The most recent inspection on July 28, 2025, found no deficiencies. Earlier inspections also generally found no rule violations during complaint investigations, with multiple substantiated complaints occurring several years ago. Past deficiencies primarily involved resident care issues such as inadequate staffing and safety measures to prevent elopement, failure to update care plans after significant changes, and one substantiated case of physical abuse. Enforcement actions, fines, or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent investigations consistently finding no violations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)2.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake ##GA00241585.
Findings
An on-site visit was made on 2023-12-14 and the investigation was completed on 2024-02-29. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake ##GA00241585 found no rule violations.
The purpose of this visit was to investigate intake #GA00224314 regarding a resident elopement incident.
Findings
The facility failed to have enough staff to meet the specific resident's health and safety needs, failed to have effective safety devices to prevent elopement, and failed to ensure adequate care and services for the resident who eloped from the memory care unit on 5/18/22 and was found outside the facility without injury.
Complaint Details
The complaint investigation was triggered by intake #GA00224314 concerning Resident #1 who eloped from the memory care unit on 5/18/22 and was found outside the facility. The investigation included record reviews, staff interviews, and review of alarm system activity.
Severity Breakdown
G: 3
Deficiencies (3)
Description
Severity
Failed to have enough staff to meet the specific resident ongoing health and safety needs for 1 of 1 sampled resident.
G
Failed to have effective safety devices to prevent residents from eloping for 1 of 1 sampled resident.
G
Failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulation for 1 of 1 sampled resident.
G
Report Facts
Resident census: 14Incontinence residents: 13Residents with special diets: 2Diabetic residents: 1Alarm activation time: 15Temperature high: 89Temperature low: 69
Employees Mentioned
Name
Title
Context
Staff A
Confirmed work schedule and investigation details; stated not present during elopement
Staff B
Heard exit door alarm and turned it off; directed head count after alarm
Staff C
On duty during elopement; last saw Resident #1; did not hear alarm
Staff D
On duty during elopement; did not hear alarm; counted residents and found Resident #1 missing
Staff E
Medication Aide
On duty during elopement; last saw Resident #1; did not hear alarm
Staff F
Described alarm system and monthly checks of exit doors
II
Witnessed Resident #1 outside facility and reported to staff
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00217641, which began on 2021-10-06 with an unannounced visit on 2021-10-15 and completed on 2021-10-28.
Findings
The facility failed to ensure staff completed required continuing education, failed to ensure staff wore identification badges, failed to obtain medication refills timely to avoid interruptions, failed to store medications in original containers with proper labeling, and failed to maintain a 3-day emergency food supply.
Complaint Details
Investigation was initiated due to intake #GA00217641, with unannounced visit on 2021-10-15 and completed on 2021-10-28.
Severity Breakdown
SS= D: 6
Deficiencies (6)
Description
Severity
Staff failed to have a minimum of sixteen (16) hours of job-related continuing education for 3 of 7 sampled staff (Staff C and Staff F).
SS= D
Employees failed to wear employee identification badges with credentials for 1 of 7 sampled staff (Staff F).
SS= D
Refills of prescribed medications were not obtained timely, causing interruption in routine dosing for 1 of 9 sampled residents (Resident #9).
SS= D
Medications were not kept in original containers with original labels intact for 1 of 9 sampled residents (Resident #6).
SS= D
Medications were not properly labeled in separate unit or multi-unit dose packaging for 2 of 9 sampled residents (Resident #5 and Resident #7).
SS= D
Facility failed to have a 3-day supply of non-perishable dry or canned foods for emergency use.
The purpose of this visit was to investigate intake #GA002211771. An unannounced visit was made to the facility on 12/24/21. The investigation started on 2/19/21 and was completed on 3/3/21.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA002211771 with no rule violations found.
The purpose of this visit was to investigate complaint intakes #GA00209167, #GA00209390, and #GA00209536 through an unannounced visit to the facility on 11/4/2020, with the investigation completed on 12/8/2020.
Findings
The facility failed to update the care plan more frequently when the needs of Resident #2 changed substantially, specifically after a COVID-19 diagnosis and subsequent decline. Resident #2 suffered a fall on 8/2/2020 resulting in a head injury and was sent to the hospital where the resident later passed away. The service plan lacked fall interventions despite the resident being at average risk for falls.
Complaint Details
The investigation was triggered by complaint intakes #GA00209167, #GA00209390, and #GA00209536. The complaint was substantiated by findings related to failure to update care plans and lack of fall interventions for Resident #2, who was diagnosed with COVID-19 and later passed away following a fall and head injury.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to update the care plan more frequently where the needs of the resident changed substantially or the resident was assigned to a specialized memory care unit for Resident #2.
SS= D
Report Facts
Resident sample size: 6Incident date: Aug 2, 2020Fall assessment score: 17Admission date: Nov 27, 2019
Employees Mentioned
Name
Title
Context
Staff B
Interviewed regarding Resident #2's care plan and condition
Staff H
Interviewed regarding Resident #2's condition after COVID-19 diagnosis
Staff K
Interviewed about Resident #2's condition and fall incident
Staff G
Interviewed about Resident #2's fall and emergency response
Staff A
Interviewed and acknowledged error in not having fall interventions in Resident #2's service plan
The purpose of this visit was to investigate intake #GA00206864, which was started on 2020-08-10 and completed on 2020-08-21.
Findings
The facility failed to ensure that one resident (Resident #1) was free from physical abuse, as evidenced by a police report documenting battery and multiple staff interviews describing rough handling and pulling the resident by his/her belt, resulting in bruises and agitation.
Complaint Details
Investigation of intake #GA00206864 regarding physical abuse of Resident #1. The complaint was substantiated based on police report and staff interviews confirming rough handling and failure to prevent abuse.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure each resident was free from physical abuse for 1 of 3 sampled residents (Resident #1), including dragging the resident by his/her belt causing harm.
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00201881.
Findings
The facility failed to ensure staff completed required continuing education, did not comply with fire safety drill requirements, failed to maintain heated water temperature below 120 degrees Fahrenheit, and did not provide adequate care and services to residents, resulting in multiple elopements from the memory care unit.
Complaint Details
The investigation was initiated due to intake #GA00201881. The complaint involved concerns about staff training, fire safety compliance, water temperature safety, and resident elopements from the memory care unit. The facility was found noncompliant in all these areas.
Severity Breakdown
SS= D: 4
Deficiencies (4)
Description
Severity
Facility failed to ensure staff had 16 hours of continuing education units (CEUs) for 1 of 8 sampled staff (Staff C).
SS= D
Facility failed to comply with applicable fire and safety rules requiring one fire drill per quarter per shift; missing drills on multiple shifts and months.
SS= D
Facility failed to maintain heated water temperature that did not exceed 120 degrees Fahrenheit; observed temperatures of 122.4 and 129.4 degrees F in resident bathrooms.
SS= D
Facility failed to provide adequate care and services to 4 of 6 sampled residents, resulting in multiple elopements from the memory care unit.
SS= D
Report Facts
Number of sampled staff: 8Number of sampled residents: 6Fire drills missing: 5Water temperature observed: 122.4Water temperature observed: 129.4
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding staff training, fire drills, resident elopement, and alarm issues
Staff B
Assigned to Resident #2 on 12/31/19; involved in elopement incident and alarm clearance
Staff C
Staff member lacking required continuing education hours
Staff F
Witnessed water temperature reading and provided information on exit door alarms and resident behavior
Staff G
Witnessed water temperature calibration
Staff H
Stated intention to reset hot water calibration
EE
Stated staffing was increased after Resident #2 elopement
FF
Reported alarm went off on 12/31/19 and was cleared without resident checks
Inspection Report Original LicensingDeficiencies: 0Jul 12, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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