Inspection Reports for Gateway Gardens Assisted Living and Memory Care
138 GATEWAY LANE, BETHLEHEM, GA, 30620.0
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 22, 2025, found no deficiencies. Earlier inspections showed a mixed record, with some citations related to nutrition, staffing, medication management, and reporting serious incidents. Prior reports noted issues such as failure to provide well-balanced meals, insufficient staff time to prevent avoidable injury, and incomplete medication management and training for memory care staff. Complaint investigations since 2023 were unsubstantiated, while earlier substantiated complaints included a resident fall resulting in death and failures in nutrition and incident reporting. The facility’s recent inspection history suggests improvement, with no deficiencies cited in the last several complaint investigations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 22, 2025
Visit Reason
The purpose of this survey was to investigate complaint numbers #GA50002724 and #GA50002855.
Complaint Details
Investigation was completed on 5/22/25 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002210 and to conduct a compliance inspection.
Complaint Details
Investigation of intake #GA50002210; no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001218.
Complaint Details
Investigation of intake #GA50001218 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 28, 2025
Visit Reason
The purpose of this survey was to investigate complaint #GA00251714 during an onsite visit on 1/28/25.
Complaint Details
Investigation of complaint #GA00251714 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2024
Visit Reason
The purpose of this visit was to investigate complaint intake numbers GA00248674, GA00248306, and GA00248842.
Complaint Details
Investigation of complaint intake numbers GA00248674, GA00248306, and GA00248842 with no violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 10, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00232672, with the investigation starting on 2023-03-09 and completed on 2023-03-10.
Complaint Details
Investigation was complaint-related under complaint #GA00232672, started on 3/9/2023 and completed on 3/10/2023.
Findings
The facility failed to provide a minimum of three regularly scheduled well-balanced meals per day, seven days a week, meeting the nutritional needs for 4 of 6 sampled residents. Observations and interviews indicated insufficient fruits and vegetables and that diabetic residents were served the same meals as others.
Deficiencies (1)
Failed to provide a minimum of three regularly scheduled well-balanced meals per day seven days a week which meet the nutritional needs for 4 of 6 sampled residents.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 16, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00229345, with the investigation starting on 12/13/2022 and completing on 12/16/2022.
Complaint Details
Investigation of complaint #GA00229345 found no rule violations.
Findings
No rule violations were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 19, 2021
Visit Reason
The purpose of this visit was to investigate complaints #GA00218358 and GA00218603. The onsite visit occurred on 11/19/2021 and was completed on 12/16/2021.
Complaint Details
The investigation was complaint-driven based on complaints #GA00218358 and GA00218603. The complaint was substantiated as the facility failed in multiple areas including staffing, nutrition, and reporting serious incidents.
Findings
The facility failed to provide sufficient staff time to protect residents from avoidable injury, failed to ensure meals met nutritional requirements for some residents, and failed to report a serious incident involving a resident's fall and injury to the Department. Resident #7 suffered an unwitnessed fall resulting in a broken neck and subsequent death.
Deficiencies (3)
Failed to provide sufficient staff time to ensure protection from avoidable injury for 1 of 7 sampled residents (Resident #7).
Failed to ensure meals met general nutritional requirements adjusted for age, sex, and activity for 3 of 7 sampled residents (Residents #3, #4, and #5).
Failed to report to the Department the abuse of any serious incident requiring medical attention for 1 of 7 sampled residents (Resident #7).
Report Facts
Sampled residents: 7
Residents with injury due to staffing deficiency: 1
Residents with nutritional deficiencies: 3
Incident date: Sep 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Failed to conduct rounds during shift and was unaware of Resident #7's fall; reprimanded | |
| Staff B | Found Resident #7 after fall, took vitals, called 911 and family | |
| Staff A | Called after Resident #7's fall, aware of findings, acknowledged failure to report incident | |
| AA | Interviewed, stated Resident #7 broke neck and passed away | |
| BB | Interviewed, stated diabetics received same meals as non-diabetics and no dietician on staff |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Aug 23, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaints GA00215776, GA00216359, and GA00216986, starting on 2021-08-04 and completed on 2021-08-23.
Complaint Details
The inspection was conducted in response to complaints GA00215776, GA00216359, and GA00216986.
Findings
The facility failed to provide required staff training in memory care, failed medication management and documentation, failed to supervise residents consistent with their needs, failed to provide sufficient staff assistance with daily hygiene, failed to provide protective and watchful oversight, failed to provide therapeutic diets as ordered, and failed to timely procure medications for residents.
Deficiencies (12)
Failure to provide specialized training in positive therapeutic interventions and activities for memory care staff.
Failure to enforce policies and procedures for medication management, including multiple medication administrations beyond prescribed frequency.
Failure to ensure staff had current certification in emergency first aid and CPR within required timeframes.
Failure to supervise residents consistent with their needs, including delayed response to call alerts.
Failure to provide sufficient staff time to assist residents with daily hygiene, including bathing and oral care.
Failure to provide protective and watchful oversight to meet residents' needs, including delayed physician notification after resident ingested perfume.
Failure to provide required initial staff training topics within six months of employment for memory care staff.
Failure to provide medication administration services in accordance with physician orders and resident needs, including over-administration of Oxycodone to Resident #7.
Failure to maintain accurate Medication Administration Records (MAR) matching controlled drug records (CDR) for Resident #7.
Failure to ensure physician orders specifying clear instructions for medication use were on file before administration, including administration of discontinued medications to Resident #2.
Failure to timely procure medications and supplies, resulting in missed or delayed medication administration for Residents #1, #3, and #7.
Failure to provide therapeutic diets as ordered by healthcare providers for residents requiring special diets, including Resident #3 not receiving diabetic diet.
Report Facts
Staff sampled: 14
Resident sampled: 11
Medication administrations: 5
Medication administration discrepancies: 12
Call alert response times: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Acknowledged findings related to training, medication management, supervision, and diet. | |
| Staff B | Named in deficiencies for lack of training, expired certifications, and medication administration. | |
| Staff D | Named in deficiencies for lack of training, medication administration errors, and interview statements. | |
| Staff F | Named in deficiencies for lack of training. | |
| Staff G | Named in deficiencies for lack of training. | |
| Staff I | Named in deficiencies for lack of training and medication administration. | |
| Staff C | Named in medication administration and interview regarding discontinued medications. | |
| Staff K | Named in medication administration records. | |
| Staff J | Named in medication administration records. | |
| Staff H | Named in medication administration records. | |
| Staff L | Named in medication administration records. | |
| Staff M | Named in medication administration records. | |
| BB | Interviewed regarding medication administration errors and MAR updates. | |
| AA | Interviewed regarding diabetic test strips availability. | |
| CC | Interviewed regarding diabetic test strips availability. |
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 7, 2020
Visit Reason
The purpose of this review is to monitor COVID-19 Cases and assess infection control process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00200430.
Complaint Details
Investigation of intake #GA00200430 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Original Licensing
Deficiencies: 1
Date: Aug 9, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection of the facility.
Findings
The facility failed to ensure that staff had completed the required 16 hours of continuing education units (CEUs) annually, as evidenced by one of six sampled staff lacking CEUs for 2018.
Deficiencies (1)
Facility failed to ensure staff had 16 hours of continuing education units (CEUs) for 1 of 6 sampled staff (Staff F).
Report Facts
Continuing education hours required: 16
Sampled staff count: 6
Staff F hire date: May 1, 2017
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