Deficiencies per Year
12
9
6
3
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 75
Capacity: 81
Deficiencies: 2
Sep 16, 2025
Visit Reason
The inspection was a follow-up visit to verify the implementation of a previously submitted plan of correction related to medication administration issues.
Findings
The submitted plan of correction was determined to be fully implemented, with ongoing audits and reeducation of staff on medication administration policies. Continued compliance must be maintained.
Deficiencies (2)
| Description |
|---|
| Resident was scheduled to receive medication at 22:00, but the medication was not administered as ordered despite documentation indicating it was given. |
| The home failed to follow the prescriber's orders by not administering the prescribed 22:00 dose of medication to a resident. |
Report Facts
License Capacity: 81
Residents Served: 75
Residents Served in Secured Dementia Care Unit: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 75
Residents with Intellectual Disability: 1
Residents with Mobility Need: 27
Inspection Report
Complaint Investigation
Census: 74
Capacity: 81
Deficiencies: 0
May 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation at Dunwoody Village on 05/22/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Report Facts
Residents Served: 74
License Capacity: 81
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 18
Hospice Current Residents: 7
Residents Age 60 or Older: 73
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 29
Inspection Report
Follow-Up
Census: 70
Capacity: 81
Deficiencies: 2
Dec 16, 2024
Visit Reason
The visit was a partial, unannounced follow-up inspection conducted on 12/16/2024 to review the implementation of a previously submitted plan of correction related to an incident.
Findings
The submitted plan of correction was determined to be fully implemented. The facility contested one violation regarding access to video evidence, clarifying that the video was not a resident record and was provided through a third party. Another violation involved abuse by a staff member, which was not substantiated by video evidence, but the employee was terminated following an internal investigation. The facility implemented training and monitoring measures to prevent abuse and ensure compliance.
Deficiencies (2)
| Description |
|---|
| Failure to provide immediate access to video recording of an incident to Department agents, citing confidentiality and internal investigation. |
| Allegation of abuse where staff person B was observed slapping a resident's hand and making inappropriate comments; video evidence did not substantiate the allegation but staff person B was terminated. |
Report Facts
License Capacity: 81
Residents Served: 70
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 3
Residents Age 60 or Older: 69
Residents Diagnosed with Mental Illness: 6
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Inspection Report
Follow-Up
Census: 72
Capacity: 81
Deficiencies: 5
Nov 21, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the submitted plan of correction related to multiple deficiencies including resident abuse reporting, treatment of residents with dignity and respect, residents' rights to associate and communicate, and proper medication storage and administration.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the Area Agency on Aging as required. |
| Staff communicated to a resident in a harsh, loud, and disrespectful tone violating treatment with dignity and respect. |
| Resident's right to freely associate and communicate was compromised when staff made a spouse leave the room during personal care. |
| Medication packaging was taped due to tear, not stored according to manufacturer’s instructions. |
| Pain medication was not available in the home due to incomplete medication orders. |
Report Facts
License Capacity: 81
Residents Served: 72
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 30
Residents with Physical Disability: 1
Residents Age 60 or Older: 71
Total Daily Staff: 102
Waking Staff: 77
Inspection Report
Follow-Up
Census: 69
Capacity: 81
Deficiencies: 7
Oct 9, 2024
Visit Reason
The inspection visit on 10/09/2024 was conducted as a follow-up to verify that the previously submitted plan of correction was fully implemented.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple violations including failure to report suspected abuse, incomplete resident contracts, treatment of residents with dignity and respect, incomplete staff contact lists, incomplete fire safety orientation, and delayed admission support plans.
Deficiencies (7)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident, with a repeat violation noted. |
| Failure to report the incident or condition to the Department within 24 hours, with a repeat violation noted. |
| Resident home contracts were not signed by the resident, with no indication the resident was given the opportunity to sign. |
| Resident was not treated with dignity and respect; staff person B was mean and pressured resident to take medication. |
| Administrator's list of staff persons did not include substitute staff. |
| Staff person C did not receive orientation on telephone use and notification of emergency services on first day. |
| Resident admitted to Secure Dementia Care Unit had initial support plan completed late. |
Report Facts
Residents Served: 69
License Capacity: 81
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 16
Hospice Current Residents: 4
Residents Age 60 or Older: 69
Residents with Mobility Need: 22
Residents Diagnosed with Intellectual Disability: 1
Inspection Report
Follow-Up
Census: 70
Capacity: 81
Deficiencies: 9
Aug 5, 2024
Visit Reason
The inspection visit was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident.
Findings
The facility was found to have fully implemented the submitted plan of correction addressing multiple deficiencies including supervision of staff after abuse allegations, privacy concerns with camera signage, safeguarding residents' money and property, staff training deficiencies, medical evaluation documentation, support plan signatures, key-locking device signage, trash management, and resident record content.
Deficiencies (9)
| Description |
|---|
| Failure to develop and implement a plan of supervision or suspend staff person involved in alleged abuse incident. |
| Lack of signage indicating cameras were recording in certain areas. |
| No system to safeguard residents' money and property, resulting in theft of credit cards. |
| Direct care staff did not complete required orientation and annual training topics within required timeframes. |
| Incomplete medical evaluation documentation missing special health or dietary needs. |
| Support plans were developed without signatures from residents and assessors. |
| Directions for operating key-locking devices were not conspicuously posted near exits. |
| Trash outside the home was not kept in covered receptacles preventing insect and rodent penetration. |
| Resident records did not include an inventory of personal property as voluntarily declared and updated. |
Report Facts
Residents Served: 70
License Capacity: 81
Capacity: 20
Residents Served: 16
Current Residents: 3
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Follow-Up
Census: 69
Capacity: 81
Deficiencies: 2
Apr 11, 2024
Visit Reason
The inspection was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following an incident and annual medical evaluation deficiencies.
Findings
The facility was found to have fully implemented the plan of correction related to an incident reporting violation and annual medical evaluation requirements. Continued compliance must be maintained.
Deficiencies (2)
| Description |
|---|
| Failure to report an incident involving alleged rough handling of a resident by staff to the Department within 24 hours. |
| Resident did not have a medical evaluation completed at least annually as required. |
Report Facts
License Capacity: 81
Residents Served: 69
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 15
Residents 60 Years or Older: 68
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 11
Inspection Report
Renewal
Census: 66
Capacity: 81
Deficiencies: 12
Feb 14, 2024
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations and verify the implementation of the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident abuse, improper treatment of residents, missing criminal background checks for contractors, ventilation issues, incomplete medical evaluations, medication storage and labeling problems, prohibited procedures, incomplete support plans, and missing resident record content. Plans of correction were accepted and implemented with ongoing monitoring and education.
Deficiencies (12)
| Description |
|---|
| Failure to immediately report suspected abuse of resident #1 to the Personal Care Administrator, Nursing Director, and Older Adult Protective Services. |
| Resident #1 was wearing multiple incontinence products simultaneously, violating dignity and respect requirements. |
| Criminal background checks were not on file for two painters and one contractor working unattended in the facility. |
| Rooms #17a and 114 lacked operable windows, fans, air conditioners, or mechanical ventilation to ensure airflow. |
| Medical evaluations for resident #1 and resident #2 did not include medical information pertinent to diagnosis and treatment. |
| Resident #2 had an unlocked container of prescription artificial tears in their room despite not being assessed as capable of self-administering medications. |
| Expired artificial tears belonging to resident #2 were not destroyed according to approved methods. |
| Pharmacy label for resident #1's medication lacked resident name, medication name, prescription date, administration instructions, and prescriber information. |
| Resident #3's prescribed medications were not available in the home. |
| A magnetic ribbon reading 'Stop Do Not Enter Stop' was placed on resident's door, posing a deterrent to leaving or entering the room. |
| Support plans for residents #4, #5, and #6 did not document the need for special diets as indicated in their assessments. |
| Resident #2 and #3's records were missing eye color, hair color, and social security number. |
Report Facts
Residents Served: 66
License Capacity: 81
Residents Served in Secured Dementia Care Unit: 16
Capacity of Secured Dementia Care Unit: 20
Current Hospice Residents: 4
Residents Diagnosed with Mental Illness: 51
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 22
Residents with Physical Disability: 22
Residents Age 60 or Older: 65
Inspection Report
Follow-Up
Census: 65
Capacity: 81
Deficiencies: 4
Mar 2, 2023
Visit Reason
The inspection visit was conducted as a follow-up to verify that the submitted plan of correction was fully implemented following a prior incident.
Findings
The submitted plan of correction was determined to be fully implemented, including supervision plans for staff involved in abuse allegations, updated resident assessment and support plans, and staff education on resident dignity and respect.
Deficiencies (4)
| Description |
|---|
| Failure to submit a plan of supervision for a staff person prior to return to work after an allegation of verbal abuse. |
| Resident #1 did not receive required assistance with activities of daily living as indicated in the resident’s assessment and support plan. |
| A resident was spoken to in a harsh and loud tone by a worker, lacking respect and dignity. |
| Resident #1's support plan was not revised to reflect changes in hearing ability and use of assistive devices. |
Report Facts
License Capacity: 81
Residents Served: 65
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 1
Residents Age 60 or Older: 64
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 15
Residents with Physical Disability: 0
Inspection Report
Follow-Up
Census: 70
Capacity: 81
Deficiencies: 1
Jan 12, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have fully implemented the plan of correction related to a privacy violation involving a staff member posting protected health information on social media. The violation was self-reported and addressed with staff education and policy reinforcement.
Deficiencies (1)
| Description |
|---|
| A staff member posted a video on a personal social media account containing a resident's last name and cause of death, violating HIPAA privacy rules. |
Report Facts
License Capacity: 81
Residents Served: 70
Memory Unit Capacity: 20
Residents Served in Memory Unit: 17
Total Daily Staff: 87
Waking Staff: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| PCA | Involved in staff education regarding social media and privacy rights | |
| Director | Involved in staff education regarding social media and privacy rights | |
| Director of Nursing | Involved in staff education regarding social media and privacy rights | |
| Director of Healthcare Services | Involved in staff education regarding social media and privacy rights | |
| Employee Development Educator | Responsible for education of new staff on social media and privacy | |
| Compliance Coordinator | Responsible for ongoing compliance education and policy review | |
| Recreation Dept. Director | Reviewed policies with staff and discussed social media violation |
Inspection Report
Follow-Up
Census: 72
Capacity: 81
Deficiencies: 4
Nov 28, 2022
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to an incident and other compliance issues at Dunwoody Village.
Findings
The submitted plan of correction was determined to be fully implemented. Deficiencies included failure to report an incident timely, verbal abuse by staff, lack of sensitivity training for staff, and improper medication administration training. Corrective actions and staff education were completed as required.
Deficiencies (4)
| Description |
|---|
| Failure to report an incident of a resident found unresponsive to the Department within 24 hours. |
| Staff made an insulting statement to a resident, constituting verbal abuse. |
| Staff training plan did not include sensitivity training when caring for older adults. |
| Certified nursing assistants were administering lotions and creams without Department-approved medication administration training. |
Report Facts
License Capacity: 81
Residents Served: 72
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 3
Total Daily Staff: 89
Waking Staff: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norm Vetter | Personal Care Administrator | Named in relation to providing training and corrective actions for incident reporting and staff education. |
| Diane Host | Staff Educator | Named in relation to providing education about verbal abuse and dignity in resident care. |
Inspection Report
Follow-Up
Census: 74
Capacity: 81
Deficiencies: 6
Oct 3, 2022
Visit Reason
The inspection visit was an unannounced partial inspection conducted due to an incident at the facility, with a follow-up on the plan of correction submission.
Findings
The report details multiple violations related to resident abuse, supervision, treatment of residents, and administrator duties. Plans of correction were submitted and accepted, with education and supervision measures implemented to address the deficiencies.
Deficiencies (6)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident and comply with reporting requirements. |
| Failure to develop or suspend a plan of supervision for staff involved in an alleged abuse incident. |
| Failure to submit a plan of supervision or suspension notice for the affected staff person to the Department. |
| Resident was not treated with dignity and respect; staff failed to properly assist resident to the bathroom, resulting in risk of fall and verbal abuse. |
| Staff person admitted to not knowing that the Act 70 form needed to be sent to Adult Protective Services; staff person A remained on schedule during investigation. |
| Resident's record did not include the reportable incident involving resident 1 and staff person A. |
Report Facts
Residents Served: 74
License Capacity: 81
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 3
Residents Age 60 or Older: 73
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 0
Total Daily Staff: 92
Waking Staff: 69
Inspection Report
Renewal
Census: 74
Capacity: 81
Deficiencies: 5
Sep 27, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license to ensure continued compliance with applicable regulations.
Findings
The inspection found several deficiencies related to fire safety system inspections, emergency telephone postings, medication storage, medical evaluations, and record keeping. All deficiencies had plans of correction submitted and were determined to be fully implemented by the follow-up date.
Deficiencies (5)
| Description |
|---|
| The ANSUL fire extinguisher/suppression system in kitchen area of Cedars East and Cedars West had not been inspected by a qualified person since 7/2020. |
| No emergency telephone numbers including nearest hospital and fire department were posted by the telephone in the Cedars West dining area. |
| A bottle of medication was found unlocked, unattended, and accessible in a resident's bedroom. |
| Resident #1's medical evaluation was not completed within 60 days prior to admission to the secured dementia care unit. |
| Correction fluid was used on resident #2's document of medical evaluation. |
Report Facts
License Capacity: 81
Residents Served: 74
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 17
Hospice Residents: 1
Residents 60 Years or Older: 74
Residents Diagnosed with Mental Illness: 2
Residents Diagnosed with Intellectual Disability: 2
Residents with Mobility Need: 18
Residents with Physical Disability: 0
Total Daily Staff: 92
Waking Staff: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Administrator | Named in relation to findings and corrective actions for medication storage, fire system inspection, and medical evaluation compliance | |
| SMCU Nurse Manager | Involved in ensuring medical evaluations are completed prior to resident move-in | |
| Social Worker | Involved in ensuring medical evaluations are completed prior to resident move-in |
Inspection Report
Census: 79
Capacity: 81
Deficiencies: 2
Jul 13, 2022
Visit Reason
The inspection was an unannounced partial inspection conducted due to an incident.
Findings
The submitted plan of correction was fully implemented and accepted. The report details procedural errors in medical evaluation and support plan documentation that were corrected with education and audits to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Resident 1's medical evaluation did not include weight, pulse rate, blood pressure, and temperature; procedural errors were corrected with education and audits. |
| The resident's support plan did not list psychological diagnoses; audits and education were implemented to ensure completeness. |
Report Facts
License Capacity: 81
Residents Served: 79
Secured Dementia Care Unit Capacity: 20
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 1
Residents Diagnosed with Mental Illness: 30
Residents Diagnosed with Intellectual Disability: 1
Residents Age 60 or Older: 78
Residents with Mobility Need: 20
Residents with Physical Disability: 0
Total Daily Staff: 99
Waking Staff: 74
Notice
Capacity: 81
Deficiencies: 0
Sep 14, 2021
Visit Reason
This document serves as a renewal notification and license issuance for Dunwoody Village Personal Care Home, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document; it is an administrative notice confirming license renewal and outlining future inspection requirements.
Report Facts
Maximum licensed capacity: 81
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Norman Vetter | Personal Care Administrator | Named as legal entity representative on the renewal application. |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Renewal
Census: 68
Capacity: 81
Deficiencies: 6
Aug 30, 2021
Visit Reason
The inspection was a renewal visit conducted on 08/30/2021 and 08/31/2021 to review compliance with licensing requirements for Dunwoody Village, a personal care home.
Findings
The inspection found multiple deficiencies including missing fee schedules in resident contracts, an expired elevator certificate, improper refrigerator and freezer temperatures, lack of emergency procedures for inoperable smoke detectors, medication storage issues, and incomplete recording of glucometer readings. Plans of correction were accepted and documented for all deficiencies.
Deficiencies (6)
| Description |
|---|
| Resident-home contracts did not include a fee schedule of actual amounts charged for available services for six residents. |
| Elevator #8 did not have a current certificate of operation; the posted certificate expired on 09/30/18. |
| Freezer temperature was 22°F and refrigerator temperature was 52°F at 10:35 am on 08/31/21, exceeding allowable limits. |
| Home's emergency procedures did not indicate what procedures will be implemented when a smoke detector or fire alarm is inoperable. |
| Half of a white loose pill was found inside the medication cart drawer in the Cedar West Unit on 08/31/21. |
| Multiple glucometer readings were not recorded on residents' medication administration records (MARs). |
Report Facts
License Capacity: 81
Residents Served: 68
Memory Care Capacity: 20
Memory Care Residents Served: 15
Hospice Residents: 4
Residents with Mental Illness: 3
Residents with Intellectual Disability: 2
Residents with Mobility Need: 16
Residents 60 Years or Older: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mia Johnson | Person making recommendations and lead reviewer for document submissions | |
| Evelyn Perez | Lead Inspector | Conducted on-site inspection on 08/30/2021 and 08/31/2021 |
| Norman Vettler | Administrator | Facility administrator addressed in the report |
| Adrianne Stevens | Administrator | Facility administrator listed in licensing inspection summary |
| Wayne Zielke Jr. | Refrigeration repair service technician who repaired freezer and refrigerator units | |
| Assistant Facilities Director | Responsible for elevator operation and inspections, and alarm operations | |
| Dining Services Director | Responsible for refrigerator and freezer operations and monitoring | |
| Unit Nurses | Responsible for checking medication carts and glucometer readings | |
| Unit Director of Nursing | Responsible for monthly medication cart checks and glucometer reading audits | |
| Personal Care Nursing Director | Responsible for overseeing medication storage and glucometer reading accuracy |
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