Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 17, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005342.
Findings
No deficiencies were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA50005342; no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2025
Visit Reason
The purpose for this visit was to conduct an investigation of complaint #GA50004101.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA50004101 with no violations cited.
Inspection Report
Follow-Up
Census: 40
Deficiencies: 0
Apr 11, 2025
Visit Reason
The purpose of this visit was to complete a follow-up/Revisit inspection related to intake 02209 and to conduct a compliance inspection and investigate intakes #GA00252530, #GA00252569, and #GA00251411.
Findings
Observations on 3/13/25 and 3/21/25 showed adequate staffing and compliance with regulations. No rule violations were cited, and the facility was found to be in compliance with staffing, training, food safety, resident rights, and reporting requirements.
Report Facts
Census: 40
Memory care residents: 14
Assisted living residents: 26
Food service inspection grade: 99
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 9
Dec 10, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate complaint intakes #GA00252530, #GA00252569, and #GA00251411 with onsite visits on 11/12/24 and 11/13/24 and investigation completed on 11/19/24.
Findings
The facility failed to ensure adequate staffing, proper staff training and certifications, and adequate oversight by the governing body. A resident with cognitive impairment eloped and was found deceased offsite. The facility failed to have required staff certifications (fingerprints, first aid, CPR), failed to maintain required staffing levels, failed to post the food safety report, and failed to timely notify law enforcement and the Department of the resident elopement.
Complaint Details
The investigation was triggered by complaint intakes #GA00252530, #GA00252569, and #GA00251411. Resident #1 eloped from the facility during the 11:00 p.m. to 7:00 a.m. shift on 11/8/24 and was found deceased in a lake approximately half a mile from the facility on 11/11/24. The facility failed to provide adequate staffing and supervision, failed to make rounds on Resident #1, and failed to notify law enforcement and the Department timely.
Severity Breakdown
D: 5
E: 3
K: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to obtain fingerprint records check for 5 of 9 sampled staff. | D |
| Governing body failed to provide necessary oversight to ensure health and safety of residents, including inadequate staffing coverage on 11/8/24. | E |
| Failed to ensure staff had first aid training for 5 of 9 sampled staff. | D |
| Failed to ensure staff were trained in CPR for 5 of 9 sampled staff. | D |
| Failed to ensure at least one staff person on each occupied floor during 11/8/24 shift; only two direct caregivers worked, leaving floors unsupervised. | K |
| Memory Care Center failed to have one registered nurse, licensed practical nurse, or certified medication aide on-site at all times on 11/8/24. | E |
| Failed to have food service inspection report posted in the community. | D |
| Failed to provide adequate care and services to Resident #1, who eloped and was found deceased; staff failed to make rounds or check on resident during overnight shift. | K |
| Failed to notify local law enforcement and Department timely of Resident #1 elopement; reported to law enforcement nearly two hours after discovery. | D |
Report Facts
Residents on first or second floor unsupervised: 26
Residents in Memory Care Center: 13
Direct caregivers working 11/8/24 overnight shift: 2
Sampled staff missing fingerprint checks: 5
Sampled staff missing first aid training: 5
Sampled staff missing CPR training: 5
Exit doors from facility: 9
Time delay in reporting missing resident to law enforcement: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed multiple times; stated fingerprint, first aid, and CPR documentation for several staff was not available; unaware of inadequate staffing on 11/8/24; stated keypad system was secure but could not erase previous access codes. | |
| Staff F | Worked alone on ALU during 11/8/24 overnight shift; did not make rounds on Resident #1; stated Resident #1 told him/her not to disturb during night. | |
| Staff K | Worked 7:00 a.m. to 3:00 p.m. shift on 11/9/24; discovered Resident #1 missing from bedroom; notified certified medication aide and manager. | |
| Staff G | Certified Medication Aide | Scheduled to work MCC on 11/8/24 overnight shift but called out without notifying management. |
| Staff N | Unable to locate food service inspection report during kitchen tour on 11/13/24. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA0025018, #GA00250226, and #GA00250878 with an onsite visit made on 10/23/2024.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation was started on 10/23/2024 and completed on 11/05/2024. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 6, 2024
Visit Reason
A visit was made to the facility on 08/06/24 to investigate complaint intakes #GA00248369 and #GA00248905.
Findings
The facility failed to ensure adequate and appropriate care for Resident #3, who was found lying on the floor after tipping a recliner chair and was left without assistance for several minutes. Resident #3 was under hospice care and died the following day. The facility investigated and found no fault with Staff B and Staff C, who returned to work.
Complaint Details
Investigation of complaint intakes #GA00248369 and #GA00248905 regarding Resident #3's fall and lack of timely assistance. Resident #3 was under hospice care with increased supervision needs. The complaint was investigated and staff were found not at fault.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate and appropriate care and supervision to Resident #3, resulting in a fall and delayed assistance. | SS= D |
Report Facts
Complaint intake numbers: 2
Date of fall video: Jul 6, 2024
Date of resident death: Jul 7, 2024
Time without staff assistance: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed in video during Resident #3's fall and delayed assistance | |
| Staff C | Observed in video during Resident #3's fall and delayed assistance | |
| Staff A | Interviewed and stated facility investigation findings | |
| AA | Interviewed regarding Resident #3's hospice care and supervision |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 15, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00246119.
Findings
There were no rule violations cited as a result of this investigation.
Complaint Details
Investigation was completed with no rule violations cited.
Report Facts
Intake number: GA00246119
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 3, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244833 with an onsite visit made to the facility on 4/3/24 and the investigation completed the same day.
Findings
The facility failed to meet multiple staffing and training requirements including insufficient ongoing staff training hours for one staff member, inadequate staffing coverage on each occupied floor, lack of required licensed nursing or certified medication aide presence in the memory care unit, and incomplete initial orientation training for direct care staff.
Complaint Details
The visit was complaint-related, investigating intake #GA00244833. The complaint was substantiated by findings of multiple deficiencies in staffing and training.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure each staff had at least sixteen (16) hours of training per year for 1 of 4 sampled staff (Staff B) who only had 5.75 hours in 2023. | SS= D |
| Facility failed to ensure at least two on-site direct care staff persons were on the premises 24 hours per day providing supervision with at least one staff person on each occupied floor; observed periods when only one staff was present on the assisted living side. | SS= D |
| Facility failed to ensure that at a minimum, the memory care center had one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times; none were present during the tour. | SS= D |
| Facility failed to ensure that each direct care staff received initial orientation training within the first thirty (30) days of caring for residents independently, including required topics; no documentation of first aid and CPR training for 3 of 4 sampled staff (Staff A, Staff C, Staff D). | SS= D |
Report Facts
Training hours: 5.75
Sampled staff: 4
Staff hired dates: Staff A hired 3/1/24, Staff C hired 3/1/24, Staff D hired 2/8/24.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Sampled staff with insufficient training hours. | |
| Staff A | Caregiver | Assigned to Assisted Living and Memory Care units; lacked orientation documentation. |
| Staff D | Med Tech | Assigned to Assisted Living side; lacked orientation documentation. |
| Staff C | Floater staff; lacked orientation documentation. | |
| Staff F | Med Tech | Left Assisted Living side around 10 A.M., causing short staffing. |
| Staff E | Interviewed regarding staffing knowledge and policies. | |
| Staff G | Interviewed; stated lack of knowledge about prior training and not responsible for orientation. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 2
Mar 6, 2024
Visit Reason
The purpose of this visit was to investigate complaint intake numbers GA00243803 and GA00243958 with an onsite visit conducted on 3/6/2024 and investigation completed on 3/20/2024.
Findings
The facility failed to provide sufficient social activities to promote the physical, mental, and social well-being of residents, and failed to provide one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times in the memory care unit.
Complaint Details
Investigation was conducted based on complaint intake numbers GA00243803 and GA00243958. The complaint was substantiated as deficiencies were found related to social activities and staffing requirements.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide sufficient social activities to promote the physical, mental, and social well-being of each resident for 4 of 4 sampled residents. | SS= D |
| Failed to provide one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times for the memory care unit. | SS= D |
Report Facts
Residents census: 46
Memory care residents: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding activity coordinator absence and memory care staffing |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 13, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241467 with an on-site visit conducted on 12/13/2023.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00241467 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 20, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239606 with an onsite visit made on 10/17/23 and inspection completed on 10/20/23.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00239606; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238303.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00238303; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236632. An onsite visit was made to the facility on 7/26/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00236632 was conducted with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2023
Visit Reason
The purpose of this visit was to investigate intake GA0023649.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA0023649 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 20, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00220622.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00220622; no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 16, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00218964. The investigation started on 2022-02-14, with an onsite visit on 2022-02-16, and was completed on 2022-02-28.
Findings
The facility failed to ensure that staff properly supervised or administered medications, resulting in Resident #1 receiving Quetiapine 300 mg (2 tablets) without a physician's order, which led to the resident being transferred to the emergency room for evaluation and treatment.
Complaint Details
Investigation was initiated due to intake #GA00218964. The complaint was substantiated as the facility failed to ensure proper medication administration and supervision, leading to an unprescribed medication being given to Resident #1.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff properly supervised or administered medications, resulting in administration of Quetiapine 300 mg (2 tablets) to Resident #1 without a physician's order. | SS= D |
Report Facts
Medication dosage: 300
Medication tablets: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and confirmed accuracy of incident report | |
| Staff C | Removed from work schedule due to medication error involving Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 1, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217243. The inspection started on 2021-09-23 and completed on 2021-11-01.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00217243 with no rule violations cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 19, 2021
Visit Reason
The purpose of this visit was to conduct an annual inspection and investigate intake #GA00213232.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 24, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00209423.
Findings
There were no rule violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00209423 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 24, 2020
Visit Reason
The inspection was conducted to investigate complaint intakes #GA00206204 and #GA00206371, started on 2020-07-16 and completed on 2020-07-24.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes #GA00206204 and #GA00206371 with no rule violations found.
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 processes.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 7, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00202430 with an on-site visit made on 2/7/20 and inspection completed on 2/13/20.
Findings
The facility failed to ensure that all residents' property and possessions were safeguarded for one of five sampled residents (Resident #5), specifically involving missing Hydrocodone tablets that could not be accounted for, leading to law enforcement notification.
Complaint Details
Investigation of intake #GA00202430 regarding missing Hydrocodone medication for Resident #5. Law enforcement was notified and a police report was filed with Marietta Police Department.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure proper storage and disposal of medications, resulting in missing Hydrocodone tablets for Resident #5. | D |
Report Facts
Missing Hydrocodone tablets: 60
Delivered Hydrocodone tablets: 60
Delivered Hydrocodone tablets: 30
Emergency supply tablets: 20
Emergency supply tablets: 20
Narcotic count: 30
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00201817 with an onsite visit made on 1/23/2020 and the investigation completed on 1/29/2020.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00201817 completed with no rule violations cited.
Inspection Report
Routine
Deficiencies: 0
Nov 15, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
There were no rule violations cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00199500.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint GA00199500 was investigated with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 28, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198809.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00198809 with no violations cited.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Apr 25, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187771 regarding staffing levels at the facility.
Findings
The community failed to maintain the required minimum on-site staff to resident ratio during waking and non-waking hours, resulting in inadequate staffing to meet residents' ongoing health, safety, and care needs. Residents reported long wait times for medication and assistance, and staff interviews confirmed insufficient staffing levels, especially during night shifts.
Complaint Details
Complaint #GA00187771 was investigated and substantiated based on findings of inadequate staffing ratios and resident reports of delayed care.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to staff above the minimum on-site staff to resident ratio to meet residents' ongoing health, safety, and care needs. | SS= D |
Report Facts
Total residents: 55
Staffing counts: 3
Staffing counts: 1
Staffing counts: 2
Staffing counts: 1
Staffing counts: 2
Staffing counts: 1
Staffing counts: 1
Wait times: 2
Wait times: 3
Inspection Report
Annual Inspection
Deficiencies: 1
Jul 19, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
The facility failed to ensure that fire drills were conducted in compliance with fire safety regulations, with documentation showing only one fire drill conducted in 2016. Staff interview confirmed lack of knowledge about prior fire drills before October 2016.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure that fire drills were conducted in compliance with fire safety regulations; only one fire drill documented in 2016. | SS= D |
Report Facts
Fire drills conducted: 1
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