The most recent inspection on October 8, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed mostly clean results, though a complaint investigation in July 2025 identified deficiencies related to inadequate care and failure to notify a responsible party about a resident’s injury. Prior reports from 2020 and 2021 noted issues with staffing, safety policies, and care for memory-impaired residents, including a substantiated complaint about a resident eloping from the memory care unit. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows some isolated care and safety issues in the past, with more recent investigations indicating improvement.
Deficiencies (last 5 years)
Deficiencies (over 5 years)1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake #GA50004637 with an onsite visit made on 2025-07-23 and the investigation completed on 2025-07-31.
Findings
The facility failed to provide adequate and appropriate care and services to Resident #1, who had multiple hand fractures and was discharged. The facility also failed to immediately notify the responsible party about the resident's injury.
Complaint Details
The investigation was initiated due to intake #GA50004637 regarding Resident #1's injury. The resident was diagnosed with fractures to multiple fingers and was taken to the hospital by emergency contact BB. Interviews revealed delays and failures in notification and appropriate response by staff.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Failed to provide each resident with care and services which were adequate and appropriate for Resident #1 with multiple hand fractures.
SS= D
Failed to immediately notify the responsible party of a resident about an injury for Resident #1.
SS= D
Report Facts
Date of emergency room discharge summary: Jun 14, 2025Date of incident report: Jun 16, 2025Date of onsite visit: Jul 23, 2025Date survey completed: Jul 31, 2025
Employees Mentioned
Name
Title
Context
Staff B
Observed applying ice to Resident #1's hand and stated BB arrived and took Resident #1 to the hospital
Staff D
Reported swelling of Resident #1's fingers and applied ice; stated he/she worked 7:00 a.m. to 3:00 p.m. on 6/14/25
Staff E
Observed Resident #1 with swollen right hand and reported incident
Staff C
Called emergency contact BB to notify of Resident #1's injury while BB was in the emergency room
BB
Emergency contact who took Resident #1 to the hospital and provided interview statements regarding the injury and notification
The inspection was conducted to investigate intake #GA00212871, which was initiated on 2021-03-22. An unannounced visit was made to the facility on 2021-04-16, and the investigation was completed on 2021-04-20.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00212871 found no rule violations.
The purpose of this visit was to investigate intake #GA00209568, which involved a complaint regarding the elopement of Resident #1 from the memory care unit (MCU).
Findings
The facility failed to implement policies and procedures to protect memory-impaired residents, failed to have adequate staffing to meet residents' safety needs, failed to utilize effective safety devices to prevent elopement, and failed to ensure adequate care and services for Resident #1. Resident #1 eloped from the MCU through a door that was slightly open and unalarmed during the day shift, was found 1.6 miles away unharmed, and returned to the facility without injury.
Complaint Details
The investigation was initiated due to intake #GA00209568 regarding Resident #1 eloping from the memory care unit on 11/5/2020. The resident was found 1.6 miles away at a nearby restaurant and returned safely. The family declined hospital evaluation. The complaint was substantiated based on findings of inadequate staffing, failure of safety devices, and failure to implement policies to protect residents with cognitive impairments.
Severity Breakdown
SS=J: 4
Deficiencies (4)
Description
Severity
Failed to implement policies, procedures, and practices to support memory impaired residents in a safe environment.
SS=J
Failed to have enough staff to meet the specific resident ongoing health and safety needs.
SS=J
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping.
SS=J
Failed to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations.
SS=J
Report Facts
Residents in MCU: 11Distance Resident #1 eloped: 1.6Times Resident #1 redirected: 3Times Resident #1 redirected: 4Residents requiring full assistance: 4Staff on duty: 2Time per resident for care: 20Temperature: 74
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding Resident #1 elopement and facility policies
Staff B
Medication Technician
Interviewed about staffing and Resident #1 elopement; reported working in office and passing medications
Staff C
Interviewed about staffing and Resident #1 elopement; reported caring for residents and monitoring
Staff D
Observed exit door slightly open and notified staff; involved in search for Resident #1