16.
Findings
No violations were cited as a result of this inspection completed on 2023-09-14.
Complaint Details
Investigation of intake GA00237219 was conducted with no violations cited.
The visit was conducted to investigate complaint intakes GA00226480 and GA00226717, focusing on allegations of mistreatment and abuse by staff at the facility.
Findings
The investigation found that Staff F mistreated Resident #1 by yelling, refusing assistance, and handling the resident roughly. Multiple staff and resident statements confirmed Staff F's disrespectful and aggressive behavior, leading to Staff F's suspension and eventual termination.
Complaint Details
The complaint investigation was substantiated based on interviews, incident reports, and staff statements confirming mistreatment by Staff F. Resident #1 reported fear and distress due to Staff F's behavior. Staff F was suspended and terminated following the investigation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect, specifically Resident #1 was verbally mistreated and roughly handled by Staff F.
SS= D
Report Facts
Dates of incidents: 2Date of staff termination: Aug 8, 2022
Employees Mentioned
Name
Title
Context
Staff F
Named in multiple findings of mistreatment and abuse towards residents
Staff B
Reported by Resident #1 and involved in removing Staff F from the facility
Staff A
Reported Resident #1's complaints about Staff F
Staff D
Observed and reported Staff F's mistreatment of residents
Staff E
Provided written statement about Staff F's aggressive behavior
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00212626, with an on-site visit made on 4/14/21 and investigation completed on 5/11/21.
Findings
The facility failed to ensure a resident was treated with dignity and respect, specifically involving Staff H allegedly using a toilet brush to clean a resident, and failed to report the alleged abuse to the Department and local law enforcement within 24 hours as required.
Complaint Details
Investigation was initiated due to intake #GA00212626 regarding allegations that Staff H used a toilet brush to clean Resident #1. Staff H was suspended and later terminated. The facility did not report the alleged abuse to authorities within 24 hours as required. Staff statements and interviews confirmed the allegations and administrative actions taken.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Facility failed to ensure each resident was treated with dignity, kindness, consideration and respect and given privacy in assisted living care for 1 of 4 residents sampled.
SS= D
Facility failed to report alleged abuse of a resident to the Department and local law enforcement within 24 hours as required by law.
SS= D
Report Facts
Residents sampled: 4Resident involved: 1Investigation start date: Apr 14, 2021Investigation completion date: May 11, 2021Staff H termination timeframe: 60
Employees Mentioned
Name
Title
Context
Staff H
Named in allegations of abuse and termination
Staff A
Provided emailed statement regarding Staff H's actions and termination
Staff B
Filled out Corrective Action Documentation and provided interview statements
AA
Witnessed Staff H's actions during shower and provided interview statements
Staff I
Mentioned as not wanting to fill out a written report regarding the incident
The purpose of this visit was to investigate intake #GA00209528, involving allegations of inadequate supervision and failure to provide protective care in the memory care unit.
Findings
The facility failed to ensure proper enforcement of policies and procedures related to resident safety and supervision, resulting in two residents sustaining serious injuries from an altercation. Resident #1 suffered a left shoulder fracture and Resident #2 sustained a right femur fracture. Staff failed to provide immediate medical attention and adequate supervision, and one staff member was terminated for failing to diffuse the situation.
Complaint Details
The investigation was complaint-driven based on intake #GA00209528. The complaint involved allegations of inadequate supervision and failure to provide protective care in the memory care unit, resulting in injuries to two residents. The complaint was substantiated based on record review and interviews.
Severity Breakdown
D: 3
Deficiencies (3)
Description
Severity
Failure to ensure policies and procedures were enforced to ensure compliance with fall and injury protocols.
D
Failure to provide protective care and watchful oversight for residents, resulting in injuries to two residents.
D
Failure to take immediate action appropriate to an accident or sudden adverse change in Resident #1's condition, including notification of legal surrogate.
D
Report Facts
Residents in memory care: 15Medication dosage: 500Medication dosage: 0.5Oxycodone dosage: 20Oxycodone dosage increased: 60Incident date: Oct 25, 2020
Employees Mentioned
Name
Title
Context
Staff B
Named in statements regarding failure to diffuse altercation and was terminated for this failure.
Staff A
Interviewed regarding incident and facility response; aware of findings.
Staff C
Interviewed; was outside on phone during incident; recalled about 15 residents in memory care.
Staff E
Assessed Resident #1 after incident and administered pain medication.
Staff G
Aware of findings related to Resident #1's injury.
BB
Notified of incident and Resident #1's fractured clavicle.
DD
Spoke with Resident #1 after incident; Resident #1 reported pain and inability to move arm.
EE
Provided information about Resident #2's injury, pain management, and decline after incident.
The purpose of this visit was to investigate complaint #GA00210354, with the investigation starting on 2021-01-13 and completing on 2021-01-26.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of complaint #GA00210354 was completed with no rule violations cited.
Inspection Report Deficiencies: 2Jul 29, 2020
Visit Reason
The inspection was conducted to assess compliance with community furnishings and safety precautions regulations, focusing on the condition and cleanliness of resident living units and the facility's housekeeping practices.
Findings
The facility failed to provide residents with mattresses that were clean and in good condition, with observed stains and lack of protective coverings. The interior of the facility, particularly the apartment of Residents #1 and #2, was found to be unsanitary with stains, trash, pills on the floor, and strong urine odors. Housekeeping was inadequate, and staff received warnings and termination related to cleaning failures. Residents with dementia required continuous assistance, and their room conditions posed health and safety risks.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Facility failed to provide each resident with a mattress clean and in good condition; mattresses had brown and yellow stains and lacked protective coverings.
SS= D
Facility failed to keep the interior free of unsanitary or unsafe conditions; apartment had brown substance smeared on walls, trash and pills on floor, and strong urine smell.
SS= D
Report Facts
Date of survey completion: Jul 29, 2020Dates housekeeping denied entry: 4Number of corrective action documentation forms for Staff H: 3Frequency of apartment cleaning by staff: 2
Employees Mentioned
Name
Title
Context
Staff A
Reported mattresses soiled and lacking waterproof covers; commented on room conditions and cleaning efforts
Staff B
Reported strong urine smell in room and cleaning efforts; purchased special cleaning products
Staff C
Received verbal warning for supervision and cleaning failures; described apartment conditions and cleaning schedules
Staff D
Described residents' dementia and care needs; reported room conditions and resident behaviors
Staff E
Reported resident behaviors and apartment cleanliness
Staff F
Described resident behaviors and cleaning efforts; reported apartment layout and cleaning frequency
Staff H
Received written warning, final warning, and termination for failure to meet cleaning responsibilities and non-attendance
AA
Provided interviews regarding resident conditions and apartment cleanliness
The purpose of this visit was to conduct a compliance inspection and to investigate allegation Intake GA00194506.
Findings
The facility failed to staff above the minimum on-site staff ratios to meet the specific residents' ongoing health, safety, and care needs. Specifically, three residents in the memory care unit required two-person assistance during transfer, but only two staff worked each shift, causing delays of 30 to 45 minutes in care.
Complaint Details
The visit was complaint-related, investigating allegation Intake GA00194506. It was substantiated that staffing was insufficient to meet residents' needs, causing delays in assistance.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to staff above the minimum on-site staff ratios to meet the specific residents' ongoing health, safety and care needs in the memory care unit.
SS= D
Report Facts
Residents requiring two-person assistance: 3Staff per shift: 2Resident census in memory care unit: 9Wait time for assistance: 30