Inspection Report Summary
The most recent inspection on July 30, 2025, found no deficiencies. Earlier inspections showed a pattern of deficiencies related mainly to resident supervision and medication management, including incidents of inadequate oversight leading to a resident being found in a walk-in freezer and medication errors causing missed or incorrect doses. There were also citations for failure to report serious incidents within required timeframes. Complaint investigations were mostly unsubstantiated, with the exception of substantiated issues involving protective care and medication administration. The trend suggests some improvement, as recent inspections have not identified deficiencies following earlier concerns.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
68 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2025
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA50004063.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA50004063; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 4, 2025
Visit Reason
The inspection was conducted to investigate complaint intakes #GA50003636 and #GA50002831 regarding the care and oversight of residents at the facility.
Findings
The facility failed to provide protective care and watchful oversight for one resident who was found inside the walk-in freezer. The resident was assessed with no injuries, but the incident revealed inadequate supervision.
Complaint Details
The visit was complaint-related, investigating two intake complaints (#GA50003636 and #GA50002831). Resident #1 was found in the freezer on 3/27/25 by Staff D, with no injuries noted. The resident has Alzheimer's disease and requires observation per care plan.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide protective care and watchful oversight for Resident #1, who was found in the walk-in freezer. | Level D |
Report Facts
Incident date: Mar 27, 2025
Temperature: 38
Temperature: -5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Found Resident #1 in the freezer and reported no injuries | |
| Staff A | Reported Resident #1 missing and found in freezer |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 15, 2024
Visit Reason
The visit was conducted to investigate intake #GA00215656 through an unannounced inspection starting on 2024-11-12 and completed on 2024-11-15.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00215656 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2024
Visit Reason
The visit was conducted to investigate intake #GA00250314 with an onsite visit made on 10/2/24.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00250314 was completed with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00249642. An unannounced visit was made on 2024-09-19 and the inspection was completed on 2024-09-24.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00249642 with no rule violations cited.
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Aug 8, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248232. An unannounced visit was made on 7/31/2024 and the inspection was completed on 8/8/2024.
Findings
The facility failed to provide medication administration services in accordance with physicians' orders for 1 of 3 sampled residents (Resident #1). Specifically, Resident #1 did not receive the correct dosage of medications including Farxiga and Memantine, with documentation showing missed or late medication administration and resulting in stroke-like symptoms.
Complaint Details
Investigation of intake #GA00248232 revealed medication errors for Resident #1, including missed doses and incorrect dosages, with substantiation based on observations, record reviews, and multiple staff interviews confirming the issues.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide medication administration services to residents in accordance with physicians' orders for Resident #1. | SS= D |
Report Facts
Facility census: 68
Memory care census: 25
Medication doses missed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Reported medication errors and missing medication for Resident #1 | |
| Staff A | Interviewed regarding medication administration and missing medication | |
| Staff B | Interviewed regarding medication availability and pharmacy packaging error | |
| Staff C | Interviewed regarding medication dosage errors and pharmacy issues | |
| DD | Interviewed regarding medication order errors and MAR reconciliation responsibility | |
| Staff D | Reported stroke-like symptoms of Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 16, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA00245196 and GA00244909 with an onsite visit on 2024-05-16 and investigation completion on 2024-05-24.
Findings
The facility failed to ensure timely procurement of medication refills, resulting in an interruption in routine dosing for one sampled resident due to acetaminophen not being available in the medication cart as prescribed.
Complaint Details
The investigation was initiated based on complaint intakes #GA00245196 and GA00244909.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure timely refills of prescribed medications to avoid interruption in routine dosing for Resident #2. | SS= D |
Report Facts
Sampled residents: 4
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication availability and procurement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 13, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243594.
Findings
No rule violation was cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00243594 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 6, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00240676 with an onsite visit made on 12/5/23 and inspection completed on 12/6/23.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00240676 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 5, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237749 with an onsite visit made on 9/5/23.
Findings
The facility failed to report serious incidents involving two residents within 24 hours after the incidents occurred, specifically for Resident #2 and Resident #3, who both experienced falls resulting in injuries and hospitalizations.
Complaint Details
Investigation of intake #GA00237749. Staff B did not report the incident for Resident #3 to the Department and was unaware of the need to report these incidents at the time they occurred.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to report to the Department serious incidents involving residents within 24 hours after the incident occurred for 2 of 6 sampled residents (Resident #2 and Resident #3). | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 3, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236339 and #GA00236373 with an onsite visit made and inspection completed on 08/03/2023.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00236339 and #GA00236373 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 9, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235123 with an onsite visit made on 2023-05-30 and the inspection completed on 2023-06-09.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00235123 with no rule violations cited.
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Sep 20, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00226856. An onsite visit was made on 2022-09-20 and the investigation was completed.
Findings
The facility failed to provide protective care and watchful oversight for 1 of 3 sampled residents (Resident #1), who exhibited wandering behavior and was involved in an incident causing injury to himself and a direct care staff (DD). The investigation included observations, record reviews, and multiple staff interviews regarding the incident on 2022-08-09.
Complaint Details
The visit was complaint-related to intake #GA00226856. The complaint involved an incident on 2022-08-09 where Resident #1 wandered into another resident's room, struck a direct care staff (DD) with a water bottle causing injury, and was sent for emergency assessment. The investigation included interviews with multiple staff and review of incident reports. Resident #1 was discharged on 2022-09-15 after exhibiting behaviors and hospitalization.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide protective care and watchful oversight for Resident #1 who exhibited harmful behaviors and wandering. | SS= D |
Report Facts
Residents observed: 45
Staff observed: 8
Resident #1 admission date: Aug 1, 2022
Resident #1 discharge date: Sep 15, 2022
Incident date: Aug 9, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Interviewed regarding incident on 2022-08-09, observed blood on Resident #1 | |
| Staff A | Interviewed regarding incident on 2022-08-09, called EMS and reported details of incident | |
| Staff B | Interviewed regarding incident on 2022-08-09, heard screams and observed injuries | |
| AA | Interviewed regarding incident and resident status, reported resident discharged | |
| DD | Direct care staff involved in incident, reported being struck by Resident #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 26, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220546 with an onsite visit made on 1/26/22 and the investigation completed on 2/4/22.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00220546 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 19, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00213395 with an onsite visit made on 4/19/21 and the investigation completed on 4/28/21.
Findings
There were no rule violations cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00213395 with no rule violations found.
Inspection Report
Original Licensing
Deficiencies: 0
Mar 5, 2021
Visit Reason
The purpose of this inspection was to conduct an initial inspection for licensing.
Findings
No rules violations were cited as a result of this inspection.
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