Inspection Report Summary
The most recent inspection on June 5, 2025, identified deficiencies related to failure to prevent abuse and neglect of one resident, resulting in staff suspension and retraining. Earlier inspections showed a mixed pattern, with prior deficiencies involving medication administration, care adequacy, staffing shortages, and financial exploitation incidents affecting the same resident. Complaint investigations included substantiated cases of abuse, neglect, and financial exploitation, but some investigations found no violations. Enforcement actions included staff termination and suspension, with no fines or license suspensions listed in the available reports. The facility’s inspection history shows ongoing challenges with resident care and abuse prevention, with no clear improvement trend over time.
Deficiencies (last 6 years)
Deficiencies (over 6 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: 1
Jun 5, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50003649 and #GA50003117, with the investigation starting and an onsite visit occurring on 6/5/2025.
Findings
The facility failed to ensure that each resident was free from mental, verbal, sexual, and physical abuse, neglect, and exploitation, specifically for one resident (Resident #1). Staff C was observed being rough and rushing care on 5/14/2025, leading to suspension and retraining.
Complaint Details
Investigation was initiated due to intake #GA50003649 and #GA50003117. The complaint was substantiated by observations and interviews confirming abuse and neglect by Staff C.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents are free from mental, verbal, sexual and physical abuse, neglect and exploitation, including physical restraints and interference with daily living for Resident #1. | SS= D |
Report Facts
Dates of incidents and actions: May 14, 2025
Dates of retraining: May 19, 2025
Dates of retraining: May 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in abuse and neglect finding; suspended and retrained | |
| Staff A | Interviewed regarding Staff C suspension and policy violation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 26, 2025
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA50001264 during an unannounced visit on 2/26/2025.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA50001264; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 8, 2023
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA00240522, with an onsite visit made on 2023-11-28 and inspection completed on 2023-12-08.
Findings
The facility failed to ensure adequate services for one of three sampled residents (Resident #1), specifically related to medication administration where pills were found on the floor and medication was not observed after the resident discharged. Staff interviews revealed in-service training was conducted to address medication administration and prevent dropped pills.
Complaint Details
Investigation of intake #GA00240522 related to medication administration issues for Resident #1, including dropped pills and lack of documentation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate services; medication for Resident #1 was not observed and pills were found on the floor. | SS= D |
Report Facts
Staff trained for medication expectations: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding medication administration training and observations about Resident #1. | |
| Staff A | Interviewed regarding in-service training and medication technician supervision. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 14, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220842.
Findings
No violations were cited as a result of this visit.
Complaint Details
Investigation of intake #GA00220842 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 16, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00221893 and conduct the compliance inspection. The investigation started on 2022-03-07 and was completed on 2022-03-16.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00221893 was conducted with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2021
Visit Reason
The purpose of this inspection was to investigate intake # GA00217493.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began on 2021-02-20 and was completed on 2021-09-23. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jun 3, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00212238.
Findings
The facility failed to ensure that the written admission agreements disclosed medication handling responsibilities for 6 sampled residents. Additionally, the facility failed to obtain timely medication refills for 1 resident, resulting in interruption of routine dosing. This resident developed multiple macerated ulcers and swelling, was hospitalized, and later passed away. The facility also failed to ensure adequate and appropriate care for this resident.
Complaint Details
Investigation of intake #GA00212238 regarding medication handling and care deficiencies for Resident #1, including failure to timely refill Lasix medication leading to health decline and death.
Severity Breakdown
SS=D: 1
SS=J: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Written admission agreements did not disclose how and by what level of staff medications were handled, nor specify responsibility for acquisition and refilling for 6 sampled residents. | SS=D |
| Failed to obtain timely refills to prevent interruption in routine dosing of medications for 1 of 6 sampled residents. | SS=J |
| Failed to ensure each resident received adequate and appropriate care in compliance with applicable laws for 1 of 6 residents. | SS=J |
Report Facts
Number of sampled residents with deficient admission agreements: 6
Duration of missed medication dosing: 57
Number of deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding lack of documentation on admission agreements for medication handling. | |
| HH | Interviewed about last fill date of Lasix medication for Resident #1. | |
| II | Interviewed about medication refill call for Resident #1. | |
| DD | Interviewed about awareness of Resident #1 not taking Lasix and pharmacy change. | |
| Staff B | Interviewed about Resident #1's swelling, open wounds, and health decline. | |
| CC | Interviewed about Resident #1's missed Lasix medication and subsequent hospitalization. | |
| GG | Interviewed about pharmacy change and medication transfer issues for Resident #1. | |
| FF | Interviewed about prescription records for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 2, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207176, which involved allegations of financial theft from Resident #1's bank card.
Findings
The facility failed to ensure the health and safety of Resident #1 by not preventing financial exploitation. Two unauthorized charges totaling $1,095.77 were made on Resident #1's bank card. Despite video footage review, the individual responsible was not identified. The resident appeared confused about the incident and declined to secure valuables in a locked safe. The investigation was ongoing at the time of the report.
Complaint Details
The investigation was initiated due to intake #GA00207176 regarding financial theft involving Resident #1's bank card. The complaint was substantiated with evidence of two unauthorized charges totaling $1,095.77. The resident was confused and unable to provide details. The facility had prior similar incidents and was unable to identify the perpetrator. The investigation was ongoing.
Severity Breakdown
SS=K: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure that policies and procedures were enforced to support the health and safety of residents, resulting in financial theft of Resident #1's bank card. | SS=K |
| Failure to ensure residents were free from mental, verbal, sexual and physical abuse, neglect and exploitation for Resident #1. | SS=K |
Report Facts
Unauthorized charges: 2
Charge amounts: 451.93
Charge amounts: 643.84
Date of incident: Aug 4, 2020
Date investigation started: Aug 20, 2020
Date investigation completed: Sep 2, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided email and interview details regarding the financial theft and video footage review. | |
| Staff B | Med-tech | Interviewed regarding awareness of the theft and job duties. |
| Staff C | Interviewed about resident valuables and facility meetings on Resident's Rights. | |
| Staff D | Reported hearing about the theft and passing medication to Resident #1. | |
| Staff E | Filed police report and interviewed Resident #1 about the incident. | |
| GG | Assigned investigator who reviewed video footage and spoke with Resident #1. | |
| FF | Handled Resident #1's finances, reported fraudulent transactions to the bank, and closed accounts. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 10, 2020
Visit Reason
The purpose of this inspection was to investigate intake # GA00205999, which involved allegations of financial theft and exploitation of Resident #1's bank card.
Findings
The investigation found that the facility failed to ensure the health and safety of residents by not preventing financial exploitation of Resident #1. Five unauthorized $500 ATM cash advances totaling $2,518.15 were made using Resident #1's bank card by Staff D, who was subsequently terminated. The police and Department were notified, and the resident was reimbursed.
Complaint Details
The complaint investigation was substantiated based on record review, staff interviews, and video evidence showing Staff D made unauthorized ATM withdrawals using Resident #1's bank card. Staff D was terminated and law enforcement was involved.
Severity Breakdown
J: 2
Deficiencies (1)
| Description | Severity |
|---|---|
| The administrator failed to ensure that policies and procedures were enforced to support the health and safety of residents, resulting in financial exploitation of Resident #1. | J |
Report Facts
Unauthorized cash advances: 5
Amount reimbursed: 2518.15
Withdrawal fees: 18.15
Distance: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff who reviewed video footage and identified Staff D as responsible for unauthorized withdrawals | |
| Staff D | Employee terminated for unauthorized use of Resident #1's bank card; denied wrongdoing | |
| Staff B | Caregiver interviewed regarding resident belongings and theft awareness | |
| GG | Interviewed individual who received Resident #1's bank statement and reported fraudulent transactions |
Inspection Report
Monitoring
Deficiencies: 0
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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 21, 2019
Visit Reason
The visit was conducted to investigate complaint intakes #GA00200210, #GA00200121, and #GA00200170 through an unannounced visit on 10/21/2019, with the investigation completed on 10/25/2019.
Findings
The facility failed to ensure residents received adequate and appropriate care, as evidenced by delayed response to a call button, insufficient staffing levels, and residents not being prepared for bed or breakfast on time due to staff shortages.
Complaint Details
The investigation was triggered by complaint intakes #GA00200210, #GA00200121, and #GA00200170. Resident #05 and staff interviews confirmed staffing shortages leading to delayed care and missed opportunities for timely assistance with activities of daily living.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received care and services which were adequate, appropriate, and in compliance with applicable federal and state law and regulations, including delayed response to call button and insufficient staffing. | SS= D |
Report Facts
Direct care staff count: 5
Call button response time: 25
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 27, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198794.
Findings
The facility failed to include a statement in the admission agreement that residents and their representatives must be informed in writing at least 30 days prior to any increase in charges related to personal services for 4 of 4 residents reviewed. The admission agreement only provided for 60 days notice for room and board charges, but immediate charges for increased care services were noted.
Complaint Details
Investigation of intake #GA00198794 regarding failure to provide proper written notice of fee increases related to personal services.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to have a statement that residents and their representatives must be informed in writing at least 30 days prior to any increase in charges related to personal services in the admission agreement for 4 of 4 residents. | SS= D |
Report Facts
Fee increase amount: 1500
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reviewed admission agreement and stated intention to discuss with corporate office. | |
| Staff D | Reviewed admission agreement with Staff A. | |
| DD | Resident whose level of care increased and was informed of immediate fee increase. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2019
Visit Reason
The purpose of this visit was to investigate intake GA00197596.
Findings
There were no rule violations cited as a result of this visit.
Complaint Details
Investigation of intake GA00197596 with no rule violations cited.
Inspection Report
Original Licensing
Deficiencies: 0
Mar 15, 2019
Visit Reason
The purpose of the visit was to conduct the initial inspection of the facility.
Findings
There were no rule violations cited as a result of this inspection.
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