Inspection Reports for Country Gardens Duluth
3450 DULUTH PARK LANE, DULUTH, GA, 30096
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 24, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to staff health screenings, documentation such as resident files and medication records, pest control, and adherence to policies including refunds and background checks. Several complaint investigations substantiated issues with medication administration records, staff training, resident care documentation, and failure to report incidents properly. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with recent inspections citing fewer deficiencies and several complaint investigations resulting in no violations.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
29 residents
Based on a May 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
The purpose of this visit was to conduct a complaint inspection (GA50005436).
Complaint Details
Complaint inspection conducted with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 18, 2025
Visit Reason
The purpose of this survey was to investigate intake #GA0000087, #GA00252926 and #GA50000647. The onsite visit was made on 3/18/25 to investigate complaints.
Complaint Details
Investigation was conducted based on intake complaints #GA0000087, #GA00252926, and #GA50000647. The investigation was completed on 3/18/25.
Findings
The facility failed to maintain an effective insect, rodent, or pest control program, as evidenced by observed roaches and resident reports of bed bugs. Additionally, the facility failed to maintain an individual resident file for one of five sampled residents.
Deficiencies (2)
Failure to maintain an insect, rodent or pest control program protecting resident health, evidenced by roaches observed and resident reports of bed bugs.
Failure to maintain an individual resident file for each resident, with one resident file missing and unavailable upon request.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A was interviewed regarding pest control program and resident file availability but no full name was provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00250743.
Complaint Details
Investigation of intake #GA00250743 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 25, 2024
Visit Reason
The purpose of this visit was to investigate intake numbers GA00250715, GA00250547, GA00250525, and GA00249993 and conduct a compliance inspection.
Complaint Details
The visit was complaint-related, investigating multiple intake numbers (GA00250715, GA00250547, GA00250525, GA00249993).
Findings
The facility failed to ensure that residents had a physical examination by a licensed provider dated within 30 days prior to admission and that the physical examination form was completed in its entirety, including tuberculosis screening results, for 2 of 4 sampled residents. Additionally, the facility failed to maintain a complete Medication Assistance Record (MAR) for one resident, missing healthcare provider contact information, side effects summary, and proper documentation of medication administration.
Deficiencies (2)
Failure to ensure residents had a physical examination dated within 30 days prior to admission and complete tuberculosis screening results for 2 of 4 sampled residents (Resident #1 and Resident #3).
Failure to maintain a Medication Assistance Record (MAR) including resident's healthcare provider name and telephone number, summary of side effects and adverse reactions, and proper documentation of medication administration for 1 of 4 sampled residents (Resident #1).
Report Facts
Sampled residents: 4
Residents with missing tuberculosis screening: 2
Medication administration dates: 9
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 4, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00249322 and #GA00249490 through an unannounced onsite visit made on 9/4/2024, with the investigation completed on 9/12/2024.
Complaint Details
Investigation was initiated based on complaint intakes #GA00249322 and #GA00249490. The complaint was substantiated as the facility did not follow refund policy for Resident #4.
Findings
The facility failed to follow its refund policy for discharged residents, specifically failing to issue a refund to Resident #4 who was discharged on 10/3/2022. Staff interviews and record reviews confirmed the facility refused to issue a refund after two years of discharge, contrary to their stated policy.
Deficiencies (1)
Facility failed to follow refund policy by not issuing a refund to Resident #4 after discharge.
Report Facts
Discharge date: Oct 3, 2022
Admission date: Oct 7, 2022
Refund policy timeframe: 60
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 9, 2024
Visit Reason
The purpose of this survey was to investigate complaint #GA00247498. The onsite visit occurred on 7/9/2024, with the survey completed on 7/31/2024.
Complaint Details
Investigation of complaint #GA00247498 found that Staff B, hired on 2/28/23, did not have a criminal background check in the file and was a convicted felon.
Findings
The facility failed to ensure that a criminal background check was obtained prior to employment for 1 of 2 sampled staff (Staff B), who was a convicted felon and had no criminal background check in the file.
Deficiencies (1)
Facility failed to obtain a satisfactory criminal background check for Staff B prior to employment.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 16, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00245564.
Complaint Details
Investigation of intake# GA00245564 with no rule violations cited.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242843. An on-site visit was made to the facility on 1/30/24. The investigation started on 1/29/24 and was completed on 1/31/24.
Complaint Details
Investigation of intake #GA00242843 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 29, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241089 with an on-site visit conducted on 11/29/23.
Complaint Details
Investigation of intake #GA00241089 found no rule violations.
Findings
The investigation was completed on 11/30/23 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Oct 19, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239478 and conduct a compliance inspection at Country Gardens Duluth.
Complaint Details
The visit was complaint-related, investigating intake #GA00239478. The complaint was substantiated as multiple deficiencies were found.
Findings
The facility failed to display the permit conspicuously, did not ensure staff received required first aid and CPR training within 60 days of employment, lacked tuberculosis screening and physical examinations for staff within 12 months prior to employment, failed to display the most recent inspection report and plan of correction, and did not document mandatory fire drills as required.
Deficiencies (6)
Facility failed to display the permit in a conspicuous place visible to residents and visitors.
Facility failed to ensure work-related training including current certification in emergency first aid for 2 of 4 sampled staff.
Facility failed to ensure current certification in cardiopulmonary resuscitation (CPR) with competency demonstration for 2 of 4 staff.
Facility failed to ensure tuberculosis screening and physical examination within 12 months prior to employment for 4 of 4 sampled staff.
Facility failed to display the most recent inspection report (2/3/23) and plan of correction.
Facility failed to document mandatory fire drills to ensure safe evacuation within 13 minutes and minimum one fire drill per month covering all shifts.
Report Facts
Sampled staff: 4
Staff without first aid training: 2
Staff without CPR training: 3
Staff without TB screening and physical exam: 4
Non-ambulatory residents allowed: 3
Fire drills missing: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff who was unaware of missing permit, training, and fire drill documentation | |
| Staff B | Staff lacking CPR training and TB screening/physical exam | |
| Staff C | Staff lacking first aid training, CPR training, and TB screening/physical exam | |
| Staff D | Staff lacking first aid training, CPR training, and TB screening/physical exam |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 3, 2023
Visit Reason
The purpose of this visit was to investigate intake numbers GA00231218, GA00231226, GA00231246, and GA00231677. An onsite visit was made on 2023-01-31 and the investigation was completed on 2023-02-03.
Complaint Details
The investigation was complaint-related, triggered by intake numbers GA00231218, GA00231226, GA00231246, and GA00231677. The complaint involved a possible sexual assault of Resident #1 and failure of the facility to notify responsible parties and report the incident to the Department.
Findings
The facility failed to notify the responsible party of specific adverse circumstances related to a sexual assault incident involving Resident #1 and also failed to report the serious incident to the Department. Multiple staff members confirmed they did not report the incident as required.
Deficiencies (2)
Facility failed to notify the responsible party of specific adverse circumstances of an incident for 1 of 3 sampled residents (Resident #1).
Facility failed to report to the Department a serious incident involving a resident for 1 of 3 sampled residents (Resident #1).
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00228733 and #GA00230167. An onsite visit was made on 12/20/22 and the investigation was completed on 12/22/22.
Complaint Details
Investigation was conducted related to intake #GA00228733 and #GA00230167.
Findings
The facility failed to maintain a personnel file for one of four sampled staff (Staff D), the new administrator, whose file was not available for inspection within one hour of request.
Deficiencies (1)
Facility failed to maintain a personnel file for Staff D available for inspection within one hour of request.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | new administrator | Personnel file not maintained and unavailable for inspection. |
| Staff A | Interviewed and stated Staff D was the new administrator and that the file was not available. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 12, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00227188. An on-site visit was made to the facility on 10/12/22, with the investigation starting on 10/11/22 and completed on 10/31/22.
Complaint Details
The investigation was initiated due to intake #GA00227188. Resident #5 reported mistreatment by staff including inappropriate touching and refusal of care. Staff H was suspended and an investigation was started. The incident was not reported to the Department and no incident report was placed in Resident #5's file. Resident #5 did not have a care plan. The facility failed to investigate and document the allegation of abuse properly.
Findings
The facility failed to maintain employee files for 3 of 8 sampled staff, failed to ensure staff wore visible identification badges, failed to keep floors and ceilings clean and in good repair, failed to sanitize the kitchen daily, failed to present the facility as clean and orderly, and failed to ensure residents were treated with dignity and respect, specifically Resident #5 who experienced mistreatment and lack of proper incident reporting and care planning.
Deficiencies (7)
Facility failed to ensure each employee maintained a file in the facility or made available for inspection for 3 of 8 sampled staff (Staff D, Staff G, and Staff H).
Facility failed to ensure staff wear employee identification badges that were readily visible for 2 of 8 sampled staff (Staff A and Staff C).
Facility failed to keep floors and ceilings clean and in good repair; stained carpets and ceilings, ripped and torn carpets near bathroom entrance.
Facility failed to sanitize the kitchen daily and more often as needed to ensure cleanliness and sanitation; buildup of grease and food particles on oven, cooktop, and heated storage cabinet.
Facility failed to present as clean and orderly; urine smell in bedrooms, overflowing garbage cans with soiled briefs, personal items and dead roach in shower stall.
Facility failed to ensure each resident was treated with dignity, kindness, consideration, and respect for Resident #5; incident of mistreatment by staff, lack of incident report and care plan.
Facility failed to take appropriate actions to address needs of Resident #5 during a sudden adverse change in condition and failed to retain a record of such change.
Report Facts
Number of sampled staff without files: 3
Number of sampled staff without visible ID badges: 2
Number of residents with stained or damaged carpets: 6
Number of residents sampled: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding missing staff files, ordering ID badges, facility repairs, and Resident #5 incident | |
| Staff H | Named in mistreatment incident involving Resident #5; suspended and investigated | |
| Staff G | Missing file and responsible for kitchen cleaning | |
| Staff C | Did not wear employee identification badge | |
| Staff I | Housekeeper | Interviewed about cleaning duties and schedule |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 14, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00225127. An on-site visit was made to the facility on 7/14/22. The investigation started on 7/5/22 and was completed on 7/21/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00225127. The investigation included review of records, observations, and interviews related to employee health screenings, staff identification, cleanliness, care plans, medication administration, resident living space cleanliness, and adequacy of care for a diabetic resident.
Findings
The facility failed to ensure employees received tuberculosis screening and physical exams prior to employment, failed to ensure staff wore visible identification badges, failed to maintain clean floors and orderly environment, failed to have written care plans for sampled residents, failed to update Medication Assistance Records for medications given or offered, failed to clean residents' private living spaces periodically, and failed to ensure adequate care and services for a resident with diabetes including proper blood sugar monitoring and insulin administration documentation.
Deficiencies (8)
Facility failed to ensure each employee received tuberculosis screening and physical examination within 12 months prior to employment for 2 of 4 sampled staff.
Facility failed to ensure staff wore employee identification badges that were readily visible for 3 of 4 sampled staff.
Facility failed to keep floors clean and in good repair; bedroom carpets stained and floors contained food particles.
Facility failed to present as clean and orderly; urine odors, soiled laundry, and overflowing garbage observed.
Facility failed to have a written care plan for 3 of 3 sampled residents.
Facility staff failed to update Medication Assistance Record each time medication was given or offered for 4 of 4 sampled residents.
Facility failed to ensure residents' private living spaces were cleaned periodically and as needed for 3 of 4 residents sampled.
Facility failed to ensure each resident received adequate care and services including proper blood sugar monitoring and insulin administration documentation for 1 of 4 sampled residents.
Report Facts
Deficiencies cited: 8
Dates of medication non-administration: 20
Resident count sampled: 4
Staff count sampled: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A, Staff B, Staff F, Staff I, Staff J, Staff G, Staff H mentioned in relation to findings and interviews but no full names provided. |
Inspection Report
Deficiencies: 2
Date: Feb 25, 2022
Visit Reason
The purpose of this visit was to conduct a CHOW inspection, which started on 2022-01-20, included an onsite visit on 2022-01-26, and was completed on 2022-02-25.
Findings
The facility failed to ensure that employees had required tuberculosis screenings and physical examinations within twelve months prior to employment for 2 of 4 sampled staff. Additionally, the facility lacked a Disaster Preparedness Plan as required by state regulations.
Deficiencies (2)
Failure to ensure tuberculosis screening and physical examination for Staff C and Staff D within twelve months prior to employment.
Failure to have a Disaster Preparedness Plan meeting state requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed and stated that Staff C and Staff D did not have physical examinations. | |
| Staff A | Interviewed and stated that he/she did not complete a Disaster Preparedness Plan. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 2, 2021
Visit Reason
The purpose of this visit was to investigate complaints #GA00211607, #GA00212029, and #GA00212075, with the investigation starting on 2021-02-17 and completed on 2021-06-02.
Complaint Details
The visit was complaint-related, investigating complaints #GA00211607, #GA00212029, and #GA00212075. The investigation was conducted from 2021-02-17 to 2021-06-02.
Findings
The facility failed to maintain cleanliness of floors and walls, with feces observed on bathroom walls and floors. Additionally, personal assistance was not adequately provided to residents unable to keep themselves clean, including soiled bed sheets. The facility also failed to update care plans annually or more frequently when residents' needs changed, as evidenced by records for three residents.
Deficiencies (3)
Floors and walls were not kept clean, with feces observed on walls and toilets in residents' bathrooms.
Failure to provide personal assistance to residents unable to keep themselves neat and clean, including soiled bed sheets.
Care plans were not updated at least annually or more frequently when residents' needs changed.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 5
Date: May 17, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00213089.
Complaint Details
The visit was complaint-related, investigating intake #GA00213089. The complaint involved incidents where residents were found outside the facility unattended, including Resident #4 who was found lying on the ground in the parking lot and sustained a skin tear, and Resident #1 who was found outside but was not reported as an elopement.
Findings
The facility failed to obtain a satisfactory fingerprint records check for a director prior to employment, failed to provide adequate staffing and supervision leading to a resident being found outside the facility unattended, failed to ensure adequate care and services for a resident who eloped and sustained injury, and failed to report a serious incident to the Department within 24 hours.
Deficiencies (5)
Failed to obtain a satisfactory fingerprint records check for the person considered for employment as a director prior to employment.
Failed to provide staffing to meet residents' health, safety, and care needs, resulting in a resident found outside the facility unattended.
Failed to provide supervision consistent with residents' needs, resulting in a resident eloping outside the facility.
Failed to ensure each resident received adequate and appropriate care and services, resulting in a resident found outside, injured, and in pain.
Failed to report a serious incident involving a resident to the Department within 24 hours using the complaint intake system.
Report Facts
Facility census: 29
Incident date: Mar 21, 2021
Skin tear size: 2
Staffing ratio: 2
Residents requiring assistance: 3
Wheelchair bound residents: 7
Residents requiring assistance with self-preservation: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director | Failed fingerprint records check prior to employment. |
| Staff A | Interviewed regarding fingerprint check and incident notifications. | |
| Staff E | On duty during incident, passed medications, reported short staffing. | |
| Staff F | On duty during incident, assisted with resident rounds, unaware resident left facility. | |
| AA | Unknown citizen who found Resident #4 outside and assisted back to facility. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00202613.
Complaint Details
Investigation of intake #GA00202613 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 6, 2020
Visit Reason
The purpose of this review was to monitor COVID-19 cases and assess infection control processes.
Findings
The report focused on monitoring COVID-19 cases and evaluating the facility's infection control procedures.
Inspection Report
Complaint Investigation
Census: 3
Deficiencies: 1
Date: Apr 9, 2019
Visit Reason
The visit was conducted to investigate complaint intakes #GA00193448 and #GA00193440, with two onsite visits made on 2018-12-27 and 2019-01-25, and the investigation completed on 2019-03-12.
Complaint Details
Investigation of complaint intakes #GA00193448 and #GA00193440 with substantiation implied by findings.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was offered to or taken by Resident #4, as evidenced by empty MAR cells from 10/20/18 to 10/25/18 for Lorazepam 0.5 mg at 8:00 a.m. and 8:00 p.m. A staff member was unaware of this issue during interview.
Deficiencies (1)
Failure to update the Medication Assistance Record (MAR) each time medication was offered to or taken by a resident.
Report Facts
Residents present during inspection: 3
Dates with empty MAR cells: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B interviewed regarding unawareness of MAR not being updated |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 24, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 3/2/18 annual inspection and to investigate self-reported incident # GA00189914. An onsite visit was made on 7/24/18 and the investigation was completed on 8/24/18.
Complaint Details
Investigation of self-reported incident # GA00189914 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 24, 2018
Visit Reason
The purpose of this visit was to investigate self reported incident # GA00189914 and to conduct a follow-up inspection to the 3/2/18 annual inspection.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Annual Inspection
Census: 66
Capacity: 76
Deficiencies: 14
Date: Mar 1, 2018
Visit Reason
The purpose of this visit was to conduct an annual inspection with on-site visits made on 3/1/18 and 3/2/18.
Findings
The facility was found deficient in multiple areas including failure to return the permit after ownership change, inadequate safety and security precautions, incomplete staff training and background checks, incomplete resident assessments, medication administration errors, food safety violations, and incomplete resident file documentation.
Deficiencies (14)
Facility failed to return the permit to the Department when the ownership and governing body changed.
Facility failed to ensure safety and security precautions to protect residents from harm by unauthorized individuals entering through an unlocked employee entrance door with a non-working alarm system.
Facility failed to ensure all staff involved with personal services received at least sixteen hours of training per year for 2 of 4 sampled staff.
Facility failed to obtain a criminal background check from previous state of employment for 1 of 4 sampled staff.
Facility failed to maintain evidence of trainings for 2 of 4 sampled staff in personnel files.
Facility failed to secure documentation of good standing by nursing board for 1 of 4 sampled staff.
Facility failed to ensure physical examination forms were completed in entirety for 2 of 5 sampled residents.
Facility failed to complete resident needs assessments at admission and update as changes occur for 3 of 5 sampled residents.
Facility failed to utilize appropriate safety devices to protect residents at risk of eloping; employee exit door latch was not fully closed and alarm system was not working.
Facility failed to update the medication assistance record (MAR) each time medication was offered or taken for 1 of 5 sampled residents.
Facility failed to obtain timely refill of prescribed medication for 1 of 5 sampled residents.
Facility failed to ensure all foods prepared and served were protected from spoilage and contamination; food was uncovered and placed next to an open garbage container, and food preparer was not wearing a hairnet.
Facility failed to keep an inventory of all personal items brought to the home by 1 of 5 sampled residents.
Facility failed to maintain a copy of the National Sex Offender Registry search results for 1 of 5 sampled residents.
Report Facts
Current census: 66
Total capacity: 76
Number of sampled staff: 4
Number of sampled residents: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding permit, safety issues, staff training, and resident assessments | |
| Staff B | Sampled staff with missing training, background check, and nursing board documentation; observed preparing medications | |
| Staff C | Sampled staff with missing training documentation; interviewed about medication refill and MAR errors | |
| Staff D | Observed assisting residents in dining room | |
| AA | Observed preparing food without hairnet and food safety violations |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 15, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The facility failed to ensure it retained only ambulatory residents capable of self-preservation with minimal assistance, as evidenced by two residents who required total assistance with ambulation and transferring.
Deficiencies (1)
The home admitted and retained residents who were not ambulatory and required total assistance with ambulation and transferring.
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