Inspection Report
Routine
Deficiencies: 0
Sep 17, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were cited as a result of this inspection and investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2024
Visit Reason
The purpose of this visit was to conduct a complaint investigation that began on 2024-11-03 and ended on 2024-11-05.
Findings
There were no rule violations as a result of this investigation.
Complaint Details
The complaint investigation was conducted from 2024-11-03 to 2024-11-05 and found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00250841 and #GA00250471.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was completed on 10/29/2024 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 23, 2024
Visit Reason
The purpose of this visit was to investigate complaint #GA00244619 and conduct a compliance inspection at At Ease Personal Care Home.
Findings
The facility failed to comply with fire and safety rules, including inadequate fire drills and poor cleanliness and maintenance of floors. Additionally, the facility lacked physician orders for medications for one resident and improperly restricted visitation rights for another resident.
Complaint Details
The complaint investigation was triggered by complaint #GA00244619. The facility was found to have denied visitation access to Resident #3's visitor, which was substantiated by interviews and records showing refusal of visits until police involvement.
Severity Breakdown
D: 3
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure compliance with fire and safety rules; only four fire drills completed in 2023 with none during sleeping hours. | D |
| Facility failed to keep floors clean and in good repair; food crumbs and dirt observed on floors and baseboards. | E |
| Facility failed to have physician's orders for medications for 1 of 5 residents (Resident #2). | D |
| Facility denied visitation access to Resident #3's visitor contrary to residents' rights. | D |
Report Facts
Fire drills completed: 4
Residents reviewed for medication orders: 5
Resident #2 blood sugar level: 95
Resident #2 insulin administration threshold: 135
Resident #3 admission date: Mar 8, 2023
Resident #3 move out date: Mar 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fire drills, cleaning practices, medication administration, and visitation denial. | |
| AA | Visitor denied access to Resident #3; provided interview about visitation denial and police involvement. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Jun 28, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235680, which started on 2023-06-26. An on-site visit was made on 2023-06-28 and the investigation was completed on 2023-07-13.
Findings
The facility was found deficient in multiple areas including failure to ensure tuberculosis screening and physical exams for employees prior to employment, floor covering issues, unclean cooking appliances and walls, inadequate sanitation of bathrooms, improper storage of solid waste, failure to maintain mechanical cooling devices to keep resident areas below 85 degrees Fahrenheit, and lack of hand-sanitizing agents and supplies in bathrooms. Additionally, the facility failed to ensure required criminal background checks for direct access employees.
Complaint Details
Investigation of intake #GA00235680 initiated on 2023-06-26, with on-site visit on 2023-06-28 and completed on 2023-07-13.
Severity Breakdown
D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure each employee had tuberculosis screening and physical exam prior to employment. | D |
| Floor covering was detached and cracked, not securely fastened. | D |
| Cooking appliances were not maintained in an efficient condition and were unclean. | D |
| Walls and floors were not kept clean, including scratches, chipped paint, debris, and stains. | D |
| Failed to sanitize bathroom daily and as needed to ensure cleanliness. | D |
| Solid waste was not stored in vermin-proof, leak-proof containers with close-fitting covers and was not removed daily. | D |
| Failed to ensure mechanical cooling devices were available to maintain resident areas below 85 degrees Fahrenheit. | D |
| Failed to provide hand-sanitizing agents or soap and water, clean towels, and toilet tissue at each commode. | D |
| Failed to ensure direct access employee had required records check application and criminal background check prior to employment. | D |
Report Facts
Temperature: 82
Temperature range: 88.9
Staff hired date: Jul 25, 2022
Staff hired date: Jun 28, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed multiple times regarding deficiencies including TB screening, facility repairs, temperature awareness, and background checks. | |
| Staff B | Interviewed regarding lack of sanitizing items in bathroom. | |
| Staff C | Employee hired 7/25/22 with no tuberculosis screening documentation. | |
| Staff D | Employee hired 6/28/23 with no criminal background check documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2023
Visit Reason
The purpose of this administrative review is to investigate intake #GA00231578.
Findings
No rule violations were cited during this investigation.
Complaint Details
Investigation of intake #GA00231578 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 5, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00222836, which began on 2022-04-13 and was completed on 2022-05-05.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00222836 was conducted with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 16, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00217197 with an on-site visit made to the facility from 2021-09-13 to 2021-09-16.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00217197; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2021
Visit Reason
The purpose of this inspection was to investigate intake GA00215604 and conduct the compliance inspection.
Findings
An onsite visit was made to the facility on 7/20/21. No specific findings or deficiencies are detailed in the provided report.
Complaint Details
Investigation of intake GA00215604.
Inspection Report
Follow-Up
Deficiencies: 1
Jan 7, 2020
Visit Reason
The purpose of this visit was to conduct a follow-up to the 1/17/19 inspection.
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 1 of 2 staff reviewed.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 1 of 2 staff (Staff B). | D |
Report Facts
Staff reviewed: 2
Staff with missing background check: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Direct care staff hired 2/12/19 without required criminal background check | |
| Staff A | Interviewed staff who did not complete the required criminal background check on Staff B |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 2, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 5/23/19 compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 4
May 23, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection of the facility.
Findings
The facility failed to complete required fire and disaster drills for 2018, did not ensure that 2 of 4 sampled staff had at least 16 hours of training per year, failed to obtain required physical examinations for 2 of 5 sampled residents within 30 days prior to admission, and did not provide evidence of routine evaluations of continued skills competencies for 2 of 4 staff.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to complete the required fire and disaster drills for 2018 to present. | D |
| Facility failed to ensure that 2 of 4 sampled staff had at least 16 hours of training per year. | D |
| Facility failed to ensure residents received physical examinations within 30 days prior to admission for 2 of 5 sampled residents. | D |
| Facility failed to provide evidence of routine evaluations of continued skills competencies for 2 of 4 staff. | D |
Report Facts
Sampled staff: 4
Sampled residents: 5
Staff not meeting training requirements: 2
Residents without required physical exam: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to fire and disaster drills, training hours, physical exam documentation, and proxy caregiver training | |
| Staff D | Named in findings related to training hours and proxy caregiver training |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 17, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 9/24/18 inspection.
Findings
The facility failed to have work performance reviews, such as skills competency checklists, for one unlicensed staff member who performed medication administration. The staff member had not completed the required medication training, and this deficiency was previously cited on 9/24/18.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to have work performance reviews, including skills competency checklists, for unlicensed staff performing medication administration. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Unlicensed staff who performed specialized tasks of medication administration and had not completed medication training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 24, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00191551 and #GA00191392.
Findings
The facility failed to keep medications in original containers with original labels intact for 1 of 3 sampled residents and failed to have annual medication competency skills checklists for 3 of 3 unlicensed staff who performed medication administration tasks.
Complaint Details
The visit was complaint-related to complaints #GA00191551 and #GA00191392.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to keep medications in original containers with original labels intact for 1 of 3 sampled residents. | D |
| Facility failed to have annual medication competency skills checklists for 3 of 3 unlicensed staff who performed medication administration. | D |
Report Facts
Sampled residents: 3
Unlicensed staff: 3
Medication skill competency expiration date: Jul 4, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in medication container labeling deficiency and medication competency skills checklist deficiency | |
| Staff B | Named in medication competency skills checklist deficiency | |
| Staff C | Named in medication competency skills checklist deficiency |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 24, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the complaint investigation of #GA 00184756 on 2/14/18.
Findings
No rule violations were cited during this follow-up inspection.
Complaint Details
Follow-up to complaint investigation #GA 00184756; no rule violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 9, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/19/18 inspection.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Annual Inspection
Census: 6
Deficiencies: 1
Mar 28, 2018
Visit Reason
An on-site visit was made to the facility on 3/28/18 to conduct the annual inspection and investigate a self-reported incident #GA00186628.
Findings
The facility failed to ensure that policies and procedures were effective to support the health and safety of residents, as evidenced by one resident who was found on the floor after lying there most of the night without assistance.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure that policies and procedures were effective to support the health and safety of residents, specifically Resident #1 who was found on the floor after lying there most of the night without assistance. | Level D |
Report Facts
Residents present: 6
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 14, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184756 regarding a resident who was missing from the facility.
Findings
The facility failed to ensure adequate care and services as Resident #1 was missing from the facility for an extended period, missing meals and medications. Additionally, the facility failed to report the initiation and discontinuation of a Mattie's Call to the Department within the required 30-minute timeframe.
Complaint Details
The investigation was triggered by complaint #GA00184756 concerning Resident #1 who was missing from the facility from 1/27/18 until returning on 1/29/18. The facility did not notify the Department within 30 minutes of initiating a Mattie's Call as required.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate and appropriate care and services, evidenced by Resident #1 being missing and missing medications. | SS= D |
| Failure to report the initiation and discontinuation of a Mattie's Call to the Department within 30 minutes of communication with law enforcement. | SS= D |
Report Facts
Incident report dates: Jan 27, 2018
Resident return date: Jan 29, 2018
Notification time delay: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #1's absence and notification failures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 18, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00182940.
Findings
The facility failed to ensure that each resident received adequate and appropriate care in compliance with applicable laws, as evidenced by an incident where Resident #1 fell and was unable to get up due to non-functioning call bells.
Complaint Details
Complaint #GA00182940 was investigated; the complaint was substantiated based on the findings related to Resident #1's fall and inadequate response due to non-working call bells.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate, appropriate care in compliance with laws; Resident #1 fell and was unable to get up due to call bells not working. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A was on duty the day of the incident and reported the call bells were not working. | ||
| Resident #2 found Resident #1 on the floor and called 911. |
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