Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 8, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248759.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00248759 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 18, 2024
Visit Reason
The visit was conducted to investigate intake # GA00246721 through an unannounced inspection on 6/18/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake # GA00246721 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2024
Visit Reason
The visit was conducted to investigate intake #GA00245342 with an onsite visit on 4/17/2024 and the investigation completed on 4/26/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00245342 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238316.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00238316 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 21, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00228634. The investigation began on 2023-02-01 and ended on 2023-02-23.
Findings
Based on record review and interviews, the facility failed to ensure each resident was free from physical abuse. The investigation found that Staff B was aggressive with Resident #1, resulting in physical altercation and subsequent termination of Staff B.
Complaint Details
Investigation of intake# GA00228634 regarding physical abuse allegation against Staff B involving Resident #1. Staff B was suspended and later terminated due to violation of the facility's abuse policy.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident was free from physical abuse involving Staff B and Resident #1. | D |
Report Facts
Date of incident: Oct 6, 2022
Date of incident report: Oct 8, 2022
Date of termination letter: Oct 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in physical abuse finding and termination | |
| Staff C | Witnessed incident and intervened | |
| AA | Reported the incident involving Staff B and Resident #1 |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jun 23, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00214812 regarding an elopement incident involving Resident #1.
Findings
The facility failed to develop, train, and enforce policies and procedures for staff to manage residents at risk of eloping, resulting in Resident #1 eloping through an unsecured gate during a power outage. The investigation found lapses in staff oversight and gate security, especially during emergencies.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to provide protective care or watchful oversight, resulting in the elopement of Resident #1 on 5/29/2021. Resident #1 was found unharmed after leaving through an unsecured gate during a power outage. The facility lacked policies for gate security checks during emergencies, and staff failed to secure gates properly.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to develop, train, and enforce policies and procedures for staff to deal with residents who may wander away, including actions to be taken if a resident elopes. | G |
Report Facts
Census: 40
Direct care staff: 6
Certified medication aide: 1
Distance: 350
Temperature: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Mentioned as escorting Resident #1 back to the facility and responsible for checking gates | |
| Staff D | Responsible for checking and securing gates, worked part-time | |
| Staff F | Last saw Resident #1 before elopement, stated responsibility of Staff D to check gates | |
| Staff E | Reported power outage and attempted to contact Staff D, found Resident #1 in courtyard | |
| Staff J | Worked first shift on day of incident, did not see Resident #1 leaving or check gate | |
| Staff A | Notified physician about Resident #1's incident and behavioral symptoms |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 2, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210788, which began on 2021-05-11 and was completed on 2021-06-02.
Findings
The facility failed to ensure that Resident #1 was treated with dignity, kindness, and respect, and failed to protect the resident from abuse. Resident #1, diagnosed with dementia and bipolar disorder, was involved in an incident where Staff C struck the resident after being punched. Staff C was terminated for resident abuse. The resident was sent to the hospital for observation due to injuries sustained.
Complaint Details
The investigation was initiated due to intake #GA00210788 regarding an incident on 12/27/20 where Resident #1 punched Staff C and Staff C retaliated by hitting Resident #1. Staff C was suspended and subsequently terminated for resident abuse.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure each resident is treated with dignity, kindness, and consideration and respect. | SS= D |
| Failed to ensure each resident had the right to be free from mental, verbal, sexual and physical abuse, neglect and exploitation. | SS= D |
Report Facts
Incident date: Dec 27, 2020
Resident admission date: Sep 10, 2020
Staff hire date: Sep 9, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Involved in resident abuse incident where Staff C struck Resident #1 after being punched | |
| Staff D | Witnessed incident and interviewed regarding Staff C's actions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 14, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00210211.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00210211 found no rule violations.
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 measures.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 2, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00201630, which involved a complaint regarding missing medication at the facility.
Findings
The facility failed to store medication securely and inventory appropriately, resulting in the loss of Hydrocodone medication for one sampled resident. Multiple staff interviews and record reviews confirmed the medication was missing since 12/14/2019 and could not be found.
Complaint Details
The visit was complaint-related to intake #GA00201630. The complaint was substantiated by findings of missing Hydrocodone medication for Resident #1. A police report dated 12/17/2019 confirmed narcotics were reported missing from the residence with unknown perpetrator.
Deficiencies (1)
| Description |
|---|
| Failed to store medication securely and inventory appropriately to prevent loss of medication for 1 of 2 sampled residents (Resident #1). |
Report Facts
Date medication missing: Dec 14, 2019
Date police report: Dec 17, 2019
Medication dosage: 10
Medication dosage: 325
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