Inspection Reports for Peachtree Creek Memory Care and Assisted Living
GA, 30339
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 22, 2025, found no rule violations during complaint investigations. Earlier inspections showed a mixed record with deficiencies primarily related to resident care, staffing documentation, and staff training, including substantiated cases of neglect and inadequate supervision. Notable issues included delayed hospital evaluations after injuries, failure to maintain accurate staffing plans, and a substantiated incident of resident neglect involving rough handling by staff that led to termination and legal action. Several complaint investigations were unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some improvement in recent years, with no deficiencies noted in the latest inspections following earlier concerns.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
61% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
May 22, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002024 and GA50002003.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes #GA50002024 and GA50002003 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2024
Visit Reason
The purpose of this visit was to investigate intake number #GA00251491.
Findings
The onsite visit was made on 12/19/24, the survey started on 12/19/24, and the investigation was completed on 12/27/24.
Complaint Details
Investigation of intake number #GA00251491.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245697 and #GA00245476.
Findings
There were no rule violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00245697 and #GA00245476 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237287.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00237287 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 25, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00233655. The onsite visit was made on 7/25/23 and completed on 7/26/23.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00233655; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 16, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00228183.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00228183; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 17, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220302 with an onsite visit made on 2022-02-09. The investigation started on 2022-02-07 and was completed on 2022-02-17.
Findings
The facility failed to retain accurate staffing plans for a minimum of one year, specifically missing the December 2021 staff schedule. Additionally, the facility failed to ensure adequate and appropriate care for Resident #1, including lack of documentation and treatment following a fall and pain complaints.
Complaint Details
The investigation was initiated due to intake #GA00220302. The complaint involved concerns about staffing records and resident care adequacy, specifically for Resident #1 who had documented falls and pain without proper treatment documentation.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to retain accurate staffing plans including monthly work schedules for all employees, including relief workers, showing planned and actual coverage for each day and night for a minimum of one year; specifically, no December 2021 staff schedule was available. | D |
| Failed to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulations for Resident #1, including lack of documentation of treatment after a fall and no records of pain medication administration. | E |
Report Facts
Date of fall: Nov 25, 2021
Medication dosage: 5
Medication dosage: 325
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 17, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00218205, with the investigation started on 2021-12-31, an on-site visit on 2022-02-17, and completion on 2022-02-21.
Findings
The facility failed to ensure that staff in the memory care center had required training and continuing education for 3 of 5 sampled staff (Staff C, Staff D, and Staff E), with no documentation of such training available and confirmation from Staff A that no training had been completed.
Complaint Details
Investigation was complaint-related intake #GA00218205, started on 2021-12-31, with on-site visit on 2022-02-17 and completed on 2022-02-21.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff in the memory care center had training and continuing education requirements for 3 of 5 sampled staff (Staff C, Staff D, and Staff E). | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 30, 2021
Visit Reason
The purpose of this visit was to investigate intake GA0021957. An unannounced visit was made to the facility on 12/30/2021. The investigation was started on 12/13/2021 and completed on 12/31/2021.
Findings
The community failed to ensure that Resident #1 received adequate and appropriate care, resulting in a delayed hospital evaluation after the resident sustained a right hip fracture. Staff interviews and record reviews revealed delays in sending the resident to the hospital despite signs of pain and mobility changes.
Complaint Details
Investigation of intake GA0021957 regarding Resident #1's delayed hospital evaluation after signs of pain and mobility changes were observed. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulations for Resident #1 who sustained a right hip fracture. | D |
Report Facts
Date of incident: Nov 24, 2021
Date resident sent to hospital: Nov 26, 2021
Medication dose: 325
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding Resident #1's hip fracture and mobility status | |
| Staff D | Interviewed about contacting physician and facility protocol for resident condition changes | |
| Staff C | Interviewed about Resident #1's pain and communication from Staff E | |
| Staff E | Reported Resident #1 screaming and showing signs of pain during care | |
| Staff F | Interviewed about facility protocol on changes in resident condition | |
| BB | Visited Resident #1 on 11/23/2021 and observed resident walking without difficulties |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 19, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00217248, which began on 2021-09-28 and was completed on 2021-10-19, including an unannounced visit on 2021-09-28.
Findings
The facility failed to ensure a resident's right to be free from neglect, as video evidence showed a Certified Nursing Assistant (Staff D) treating Resident #1 roughly during assistance with toileting and bed placement. Staff D was terminated and an arrest warrant was issued for elder abuse.
Complaint Details
Investigation was initiated due to intake #GA00217248 following family concerns about possible abuse. Video footage showed rough handling by Staff D. Staff D was terminated and an arrest warrant for elder abuse was issued. Police report was filed.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident #1 was free from neglect, evidenced by rough handling by Staff D during toileting and bed assistance as shown in video footage. | G |
Report Facts
Investigation start date: Sep 28, 2021
Investigation completion date: Oct 19, 2021
Incident report date: Aug 31, 2021
Staff D hire date: May 14, 2021
Resident #1 admission date: Mar 2, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant | Named in neglect and rough handling findings; terminated after investigation; arrest warrant issued for elder abuse |
| Staff A | Facility staff who reviewed videos and confirmed rough handling; reported police report filed | |
| Staff F | Facility staff who viewed video and confirmed unprofessional and rough treatment by Staff D | |
| Staff G | Conducted physical assessment of Resident #1 after abuse reports; found no physical injury | |
| AA | Family member who installed video cameras and reported concerns about abuse |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214467.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2021-06-01 and completed on 2021-06-08 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210741 and GA00210592.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began 2021-02-10 and was completed 2021-02-12. No rule violations were found.
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 2
Nov 20, 2020
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA00208995, #GA00209602, #GA00209613, #GA00209617, and #GA00209618) related to allegations of sexual assault involving residents.
Findings
The facility failed to provide adequate staffing and supervision, resulting in two residents being sexually assaulted by another resident. The facility did not ensure adequate care and behavior modification for the resident responsible, leading to immediate discharge. Multiple interviews and record reviews confirmed these findings.
Complaint Details
The investigation was triggered by complaints of sexual assault involving Resident #1 and Resident #2 by Resident #4 occurring on 11/6/20 and 11/7/20. The allegations were substantiated based on incident reports, police reports, and staff interviews.
Severity Breakdown
J: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide staff above the minimum ratio to meet specific health and safety needs for 3 of 6 sampled residents. | J |
| Failed to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations. | J |
Report Facts
Facility census: 27
Residents on unit: 13
Number of sampled residents: 6
Number of residents involved in incidents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding Resident #4's behavior and supervision; scheduled sitter and implemented 30-minute checks. | |
| Staff F | Assigned to Resident #4 on 11/6-11/7; left early on 11/7; reported checking Resident #4 every two hours. | |
| Staff G | Discovered Resident #2 in Resident #4's bedroom on 11/6. | |
| Staff H | Assigned to unit on 11/7; could not be interviewed. | |
| Staff I | Medication Tech | Called to unit on 11/7 after Resident #1 found in Resident #4's room; assisted in removing Resident #1. |
| LL | Witnessed incidents on 11/7; reported findings to staff and assisted in removing Resident #1. | |
| HH | Commented on staffing levels on the unit. | |
| MM | Commented on Resident #4's behavior and staffing at new facility. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 5, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206519.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2020-07-27 and was completed on 2020-08-05. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00204893, which was started on 2020-05-20 and completed on 2020-05-29.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00204893 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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 19, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00200727 and #GA00200973.
Findings
The facility failed to properly dispose of unused medications for one resident and failed to ensure a resident's right to be free from neglect, as evidenced by an incident where a resident was left on the floor without assistance for nearly an hour.
Complaint Details
The complaint investigation was triggered by intake #GA00200727 and #GA00200973. The investigation found substantiated neglect of Resident #2, who was left on the floor from 9:55 p.m. to 10:45 p.m. without assistance from Staff B, who was reprimanded.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to properly dispose of unused medications for Resident #4, including discontinued sertraline 25 mg. | D |
| Failed to ensure Resident #2 was free from neglect when Staff B refused to assist the resident off the floor and denied access to his/her blanket. | D |
Report Facts
Residents sampled: 4
Time resident left on floor: 50
Date medication discontinued: Jun 9, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in neglect finding for refusing to assist Resident #2 off the floor and denying access to blanket; reprimanded. | |
| Staff A | Interviewed regarding camera evidence of neglect involving Staff B. | |
| Staff D | Interviewed about events on 11/15/19 involving Resident #2 and Staff B. | |
| Staff E | Interviewed about Resident #2 being left on the floor. | |
| AA | Interviewed regarding discontinued medication for Resident #4. | |
| BB | Interviewed regarding camera evidence of neglect involving Resident #2 and Staff B. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2019
Visit Reason
The purpose of this visit was to conduct an investigative intake #GA00197395, which started on 2019-06-25 and completed on 2019-07-01.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation intake #GA00197395 was conducted; no rule violations were found.
Inspection Report
Follow-Up
Deficiencies: 0
May 1, 2019
Visit Reason
The visit was conducted to investigate intake #GA00194897 and to perform a follow-up inspection to the 12/27/18 inspection.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 8, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 12/27/18 compliance inspection and to investigate intake #GA00194897.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00194897 was conducted during this visit.
Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 17, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint GA00193252. An on-site visit was made on 12/17/18 and the investigation was completed on 12/27/18.
Findings
The facility failed to ensure that staff hired to provide hands-on personal services received proper CPR training with return demonstration of competency for 1 of 4 sampled staff. Additionally, the facility failed to comply with fire and safety rules, including missing documentation of fire drills for January and November 2017 and a sprinkler system with a yellow non-compliance tag.
Complaint Details
Complaint GA00193252 was investigated during this visit. The investigation included review of staff training and fire safety compliance.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff received CPR training with return demonstration of competency for 1 of 4 sampled staff (Staff A). | SS= D |
| Failed to comply with fire and safety rules including missing documentation of fire drills for January and November 2017 and a sprinkler system with a yellow NON COMPLIANCE tag. | SS= D |
Report Facts
Date of CPR certification for Staff A: Mar 16, 2018
Fire drills missing documentation: 2
Sprinkler system service date: Dec 3, 2018
Inspection Report
Follow-Up
Deficiencies: 0
Apr 18, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the 10/24/17 complaint investigation GA#00180993.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up inspection to the 10/24/17 complaint investigation GA#00180993.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 29, 2018
Visit Reason
The purpose of this visit was to conduct a follow-up to the 10/20/17 inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 2, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA 00183077.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Complaint GA 00183077 was investigated and found to have no violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 5, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00182564.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00182564 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 23, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00180993. An on-site visit was made on 10/23/17 and an investigation was completed on 10/24/17.
Findings
The facility failed to update the Medication Assistance Record (MAR) each time medication was taken or refused for one sampled resident. Additionally, the community failed to obtain timely refills of prescribed medications, resulting in missed doses for the resident.
Complaint Details
The visit was complaint-related, investigating complaint #GA00180993. The complaint was substantiated by findings of failure to update medication records and failure to obtain timely medication refills.
Severity Breakdown
D: 1
J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to update the Medication Assistance Record (MAR) each time medication was taken or refused for Resident #1. | D |
| Failed to obtain refills of prescribed medications timely, causing missed doses for Resident #1. | J |
Report Facts
Medication doses missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Interviewed and stated staff forgot to sign the October 2017 MAR but medications were given. | |
| Staff B | Interviewed and stated the facility was waiting for AA to bring the medications. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 20, 2017
Visit Reason
The purpose of this visit was to investigate complaints #GA00178355 and #GA00179240, and self-reported incidents #GA00178454, #GA00179270, and #GA00179689. The investigation started on 2017-08-14 and completed on 2017-10-20 with onsite visits on 2017-08-14 and 2017-09-20.
Findings
The community failed to ensure adequate and appropriate care for 2 of 56 residents sampled, specifically Resident #2 who was found with unexplained bruising on the face. Staff interviews and clinical notes indicated no known cause or indication of abuse for the bruising.
Complaint Details
Investigation was complaint-driven based on complaints #GA00178355 and #GA00179240, and self-reported incidents #GA00178454, #GA00179270, and #GA00179689. The bruising on Resident #2 was observed and investigated but no cause or abuse was identified.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate and appropriate care resulting in unexplained bruising on Resident #2's face. | D |
Report Facts
Residents sampled: 56
Residents with deficiencies: 2
Inspection Report
Annual Inspection
Deficiencies: 3
Jun 27, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate complaint #GA00176045. The investigation was started on 2017-06-26 and completed on 2017-06-27.
Findings
The facility failed to develop care plans that included residents' preferences regarding care, activities, and interests for 4 of 4 sampled residents. Additionally, the facility failed to provide evidence of family involvement in care plan development for these residents and failed to ensure that written care plans were reviewed at least quarterly and modified as needed for 3 of 4 residents sampled.
Complaint Details
Complaint #GA00176045 was investigated during this visit, which was started on 2017-06-26 and completed on 2017-06-27.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to develop care plans including residents' preferences regarding care, activities, and interests for 4 of 4 residents sampled. | SS= D |
| Facility failed to provide evidence of family involvement in the development of residents' care plans for 4 of 4 sampled residents. | SS= D |
| Facility failed to ensure that the written care plan was reviewed at least quarterly and modified as changes in the resident's needs occur for 3 of 4 residents sampled. | SS= D |
Report Facts
Residents sampled: 4
Residents with care plan review deficiencies: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed staff member who was unaware of care plan requirements and stated intentions to correct deficiencies |
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