The most recent inspection on September 29, 2025, found no deficiencies. Earlier inspections generally showed compliance with no rule violations cited during complaint investigations and routine visits. Prior deficiencies involved medication refill delays, exceeding licensed capacity, and issues related to resident dignity and privacy, but these were isolated and addressed. Complaint investigations were mostly unsubstantiated, with no fines, immediate jeopardy findings, or enforcement actions listed in the available reports. The facility’s inspection history indicates improvement over time, with recent inspections consistently free of cited deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate facility reported intake GA00233023.
Findings
The facility failed to ensure that refills of prescribed medications were obtained timely, resulting in an interruption in routine dosing for Resident #1. Specifically, the medication Trazodone was documented as given but was not available on the medication cart due to lack of a current refill order.
Complaint Details
Investigation of facility reported intake GA00233023 regarding medication refill issues for Resident #1. The complaint was substantiated based on observations, record review, and staff interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failed to ensure timely refills of prescribed medications, causing interruption in routine dosing for Resident #1.
The purpose of this visit was to investigate complaint intakes #GA002232688 and #GA002232120 with an on-site visit made on 3/8/23 and the investigation completed on 3/16/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes #GA002232688 and #GA002232120 resulted in no rule violations.
The purpose of this visit was to investigate intake #GA00223089 and #GA00222813 with an onsite visit made to the facility on 4/19/22.
Findings
The facility failed to ensure that they did not serve more residents than its approved licensed capacity. The memory care unit had 25 residents present, exceeding the licensed capacity of 24.
Complaint Details
Investigation was initiated based on intake #GA00223089 and #GA00222813. The complaint was substantiated by the finding that the facility exceeded licensed capacity.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility served more residents than its approved licensed capacity in the memory care unit.
D
Report Facts
Residents in memory care unit: 25Licensed capacity: 24
The purpose of this visit was to investigate intake #GA00220493 with an onsite visit made on 2022-01-14 and the investigation completed on 2022-01-18.
Findings
The facility failed to ensure that two residents were treated with dignity, kindness, consideration, and respect, and given privacy in the provision of assisted living care. Staff B and Staff C posted a video of two residents on social media without proper consent, resulting in their immediate termination.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00220493. The complaint involved unauthorized posting of resident videos on social media by staff. Staff B and Staff C were terminated. Resident #1 had signed authorization for social media use, Resident #2 did not authorize release of information. Attempts to interview Resident #2 and the involved staff were unsuccessful.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure residents were treated with dignity, kindness, consideration, and respect and given privacy; staff posted resident videos on social media without consent.
D
Report Facts
Incident report date: Jan 3, 2022Staff B hire date: Jun 2, 2021Staff C hire date: Dec 31, 2020Staff termination date: Jan 3, 2022Resident #1 admission date: Oct 31, 2021Resident #2 admission date: May 16, 2020
The purpose of this visit was to investigate intake GA00219141. An unannounced visit was made to the facility on 12/01/2021, with the investigation starting on 11/30/2021 and completing on 12/08/2021.
Findings
The facility failed to ensure that a serious injury to a resident requiring medical attention was reported to the Department within 24 hours after the incident. Specifically, Resident #5 sustained a fall with a laceration and was hospitalized, but the Department was not notified as required.
Complaint Details
The visit was complaint-related, investigating intake GA00219141. The complaint was substantiated as the facility did not notify the Department of a serious injury incident involving Resident #5.
Severity Breakdown
E: 1
Deficiencies (1)
Description
Severity
Failed to report a serious injury requiring medical attention to the Department within 24 hours for Resident #5 after a fall resulting in a laceration and hospital evaluation.
E
Report Facts
Incident report date: Nov 19, 2021Previous citation date: Mar 27, 2021
Employees Mentioned
Name
Title
Context
Staff A
Interviewed and stated the Department was not notified of the 11/19/2021 incident report
The purpose of this visit was to investigate complaint intakes #GA00217303, #GA00217899, and #GA00217945, including allegations of sexual abuse and failure to notify family of change in resident condition.
Findings
The facility failed to ensure a resident was free from sexual abuse when Resident #3 kissed Resident #2 without consent, and failed to notify the family of Resident #1 about a hospital transfer following a change in condition. The investigation included interviews, record reviews, and incident report analysis.
Complaint Details
The investigation was complaint-driven based on intake numbers GA00217303, GA00217899, and GA00217945. Substantiation status is not explicitly stated in the report.
Severity Breakdown
SS= D: 1SS= E: 1
Deficiencies (2)
Description
Severity
Facility failed to ensure each resident had the right to be free from sexual abuse for 1 of 6 sampled residents (Resident #2) involving non-consensual kissing by Resident #3.
SS= D
Facility failed to notify the resident's next of kin/legal representative related to a change in the resident's condition for 1 of 6 sampled residents (Resident #1).
SS= E
Report Facts
Incident report date: Sep 24, 2021Emergency pendant activations: 10Hospital transfer date: Aug 31, 2021Sampled residents: 6Days notice given: 30
Employees Mentioned
Name
Title
Context
Staff A
Provided information about 30 days notice to Resident #3's family and email about failure to notify Resident #1's family
Staff G
Interviewed regarding Resident #2's report of non-consensual kissing by Resident #3
Staff F
Mentioned as recipient of Resident #2's report and instructed not to allow Resident #3 into Resident #2's bedroom; unresponsive to interview attempts
DD
Interviewed and stated unawareness of Resident #1 hospital transfer until hospital called
EE
Interviewed regarding Resident #2's report of non-consensual kissing by Resident #3
The purpose of this visit was to investigate intake #GA00209445 and #GA00209778 with an onsite visit made on 11/16/20 and the investigation completed on 11/30/20.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00209445 and #GA00209778 with no rule violations cited.
The purpose of this visit was to conduct a compliance inspection and to investigate complaint intakes #GA00203031, #GA00202854, and #GA00203379, which were open on 2020-03-02 and completed on 2020-03-27.
Findings
The facility failed to ensure adequate and appropriate care for Resident #3 who had multiple falls resulting in serious injuries and death, failed to notify the resident's next of kin/legal representative for Resident #9 after a fall, and failed to report a serious injury to the Department within 24 hours for Resident #3.
Complaint Details
The inspection was complaint-related, investigating intakes #GA00203031, #GA00202854, and #GA00203379. Findings included substantiated failures in care, notification, and reporting related to Resident #3 and Resident #9.
Severity Breakdown
J: 1D: 2
Deficiencies (3)
Description
Severity
Facility failed to ensure adequate care and services for Resident #3 who sustained falls resulting in abrasions, hematoma, possible fracture, and death.
J
Facility failed to notify Resident #9's next of kin/legal representative of a change in condition after a fall.
D
Facility failed to report serious injury to the Department within 24 hours for Resident #3.
D
Report Facts
Sampled residents: 9Incident dates: Aug 8, 2019Incident dates: Oct 8, 2019Incident dates: Feb 13, 2020
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding Resident #3 fall, hospital admission, hospice, and Department notification
Staff H
Interviewed regarding Resident #3 fall in bathroom and calling 911
Staff K
Interviewed regarding failure to notify family of Resident #9 fall
The purpose of this visit was to investigate intake #GA00201522 regarding potential missing narcotics at the facility.
Findings
The facility failed to ensure that residents' property and possessions were safeguarded, with multiple residents found to have missing narcotics that were tampered with and replaced by other medications. An internal investigation and police report confirmed the theft and tampering of medications.
Complaint Details
The investigation was initiated due to intake #GA00201522 concerning missing narcotics. The complaint was substantiated by record review, staff interviews, and a police report confirming medication theft and tampering.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failed to ensure that all residents' property and possessions were safeguarded for 4 of 4 sampled residents, with missing and tampered narcotics.
Notified of potential missing narcotics and reported the incident to the Department
Staff B
Reviewed narcotics cards, conducted audit, notified director of health services, local police, pharmacy, and proxy care nurse, and initiated internal investigation
Staff D
Counted medications and observed tampering on narcotics cards
Inspection Report Original LicensingDeficiencies: 4Mar 11, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection and to investigate intake #GA00194996.
Findings
The facility failed to comply with fire safety rules, maintain clean and safe conditions, secure outdoor spaces to prevent undetected egress, and ensure proper handling of food to prevent contamination.
Complaint Details
Investigation included intake #GA00194996.
Severity Breakdown
D: 4
Deficiencies (4)
Description
Severity
Failure to comply with fire and safety rules including presence of unplugged space heaters and missing documentation of fire drills in June 2018.
D
Failure to maintain interior clean, in good repair, and free of unsafe conditions including water infiltration causing stained ceiling tiles.
D
Failure to secure outdoor spaces preventing undetected egress; gate latch allowed residents to exit without lock.
D
Failure to ensure all foods stored were protected from spoilage and contamination; uncovered food containers found unattended.
D
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding deficiencies and corrective actions.
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