Inspection Reports for Gaines Park Senior Living
1740 OLD HIGHWAY 41, KENNESAW, GA, 30152
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 1, 2025, identified deficiencies related to missing monthly documented fire drills for several months and unsecured medication storage in a resident’s room. Earlier inspections showed a pattern of issues including staffing shortages, missed medication doses, delayed response to call lights, and lapses in fire safety and emergency procedures. Complaint investigations substantiated concerns about nurse staffing and medication administration interruptions, while some complaints were found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows recurring challenges in safety drills, medication management, and staffing, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Re-Inspection
Deficiencies: 2
Date: Oct 1, 2025
Visit Reason
The purpose of this visit was to conduct a re-licensure and complaint inspection. An unannounced on-site visit was made on 10/1/25 and the inspection was completed on 10/10/25.
Complaint Details
The inspection included a complaint investigation (GA50005804) as part of the re-licensure process.
Findings
The facility failed to ensure monthly documented fire drills covering all shifts for the months of January, February, March, April, May, and September 2025. Additionally, the facility failed to maintain accountability for medication storage, with unsecured medications found in a resident's room.
Deficiencies (2)
Failure to ensure monthly documented fire drills covering all shifts as required.
Failure to ensure accountability for medication storage, with unsecured medications found in a resident's room.
Report Facts
Months without documented fire drills: 6
Residents with medication storage issue: 1
Residents reviewed for medication storage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fire drill documentation and medication storage issues |
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 1
Date: Jan 10, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00242013 and #GA00242032.
Complaint Details
Investigation was conducted based on complaint intakes #GA00242013 and #GA00242032. The complaint was substantiated as the facility did not have the required professional nurse coverage.
Findings
The facility failed to provide one registered professional nurse or licensed practical nurse on-site at all times for a minimum of 8 hours per week for memory care with 1 to 12 residents. During the tour on 1/10/24, no professional nurse was on-site, and interviews confirmed the facility did not meet the required staffing hours.
Deficiencies (1)
Failed to provide one registered professional nurse or licensed practical nurse on-site at all times for a minimum of 8 hours per week for memory care with 1 to 12 residents.
Report Facts
Memory care residents: 8
Required nurse hours per week: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00231723, GA00231599, GA00230848 and GA00229978.
Complaint Details
Investigation of multiple intakes as listed; no violations found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 21, 2022
Visit Reason
The visit was conducted to investigate complaint intakes #GA00227015, #GA00227574, and #GA00227607, with an onsite visit on 2022-09-21 and investigation completion on 2022-10-06.
Complaint Details
The investigation was complaint-driven based on intake numbers #GA00227015, #GA00227574, and #GA00227607. The complaint was substantiated with findings of medication administration interruptions and delayed call light responses.
Findings
The facility failed to ensure no interruption in routine medication dosing for Resident #1 and failed to provide adequate and appropriate care and services for Residents #1 and #4, including delayed response times to call lights ranging from 16 to 61 minutes.
Deficiencies (2)
Failure to ensure no interruption of routine dosing of medication for Resident #1, specifically missed doses of Carvedilol 6.25 mg tablets on multiple dates in August 2022.
Failure to ensure adequate and appropriate care and services for Residents #1 and #4, including delayed response times to call lights with longest delays up to 61 minutes.
Report Facts
Missed medication days: 4
Call light response time (minutes): 16
Call light response time (minutes): 61
Call light response time (minutes): 41
Call light response time (minutes): 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Stated he/she did not administer medication and that call light response may have been made but staff may have forgotten to reset call button. | |
| Staff E | Provided information about hospice responsibility for medication refills and pharmacy changes. | |
| AA | Reported Resident #1 missed 4 days of medication and delays in call light responses. | |
| DD | Reported slow response to pendent calls, especially early morning and at night. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2021
Visit Reason
The purpose of this inspection was to investigate intake GA00212573 and conduct the compliance inspection.
Complaint Details
Investigation began on 3/29/21 and was completed on 3/31/21. No deficiencies were found.
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 is to monitor COVID 19 cases and assess infection control processes.
Findings
The report focuses on monitoring COVID-19 cases and assessing the facility's infection control processes.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 11, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 4/30/19 compliance inspection and complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 18, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00195903, with an on-site visit made on 4/18/19 and inspection completed on 4/30/19.
Complaint Details
The inspection was triggered by intake #GA00195903 to investigate complaints regarding compliance with criminal background checks, fire safety drills, admission criteria, and emergency procedures.
Findings
The facility failed to obtain satisfactory criminal records checks for 3 of 9 sampled staff, did not conduct required fire drills after 9/20/18, admitted and retained a non-ambulatory resident unable to self-preserve, and failed to initiate cardiopulmonary resuscitation (CPR) immediately for a resident experiencing respiratory arrest.
Deficiencies (4)
Failed to obtain a satisfactory criminal records check prior to employment for 3 of 9 sampled staff (Staff B, Staff D, Staff E).
Failed to ensure compliance with fire and safety rules requiring fire drills every other month; no documented fire drills after 9/20/18.
Admitted and retained a resident (Resident #5) who was not ambulatory and unable to self-preserve with minimal assistance.
Failed to immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who experienced respiratory arrest and was a full code.
Report Facts
Sampled staff: 9
Staff with missing CRC: 3
Fire drills documented: 5
Sampled residents: 6
Resident #5 bed-bound since: 15
Incident report date: Apr 3, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiency for failure to obtain satisfactory criminal records check | |
| Staff D | Named in deficiency for failure to obtain satisfactory criminal records check | |
| Staff E | Named in deficiency for failure to obtain satisfactory criminal records check and involved in Resident #1 incident | |
| Staff H | Interviewed regarding use of third party company for criminal records checks | |
| Staff G | Interviewed regarding missing November 2018 fire drills | |
| Staff F | Interviewed regarding Resident #5 being bed-bound and requiring assistance | |
| Staff A | Interviewed regarding Resident #1 health decline and hospice discussion | |
| Staff I | Interviewed regarding notification of Resident #1 family and calling 911 | |
| BB | Interviewed regarding observations of Resident #1 condition |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 06/16/17 annual inspection and complaint investigation GA 00176073.
Complaint Details
Follow-up to complaint investigation GA 00176073; no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 16, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection and to investigate complaint #GA00176073.
Complaint Details
Investigation included complaint #GA00176073 related to Resident #1 eloping from the facility on 06/08/17.
Findings
The facility failed to ensure that one resident received adequate and appropriate care, as evidenced by the resident eloping from the facility on 06/08/17 after unlocking a side door. The incident involved delayed notification and intervention, with the resident being found and returned by a stranger.
Deficiencies (1)
Facility failed to ensure each resident received care and services which must be adequate, appropriate, and in compliance with applicable federal and state law and regulations for 1 of 9 residents sampled (Resident #1) who eloped from the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding the elopement incident of Resident #1 on 06/08/17. |
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