Inspection Reports for Charter Senior Living at Southern Pines
423 COVINGTON AVENUE, THOMASVILLE, GA, 31792
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 15, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a mixed record with some substantiated deficiencies, including inadequate staffing in July 2024 and issues with resident supervision and safety in August 2025, when a resident eloped due to unsecured exit doors and insufficient oversight. Prior reports also cited concerns about resident dignity and respect in early 2021 and 2021, as well as lapses in infection control and staff background checks in 2020 and 2022. Complaint investigations were mostly unsubstantiated except for the noted cases involving staffing, resident elopement, and mistreatment, with no fines or enforcement actions listed in the available reports. The facility’s recent clean inspection suggests some improvement following earlier issues.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 15, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50006125 and #GA50006225.
Complaint Details
Investigation of intake #GA50006125 and #GA50006225 found no rule violations.
Findings
The investigation was completed on 10/15/25 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 5, 2025
Visit Reason
The purpose of this visit was to conduct a complaint inspection for GA50004378 and GA50004914, triggered by an incident where Resident #1 eloped from the facility.
Complaint Details
The complaint investigation was substantiated based on the incident where Resident #1 eloped from the memory care unit on 06/18/2025 due to unsecured exit doors and lack of staff awareness. Resident #1 was found by a community member and returned by law enforcement uninjured.
Findings
The facility failed to ensure the memory care center was designed with an effective automated alert system for unauthorized exit, resulting in an unsecured outdoor patio door. Resident #1, diagnosed with Lewy Body Dementia, eloped from the facility due to staff not securing the door and inadequate supervision. The resident was found and returned by law enforcement uninjured. The facility lacked a care plan for the resident and failed to provide adequate protective oversight, posing a serious safety risk.
Deficiencies (2)
Failure to ensure memory care center design included an effective automated alert system for unauthorized exit.
Failure to provide adequate, appropriate care and supervision resulting in resident elopement.
Report Facts
Incident date: Jun 18, 2025
Incident time: 1905
Last seen time: 1830
Distance from facility: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged door malfunction due to low battery allowing resident to exit | |
| Staff B | Last saw Resident #1 wandering before elopement and was unaware resident was gone until law enforcement returned resident | |
| Staff C | Acknowledged not closing the outdoor patio door completely after exercising with residents | |
| Staff D | Acknowledged outdoor memory care area was not secured |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 7, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004187 through an unannounced visit made on 7/7/2025 at 1:21 p.m.
Complaint Details
Investigation of intake #GA50004187 found no rule violations.
Findings
No rule violations were cited as a result of this investigation completed on 7/9/2025.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
The purpose of this visit was to conduct a complaint inspection GA50002958. The inspection started on 2025-06-02 and was completed on 2025-06-17, with an on-site visit on 2025-06-12.
Complaint Details
Complaint inspection GA50002958 was conducted; no substantiation status is provided.
Findings
The document is a statement of deficiencies and plan of correction related to the complaint inspection. Specific findings or deficiencies are not detailed in the provided text.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001777 and #GA50001796.
Complaint Details
Investigation of intake #GA50001777 and #GA50001796 completed with no rule violations.
Findings
The investigation was completed on 3/24/25 with no rule violations found as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
The purpose of this visit on 3/3/25 was to investigate complaint #GA50001490.
Complaint Details
Investigation of complaint #GA50001490 completed with no rule violations cited.
Findings
The investigation was completed on 3/6/25 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249151.
Complaint Details
Investigation was unannounced and conducted from 2024-08-19 to 2024-08-21. No violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 22, 2024
Visit Reason
The visit was conducted to investigate intake #GA00248377. An unannounced visit was made on 7/22/2024 at 2:00 p.m. and the investigation was completed on 7/25/2024.
Complaint Details
Investigation was initiated due to intake #GA00248377. The complaint was substantiated as rule violations were cited related to inadequate staffing.
Findings
The facility failed to provide adequate staffing to meet the specific health, safety, and care needs of residents. Staffing shortages were documented with caregivers and medication technicians frequently working double shifts or covering multiple buildings, resulting in inadequate coverage during various shifts.
Deficiencies (1)
Facility failed to provide adequate staffing to meet residents' health, safety, and care needs for 2 sampled residents.
Report Facts
Residents in gardens during night shift: 29
Resident assistance (RA) staff scheduled: 2
Medication technicians scheduled: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 25, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intakes #GA00247512, GA00247545, and GA00247643.
Complaint Details
Investigation of intakes #GA00247512, GA00247545, and GA00247643 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 20, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00246538. An unannounced visit was made on 5/20/2024 at 9:30 a.m. and the investigation was completed on 5/21/2024.
Complaint Details
Investigation of intake #GA00246538 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 6, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00246065 and #GA00245705.
Complaint Details
Investigation of intakes #GA00246065 and #GA00245705 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243192. An unannounced visit was made on 3/4/2024 and the investigation was completed on 3/6/2024.
Complaint Details
Investigation of intake #GA00243192 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00242161, #GA00241824, and #GA00241687.
Complaint Details
Investigation was completed on 2/5/24 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 3, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00236933 and conduct the compliance inspection.
Complaint Details
Investigation of intake GA00236933; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
The purpose of this visit on 3/9/23 was to conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 10, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00226209.
Complaint Details
Investigation of intake #GA00226209 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 6, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00218892.
Complaint Details
Investigation of intake #GA00218892 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 16, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00218892.
Complaint Details
Investigation started on 2021-11-15 and was completed on 2021-11-16. No rule violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 29, 2021
Visit Reason
The purpose of this investigation was to investigate complaint intakes #GA00217483 and #GA00217577 with an on-site visit made to the facility on 09/29/2021.
Complaint Details
Investigation was based on complaints filed by paramedics regarding Staff B's conduct of spraying Resident #1 with Lysol disinfectant prior to entry. Resident #1 could not recall the incident. Staff B was hired on 5/19/21 and was immediately terminated following the investigation.
Findings
The facility failed to ensure that a resident was treated with dignity and given privacy during personal care, as staff sprayed Resident #1 with Lysol disinfectant from head to toe before allowing entry. Staff B was terminated and all staff were re-trained on residents' rights.
Deficiencies (1)
Facility failed to ensure each resident was treated with dignity, kindness, consideration and respect and given privacy in the provision of personal care; specifically, Staff B sprayed Resident #1 with Lysol disinfectant from head to toe before permitting entry.
Report Facts
Complaint intake numbers: 2
Date of incident: Sep 5, 2021
Staff B hire date: May 19, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiency for spraying Resident #1 with Lysol and subsequently terminated | |
| Staff A | Interviewed during on-site visit; reported Staff B was terminated and staff re-trained |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
The purpose of this inspection was to investigate intake # GA00214813. The investigation began on 2021-06-14 and was completed on 2021-06-24 at 3:00 p.m.
Complaint Details
Investigation of intake # GA00214813 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 25, 2021
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate complaints #GA00214159, #GA00214410, and #GA00213513. The investigation began on 2021-05-17 and was completed on 2021-05-25.
Complaint Details
Investigation of complaints #GA00214159, #GA00214410, and #GA00213513 resulted in no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00212104.
Complaint Details
Investigation of intake #GA00212104 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 5, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00211211, which started on 2021-01-25 and was completed on 2021-02-05.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00211211. The complaint involved mistreatment of Resident #1 by Staff B, substantiated by video evidence. Staff B was terminated for mis-handling and ill treatment. The family requested Resident #1 not be interviewed due to potential upset and memory issues.
Findings
The facility failed to ensure that Resident #1 was treated with dignity and respect, as evidenced by Staff B's mistreatment captured on video. Additionally, the facility failed to report a serious incident involving Resident #1 to the Department within 24 hours.
Deficiencies (3)
Facility failed to ensure each resident was treated with dignity, kindness, and respect, including Staff B's verbal abuse and mishandling of Resident #1.
Facility failed to ensure residents received adequate and appropriate care in compliance with federal and state law.
Facility failed to report a serious incident involving Resident #1 to the Department within 24 hours.
Report Facts
Residents involved: 1
Staff involved: 1
Incident date: Dec 11, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in mistreatment and termination for resident abuse | |
| Staff A | Interviewed regarding the incident and video evidence |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 4, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00204734. The investigation began on 5/4/20 and was completed on 6/10/20.
Complaint Details
Investigation of complaint #GA00204734 conducted from 5/4/20 to 6/10/20.
Findings
The facility failed to enforce policies and procedures to support resident health and safety, specifically failing to take residents' temperatures twice daily as required. The infection control program was ineffective due to lack of documented staff training on updated policies. Additionally, the facility failed to ensure required criminal background checks for direct care staff hired after October 1, 2019.
Deficiencies (3)
Administrator failed to ensure policies and procedures were enforced to support health and safety of residents, including failure to take temperatures twice daily for 2 of 4 sampled residents.
Facility failed to have an effective infection control program including lack of documented staff training on updated infection control policy.
Facility failed to ensure direct care staff hired after October 1, 2019 had required criminal background checks upon employment or prior to placement for 2 of 5 sampled staff.
Report Facts
Number of sampled residents with temperature recording issues: 2
Number of sampled staff without required criminal background checks: 2
Number of sampled residents reviewed for temperature records: 4
Number of sampled staff reviewed for background checks: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding temperature recording and background check deficiencies | |
| Staff D | Interviewed regarding infection control training and background check deficiencies | |
| Staff I | Direct care staff without required criminal background check | |
| Staff J | Direct care staff without required criminal background check and no documented infection control training |
Inspection Report
Monitoring
Deficiencies: 0
Date: 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 the facility's infection control processes.
Inspection Report
Deficiencies: 0
Date: Mar 31, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Charter Senior Living at Southern Pines, indicating a regulatory inspection was conducted.
Findings
The report includes opening comments but does not provide specific details on deficiencies or findings within the visible content.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 11, 2020
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00202503.
Complaint Details
Investigation of intake #GA00202503 regarding missing fingerprint records check determinations for Staff D and Staff F.
Findings
The facility failed to ensure that direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 2 of 5 sampled staff (Staff D and Staff F).
Deficiencies (1)
Failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement for 2 of 5 sampled staff (Staff D and Staff F).
Report Facts
Number of sampled staff missing fingerprint checks: 2
Number of sampled staff reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiency for missing fingerprint records check. | |
| Staff F | Named in deficiency for missing fingerprint records check. | |
| Staff A | Interviewed and stated files for Staff D and Staff F did not contain fingerprint check determinations. |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 26, 2019
Visit Reason
The purpose of this visit was to conduct an inspection to increase the facility's capacity.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 4, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00194219.
Complaint Details
Complaint #GA00194219 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Capacity: 102
Deficiencies: 1
Date: Jan 15, 2019
Visit Reason
The purpose of this visit was to complete an initial inspection and to investigate complaint # GA 00193045.
Complaint Details
Investigation of complaint # GA 00193045 was part of the visit.
Findings
The facility was found to be serving more residents than its approved licensed capacity, with a census of 110 residents exceeding the licensed capacity of 102.
Deficiencies (1)
The home was serving more residents than its approved licensed capacity.
Report Facts
Current census: 110
Licensed capacity: 102
Requested capacity increase: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding census and capacity |
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