Inspection Reports for Marshall Pines Assisted Living & Memory Care
GA, 30809
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 29, 2025, found no deficiencies. Earlier inspections showed a mix of results, with several complaint investigations citing issues related primarily to staff training, medication management, and resident care. Deficiencies included failures in staff emergency training, medication security, and ensuring residents’ rights to access records, along with some concerns about cleanliness and resident safety. Complaint investigations were mostly unsubstantiated, except for a substantiated medication handling issue in 2020 that led to staff termination. The facility’s recent inspections indicate improvement, with no deficiencies noted in the last two routine or complaint investigations.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
3.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 29, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004578 with an on-site visit made on 2025-08-20. The investigation started on 2025-08-20 and was completed on 2025-09-29.
Complaint Details
Investigation of intake #GA50004578 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this inspection and investigation.
Inspection Report
Routine
Deficiencies: 0
Date: Mar 26, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection at Marshall Pines Alzheimer's Special Care Center.
Findings
No rule violations were cited as a result of this inspection and investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245835 with an on-site visit made on 5/29/2024 and the investigation completed on 5/30/2024.
Complaint Details
Investigation of intake #GA00245835 was conducted with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 20, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243057, with the investigation beginning on 2/19/2024 and an onsite visit conducted on 2/20/2024.
Complaint Details
Investigation of intake #GA00243057 found that Resident #1's representative requested the resident's records multiple times via email and attorney letter but was not provided the records by Staff A.
Findings
The facility failed to ensure that each resident, representative, or legal surrogate had the right to inspect and obtain copies of all records pertaining to the resident. Specifically, Resident #1's representative requested the resident's records multiple times but was repeatedly ignored and the records were not provided.
Deficiencies (1)
Failed to ensure that each resident, representative, or legal surrogate had the right to inspect and obtain copies of all records pertaining to the resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in relation to failure to provide Resident #1's records to the representative. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00239086. An onsite visit was made to the facility on 10/24/23.
Complaint Details
Investigation started on 10/23/23 and completed on 11/13/23. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237088 with an onsite visit made on 8/1/23. The investigation started on 8/1/23 and was completed on 8/14/23.
Complaint Details
Investigation of intake #GA00237088 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 13, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00232848.
Complaint Details
Investigation of intake #GA00232848 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 3, 2021
Visit Reason
The purpose of this visit was to conduct the Annual compliance inspection of the facility.
Findings
No rule violations were cited as a result of the visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 2, 2021
Visit Reason
The purpose of this visit was to investigate complaint intake numbers GA00211271 and GA00211401.
Complaint Details
Investigation began on 2021-01-25 and was completed on 2021-02-02 with an on-site visit made on 2021-02-02. No deficiencies were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 21, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00209453, which was opened on 11/17/2020 and completed on 1/21/2021.
Complaint Details
The inspection was complaint-related, investigating intake #GA00209453 opened on 11/17/2020 and completed on 1/21/2021.
Findings
The facility failed to ensure that the assisted living community cleaned residents' private living spaces periodically and as needed to prevent foul odors and health hazards. A strong urine odor was noted in Resident #1's bedroom, confirmed by staff, with urine found on the floor between the bed and wall.
Deficiencies (1)
Facility failed to ensure residents' private living spaces were cleaned periodically and as needed to prevent foul odors and health hazards.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A confirmed the presence of urine odor and urine on the floor in Resident #1's room. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 29, 2020
Visit Reason
The visit was conducted to investigate intake #GA00207770, which was initiated on 2020-09-23 and completed on 2020-10-29.
Complaint Details
The investigation was complaint-driven based on intake #GA00207770. The complaint involved missing narcotic medications and improper medication handling by staff. Staff D was found to have discontinued medications without physician orders, shared login credentials, and destroyed medications without proper documentation. The complaint was substantiated leading to termination of Staff D.
Findings
The facility failed to ensure effective enforcement of policies and procedures regarding narcotics management, resulting in missing narcotic medications and unauthorized medication discontinuations. Staff D was terminated due to unsatisfactory performance and policy violations related to medication handling. The facility also failed to maintain secure storage and accurate inventory logs for medications for three residents.
Deficiencies (2)
Administrator failed to ensure policies and procedures were effective and enforced for narcotics management, leading to missing medications and delayed investigation.
Facility failed to ensure medications were stored securely and inventoried appropriately, including maintaining a daily updated log for inventory for 3 residents.
Report Facts
Missing narcotic prescriptions: 4
Medication quantities: 60
Medication doses given: 2
Missing Hydrocodone tablets: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator who failed to ensure effective enforcement of narcotics policies and delayed investigation. | |
| Staff C | Staff who reported missing narcotics and provided written statements. | |
| Staff D | Staff terminated for unsatisfactory performance, policy violations including unauthorized medication discontinuation, sharing login credentials, and improper medication destruction. | |
| Staff E | Staff who investigated missing narcotics and reported suspicions about Staff D's medication handling. | |
| Staff G | Staff who recalled medication issues during weekend shifts. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 1, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00203873.
Complaint Details
Investigation began on 2020-04-21 and was completed on 2020-05-01. No citations were issued.
Findings
No citations were issued as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 7, 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 evaluating the infection control process at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 5, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00201193.
Complaint Details
Investigation of complaint #GA00201193 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 16
Date: Dec 5, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaints #GA00201020 and #GA00200852.
Complaint Details
The inspection was conducted to investigate complaints #GA00201020 and #GA00200852.
Findings
The facility failed to meet multiple training and documentation requirements for staff, including initial training on residents' rights, infection control, emergency preparedness, emergency first aid, CPR, medical and social needs of residents, ongoing continuing education, staff health exams and screenings, criminal background checks, employment history, fire safety compliance, community safety precautions, and certified medication aide requirements.
Deficiencies (16)
Failed to ensure staff received training within the first 60 days on residents' rights and identification of abuse, neglect, or exploitation.
Failed to ensure staff received training within the first 60 days on general infection control principles.
Failed to ensure staff received training within the first 60 days on emergency preparedness.
Failed to ensure staff providing hands-on personal services received emergency first aid training within the first 60 days.
Failed to ensure staff providing hands-on personal services received CPR training within the first 60 days.
Failed to ensure staff received training on medical and social needs and characteristics of the resident population.
Failed to ensure staff received training on residents' rights and individualized care.
Failed to ensure staff had 16 hours of continuing education annually.
Failed to ensure staff received physical examination and tuberculosis screening within 12 months prior to providing care.
Failed to obtain and maintain criminal history background checks for employees.
Failed to obtain and maintain employment history for staff.
Failed to comply with fire safety rules; no documentation of fire drills in 2018 and fire extinguisher tag torn without service date.
Hot water temperature exceeded 120 degrees Fahrenheit in resident rooms.
Failed to ensure memory care staff received training on the role of the family in caring for residents with dementia within 6 months of hire.
Failed to ensure certified medication aides had documented skills competency checks.
Failed to maintain documentation of quarterly observations of medication administration for certified medication aides.
Report Facts
Sampled staff: 8
Staff lacking training on residents' rights: 5
Staff lacking infection control training: 5
Staff lacking emergency preparedness training: 4
Staff lacking emergency first aid training: 5
Staff lacking CPR training: 4
Staff lacking training on medical and social needs: 3
Staff lacking continuing education: 4
Staff lacking physical exam and TB screening: 4
Staff lacking criminal record check: 2
Staff lacking employment history: 1
Certified medication aides reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed multiple training and documentation requirements including residents' rights, infection control, emergency preparedness, continuing education, physical exam, and TB screening. | |
| Staff C | Failed multiple training and documentation requirements including infection control, emergency preparedness, emergency first aid, CPR, medical and social needs training, continuing education, and criminal record check. | |
| Staff D | Failed emergency first aid training, CPR training, continuing education, and dementia family role training. | |
| Staff E | Failed infection control training, emergency preparedness training, emergency first aid training, residents' rights training, physical exam and TB screening, and criminal record check. | |
| Staff F | Failed physical exam and TB screening. | |
| Staff G | Failed residents' rights training, infection control training, emergency preparedness training, residents' rights training, employment history documentation, physical exam and TB screening. | |
| Staff H | Failed infection control training, emergency first aid training, CPR training, continuing education, medication aide skills competency checklist, and quarterly medication administration observations. | |
| Staff K | Interviewed staff who stated inability to locate staff files and documentation. | |
| Staff A | Interviewed staff who stated inability to locate fire drill documentation and unaware of high water temperature. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jul 22, 2019
Visit Reason
The purpose of this visit was to investigate complaints #GA00198381 and #GA00198489 with an onsite visit made on 7/22/19 and inspection completed on 8/6/19.
Complaint Details
The visit was complaint-related, investigating complaints #GA00198381 and #GA00198489. The complaint involved failure to provide required staff training, health screenings, background checks, and failure to protect a resident who eloped and suffered heat exhaustion.
Findings
The facility failed to ensure staff received required emergency first aid training, continuing education units, physical examinations, and criminal background checks. Additionally, the facility failed to provide protective care and watchful oversight for a resident who had an unwitnessed fall and was found outside the facility with heat exhaustion. The facility also failed to utilize appropriate safety devices to prevent elopement of residents at risk.
Deficiencies (6)
Staff hired to provide hands-on personal services did not receive emergency first aid training within the first 60 days of employment for 2 of 6 sampled staff (Staff D and Staff E).
Staff failed to complete 16 hours of continuing education units within the first year of employment for 1 of 4 sampled staff (Staff C).
Staff did not receive a physical examination by a licensed provider within 12 months prior to providing care for 2 of 6 sampled staff (Staff D and Staff E).
Failed to obtain a satisfactory criminal records check for 1 of 6 sampled staff (Staff B).
Failed to provide protective care and watchful oversight for 1 sampled resident (Resident #1) who had an unwitnessed fall and was found outside the facility with heat exhaustion.
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping from the premises for Resident #1.
Report Facts
Staff sampled: 6
Staff sampled: 4
Staff sampled: 6
Resident sampled: 1
Resident vital signs: 105.1
Resident vital signs: 160
Resident vital signs: 89
Resident vital signs: 62
Resident vital signs: 71
Resident vital signs: 97
Temperature: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Failed emergency first aid training and physical examination within 12 months | |
| Staff E | Failed emergency first aid training and physical examination within 12 months | |
| Staff C | Failed to complete 16 hours of continuing education units | |
| Staff B | Failed to obtain satisfactory criminal background check after rehire | |
| Staff A | Interviewed staff unable to provide documentation for deficiencies | |
| Staff F | Reported no alarm on door adjacent to zone 1 and informed Staff C |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 1, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00197483.
Complaint Details
The inspection was conducted to investigate intake #GA00197483.
Findings
The facility failed to ensure staff had current certification in emergency first aid and cardiopulmonary resuscitation (CPR) training within the first 60 days of employment for multiple staff. Additionally, the facility failed to ensure staff received a physical examination and tuberculosis screening within 12 months prior to providing care for several staff members.
Deficiencies (3)
Facility failed to ensure staff had current certification in emergency first aid training for 2 of 5 sampled staff (Staff B and Staff C).
Facility failed to ensure staff received training in cardiopulmonary resuscitation (CPR) within the first 60 days of employment for 2 of 5 sampled staff (Staff C and Staff E).
Facility failed to ensure staff received a physical examination and tuberculosis screening within 12 months prior to providing care for 3 of 5 sampled staff (Staff B, Staff C, and Staff E).
Report Facts
Staff sampled: 5
Staff without first aid certification: 2
Staff without CPR certification: 2
Staff without physical exam and TB screening: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings for lack of first aid certification and physical exam | |
| Staff C | Named in findings for lack of first aid certification, CPR certification, and physical exam | |
| Staff E | Named in findings for lack of CPR certification and physical exam | |
| Staff A | Interviewed staff regarding certification and physical exam documentation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 24, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00191468 with an on-site visit made to the facility on 9/24/18 and the investigation completed on 9/26/18.
Complaint Details
Complaint #GA00191468 was investigated and found to have no violations.
Findings
There were no violations cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 11, 2017
Visit Reason
The purpose of this visit was to conduct a follow up to the 6/14/17 annual inspection and to investigate complaint #GA00180271.
Complaint Details
Complaint #GA00180271 was investigated during this visit.
Findings
No rule violations were cited as a result of the follow up inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 11, 2017
Visit Reason
The visit was conducted to investigate complaint #GA00180271 and to perform a follow-up to the 6/14/17 annual inspection.
Complaint Details
Complaint #GA00180271 was investigated and found to have no rule violations.
Findings
No rule violations were cited as a result of the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jun 14, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate complaint #GA00176083.
Complaint Details
Complaint #GA00176083 was investigated during this visit.
Findings
The facility failed to ensure that all staff had current CPR training for 1 of 6 sampled staff and failed to ensure that a resident incapable of assisted self-preservation was not retained in the facility.
Deficiencies (2)
Facility failed to ensure that all staff had current training in cardiopulmonary resuscitation (CPR) for 1 of 6 sampled staff (Staff E).
Facility failed to ensure that they did not retain a resident who was incapable of assisted self-preservation for Resident #4.
Report Facts
Number of sampled staff without CPR training: 1
Date of hospice nurse notes: Jun 6, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Staff E lacked current CPR training. | |
| Staff A | Staff A provided interview statements regarding CPR training and Resident #4's care. |
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