The most recent inspection on July 11, 2025, identified a deficiency related to a staff member lacking a satisfactory fingerprint record check. Earlier inspections showed a mix of deficiencies primarily involving personnel file management, medication administration records, resident oversight, and physical plant issues such as missing grab bars and emergency preparedness documentation. Complaint investigations were mostly unsubstantiated, except for a substantiated case in October 2024 involving a resident elopement, missing records, and delayed reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows some recurring administrative and oversight issues, with no clear pattern of improvement or worsening over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to conduct a re-licensure inspection with an onsite visit made from 2025-07-01 to 2025-07-14.
Findings
The facility failed to ensure that each staff member obtained a satisfactory fingerprint record check, as evidenced by one sampled staff member (Staff B) lacking a background check on file.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure that each staff obtain a satisfactory fingerprint record check for 1 of 1 sampled staff (Staff B).
D
Employees Mentioned
Name
Title
Context
Staff B
Sampled staff member without a satisfactory fingerprint record check.
Staff A
Confirmed during interview that Staff B did not have a background check on file and stated Staff B will complete a background check.
The purpose of this visit was to complete a compliance inspection and to investigate complaint intakes #GA00249895 and #GA00249902. An unannounced onsite visit was made on 2024-09-10 and the investigation was completed on 2024-10-08.
Findings
The facility failed to provide adequate oversight by the governing body, resulting in a resident elopement incident. Deficiencies included failure to maintain individual resident files, failure to update medication administration records, and failure to timely report the elopement to the Department as required by regulation.
Complaint Details
The investigation was triggered by complaint intakes #GA00249895 and #GA00249902 regarding Resident #1 eloping from the facility on 2024-08-22. The complaint was substantiated as the facility failed to prevent elopement, maintain required records, and report the incident timely.
Severity Breakdown
SS= D: 4
Deficiencies (4)
Description
Severity
Failure of the governing body to provide oversight in compliance with applicable rules, evidenced by Resident #1 eloping from the facility unnoticed and lack of surveillance or sign in/out policy.
SS= D
Failure to update the Medication Assistance Record (MAR) each time medication was given or offered to Resident #5.
SS= D
Failure to maintain an individual resident file for Resident #1, including required documentation such as admission agreement, physical exam, and care plans.
SS= D
Failure to report the initiation and discontinuation of a Mattie's Call to the Department within 30 minutes of communication with law enforcement for Resident #1's elopement.
SS= D
Report Facts
Sampled residents: 5Date of elopement: Aug 22, 2024Time of elopement: 1330Time police notified: 1347Medication administration frequency: 2
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding Resident #1 elopement, lack of surveillance, sign in/out policy, and reporting failure
Staff C
Interviewed regarding medication administration to Resident #5 and lack of MAR
The purpose of this visit was to investigate intake #GA00242020. An on-site visit was made to the facility on 1/11/24, with the investigation completed on 1/12/24.
Findings
The facility failed to ensure employee personnel files were available for inspection for 3 sampled staff members, and the facility lacked a working doorbell or doorknocker audible to staff inside at all times.
Complaint Details
Investigation was initiated based on intake #GA00242020. The investigation was conducted on 1/11/24 and completed on 1/12/24.
Severity Breakdown
D: 2
Deficiencies (2)
Description
Severity
Facility failed to ensure each employee file was available in the home or made available for inspection for 3 of 3 sampled staff.
D
Facility failed to have a doorbell or doorknocker audible to staff inside at all times.
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00239088.
Findings
The facility failed to provide personnel files within one hour of request, failed to install grab bars in all showers and bath areas, and failed to show documentation of emergency preparedness, drills, and evacuation requirements.
Complaint Details
Investigation of intake #GA00239088; deficiencies found related to personnel file accessibility, home design requirements, and physical plant health and safety standards.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Facility failed to provide personnel files within one hour of request or prior to the end of the on-site survey.
SS= D
Facility failed to install grab bars in all showers and bath areas; temporary grab bars were observed lying on the back of commodes in some bathrooms.
SS= D
Facility failed to show documentation of emergency preparedness, drills, and evacuation requirements; no documentation of fire drills was available.