Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 5, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004165; #GA50004283; #GA50005299.
Findings
No deficiencies were cited as a result of this visit.
Complaint Details
Investigation of complaint intakes #GA50004165, #GA50004283, and #GA50005299 with no deficiencies found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 14, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002216. An unannounced visit was made on 2025-05-07 and the inspection was completed on 2025-05-14.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA50002216 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA00251003 and GA00250944.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes #GA00251003 and GA00250944 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 2
May 22, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00246695, with an onsite visit made on 5/22/24 and inspection completed on 5/24/24.
Findings
The facility failed to ensure individual privacy in one of four sampled bathrooms due to an inoperable bathroom door lock. Additionally, the facility failed to ensure food used was free from spoilage, as four containers of shrimp base with a best used by date of 6/2/2023 were found in the pantry.
Complaint Details
The inspection was conducted to investigate intake #GA00246695.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Toilets did not provide individual privacy due to an inoperable lock on the bathroom door adjacent to the dining room. | SS= D |
| Food used in the facility was not free from spoilage; four containers of shrimp base with a best used by date of 6/2/2023 were found in the pantry. | SS= D |
Report Facts
Containers of shrimp base: 4
Sampled bathrooms: 4
Bathrooms with privacy issue: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Interviewed regarding the inoperable bathroom door lock. | |
| Staff F | Interviewed regarding the shrimp base expiration status. | |
| Staff A | Interviewed regarding facility policy on food storage and best used by dates. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 19, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245185 with an onsite visit made on 2024-04-17 and inspection completed on 2024-04-19.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00245185 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244594 with an onsite visit made on 3/26/24 and inspection completed on 3/28/24.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00244594 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239688, GA00239646, and GA00239608. The investigation began on 2023-10-19 and was finalized on 2023-10-24.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00239688, GA00239646, and GA00239608 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 5, 2023
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00238716, with the investigation starting on 2023-09-28 and completing on 2023-10-05.
Findings
The facility failed to utilize effective safety devices that did not impede mobility or violate fire safety standards to protect residents at risk of eloping. Specifically, one exit door on the memory care unit was unsecured without any alarming device, and no audible alarm was detected on certain exit doors.
Complaint Details
Investigation was initiated due to intake #GA00238716. The complaint was substantiated based on observations, interviews, and record review indicating unsecured exit doors without alarms on the memory care unit.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to utilize effective safety devices to protect residents at risk of eloping; unsecured door on memory care unit without alarm device. | D |
Report Facts
Exit doors observed: 5
Date survey completed: Oct 5, 2023
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA002356090 with an onsite visit made on 7/5/23 and inspection completed on 7/19/23.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA002356090 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 22, 2023
Visit Reason
The visit was conducted to investigate multiple complaint intakes (#GA00235382, #GA00235395, #GA00235429, #GA00235454, #GA00235892) with an onsite visit made on 2023-06-13 and investigation completed on 2023-06-22.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of complaint intakes #GA00235382, #GA00235395, #GA00235429, #GA00235454, and #GA00235892 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA0023159.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA0023159 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 6
Nov 4, 2022
Visit Reason
The purpose of this visit was to investigate multiple complaint intakes (#GA00226914, #GA00227468, #GA00228829, #GA00228854, and #GA00228943) with an onsite visit made on 10/20/22 and the investigation completed on 11/4/22.
Findings
The facility failed to ensure proper investigation and reporting of resident injuries, failed to make records available for inspection, failed to maintain clean floors, failed to ensure uninterrupted medication dosing, and failed to report a serious injury within 24 hours for Resident #2. Additionally, there were missed medication doses for Resident #1 and inadequate care and services for Resident #2.
Complaint Details
The visit was complaint-related, investigating multiple intake numbers. The facility was found to have failed in proper injury investigation and reporting, record availability, cleanliness, medication administration, adequate care, and timely reporting of serious injury.
Severity Breakdown
SS= D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure the investigation and reporting of injuries of residents for 1 of 3 sampled residents (Resident #2). | SS= D |
| Failed to make its records available for examination to the Department for inspection. | SS= D |
| Failed to ensure floors were kept clean for 1 of 3 sampled residents (Resident #2). | SS= D |
| Failed to ensure there was no interruption in the routine dosing of medication for 1 of 3 sampled residents (Resident #1). | SS= D |
| Failed to ensure each resident received care and services which were adequate and appropriate for 1 of 3 sampled residents (Resident #2). | SS= D |
| Failed to report to the Department, within 24 hours, a serious injury for 1 of 3 sampled residents (Resident #2). | SS= D |
Report Facts
Missed medication doses: 4
Medication doses documented: 3
Resident checks per day: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Mentioned in relation to record availability issues and resignation of wellness director. | |
| Staff G | Mentioned regarding remitting previously requested information and not being available until following week. | |
| Staff H | Stated memory care director did not complete incident reports for injuries. | |
| Staff I | Provided email communication showing no incident report for Resident #2 on 8/22/22. | |
| CC | Cardiologist who changed medication order for Resident #1 and notified administrator. | |
| AA | Interviewed regarding Resident #2's fall and condition. | |
| Staff F | Mentioned regarding cleaning responsibility of floors. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 7, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA002221149.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 1, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and to investigate complaint intakes #GA00213859 and #GA00214353.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was started on 2021-05-18 and completed on 2021-06-01; no rule violations were 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 process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 8, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00200051, #GA00200072, and #GA00200171 through on-site inspections conducted on 10/8/19 and 12/5/19, with the investigation completed on 12/5/19.
Findings
The facility failed to ensure that one staff member (CC) adhered to policies regarding appropriate conduct with a resident, including inappropriate online communications and alleged supplying of alcohol. Additionally, the facility retained a resident (Resident #3) who was not ambulatory or capable of self-preservation with minimal assistance, contrary to admission requirements.
Complaint Details
The investigation was initiated due to complaints alleging inappropriate personal relationship and conduct between staff member CC and Resident 01, including supplying alcoholic beverages. The allegations were investigated, and CC's employment was terminated. A police report found no offense. Resident 01 was moved to another facility. The complaint also included concerns about facility admission practices regarding Resident #3's ambulatory status.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff member CC adhered to policies on appropriate conduct, including use of vulgarity, inappropriate language, and unprofessional behavior in interactions with Resident 01. | SS= D |
| Failure to admit and retain only ambulatory residents capable of self-preservation with minimal assistance, as Resident #3 was wheelchair-bound and unable to self-propel. | SS= D |
Report Facts
Number of sampled staff: 11
Number of sampled residents: 6
Dates of inspections: On-site inspections conducted on 2019-10-08 and 2019-12-05
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Staff member who violated conduct policies and was terminated | |
| Staff A | Received evidence of inappropriate conduct from BB | |
| BB | Reported concerns about CC and Resident 01 relationship and supplied evidence | |
| Staff C | Provided information about Resident #3's inability to self-preserve | |
| Staff D | Observed wheeling Resident #3 in wheelchair | |
| DD | Resident 01's contact who alerted BB about the relationship | |
| II | Person informed about CC supplying alcohol to Resident 01 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA000200072, which was previously investigated under intake #GA00200051.
Findings
The report is a statement of deficiencies and plan of correction related to the complaint investigation; specific findings are not detailed in the provided text.
Complaint Details
Investigation of intake #GA000200072, previously investigated under intake #GA00200051.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 19, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00197284 with an onsite visit made on 6/19/19 and the investigation completed on 6/28/19.
Findings
The facility failed to manage medications to prevent unauthorized access for one of three sampled residents. Thirty Oxycodone/Acetaminophen tablets were discovered missing from Resident #1's medication supply, leading to staff suspension and termination for violating medication policy.
Complaint Details
Investigation of intake #GA00197284 regarding missing controlled medication (Oxycodone/Acetaminophen) for Resident #1. Staff B was suspended and later terminated for violating medication policy. Police and department were notified.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to manage medications to prevent unauthorized access for Resident #1, resulting in missing controlled medication. | SS= D |
Report Facts
Missing medication tablets: 30
Medication dosage: 5.325
Shift hours: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Suspended and terminated for violating medication policy related to missing controlled medication. | |
| Staff C | Received medication from family and gave it to Staff B; reported missing medication. | |
| Staff A | Reported medication handling and policy violation details during interview. | |
| Staff E | Reported missing medication and administered alternative pain medication. | |
| AA | Reported medication was given to staff on admission and that Resident #1 had not taken medication during the year. |
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