Inspection Report
Follow-Up
Deficiencies: 0
Oct 3, 2025
Visit Reason
The purpose of this visit was to conduct a follow up inspection. An unannounced onsite visit was made on 10/2/25 and completed on 10/3/25.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 10, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005681, with the inspection starting on 2025-09-09 and completing on 2025-09-10.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA50005681; no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 12, 2025
Visit Reason
The purpose of this visit was to conduct investigations of intake #50004416, GA50004775, and GA50004786 with an on-site visit made on 8/12/25.
Findings
The inspection was started on 8/12/25 and completed on 8/14/25. No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes #50004416, GA50004775, and GA50004786. No rule violations were found.
Inspection Report
Follow-Up
Deficiencies: 3
Aug 5, 2025
Visit Reason
The visit was conducted as a follow-up to the complaint investigation initiated on 2025-05-15, with an unannounced onsite visit made on 2025-07-29 and completed on 2025-08-05.
Findings
The facility failed to maintain required personnel files for employees and individual resident files for residents, with repeated violations noted from previous inspections. These deficiencies compromise the facility's ability to ensure compliance with state rules and provide consistent, personalized care.
Complaint Details
This follow-up visit was conducted in response to a complaint investigation initiated on 2025-05-15. The report documents repeated violations related to personnel and resident files, indicating ongoing noncompliance.
Severity Breakdown
SS=F: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain personnel files in the assisted living community for each employee for 3 of 3 sampled staff (Staff B, Staff C, Staff D). | SS=F |
| Failure to maintain an individual resident file for each resident in the assisted living community for 3 of 3 sampled residents (Resident #1, Resident #2, Resident #3). | SS=F |
| Failure of the governing body to ensure the home operated in compliance with state rules and regulations, including maintaining personnel and resident files. | SS=D |
Report Facts
Previous violation dates: 5
Sampled staff without personnel files: 3
Sampled residents without files: 3
Inspection Report
Follow-Up
Census: 22
Deficiencies: 4
Jun 5, 2025
Visit Reason
The purpose of this visit was to conduct a follow-up to survey #44636 with an unannounced onsite visit made on 6/4/2025 and completed on 6/5/2025.
Findings
The facility failed to maintain personnel files for staff, individual resident files, and did not have a registered nurse or licensed practical nurse on-site as required. These deficiencies were previously cited in prior inspections and remain uncorrected.
Severity Breakdown
SS=F: 2
SS=E: 1
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to maintain personnel files in the assisted living community for 3 of 3 sampled staff (Staff B, Staff C, and Staff D). | SS=F |
| Failure to maintain individual resident files for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). | SS=F |
| Failure to ensure a registered professional nurse or licensed practical nurse was on-site to support care and oversight of residents (minimum 8 hours per week for communities with 1 to 30 residents). | SS=E |
| Failure of the governing body to provide oversight to ensure compliance with state rules and regulations. | SS=D |
Report Facts
Residents: 22
Staff with missing personnel files: 3
Residents with missing files: 3
Minimum RN/LPN hours required: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and stated no staff or resident files were available for review | |
| Staff B | Staff member with missing personnel file | |
| Staff C | Staff member with missing personnel file | |
| Staff D | Staff member with missing personnel file and present during onsite visit |
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 30, 2025
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA50002245, #GA50002251, #GA50002438, and #GA50002551. An onsite visit was made on 4/30/2025 and the investigation was completed on 5/15/2025.
Findings
The facility failed to maintain personnel files for employees, resident files including admission agreements and retention after discharge, failed to take appropriate actions and document adverse changes in residents' conditions, and failed to report serious injuries requiring medical attention to the Department within required timeframes. Observations included residents with injuries and missing documentation, and interviews revealed lack of incident reports and inconsistent staff knowledge regarding injuries and reporting.
Complaint Details
The visit was complaint-related, investigating four complaint intakes (#GA50002245, #GA50002251, #GA50002438, #GA50002551). The facility failed to submit required reports to the Department regarding serious injuries to residents. Complaints were submitted by EE, FF, GG, and KK, but none were submitted by the facility. KK submitted a report regarding a serious injury of Resident #2 that required medical attention.
Severity Breakdown
F: 1
D: 3
G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain personnel files for 2 of 3 sampled staff (Staff C and Staff D). | F |
| Failed to include a signed copy of the admission agreement for 1 of 3 sampled residents (Resident #2). | D |
| Failed to maintain resident files for a period of three years after discharge for 1 of 3 sampled residents (Resident #1). | D |
| Failed to take appropriate actions and retain records of adverse changes in condition for 2 of 3 sampled residents (Resident #2 and Resident #3). | D |
| Failed to report serious injuries requiring medical attention for 3 of 3 sampled residents (Resident #2 and Resident #3). | G |
Report Facts
Sampled staff: 3
Sampled residents: 3
Previous citations: 2
Fall date: Mar 25, 2025
Photo date: Mar 26, 2025
Admission date: Nov 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding missing personnel files, resident files, injury reports, and incident documentation | |
| Staff C | Interviewed regarding resident injuries and falls; provided statements about observations and assumptions | |
| Staff D | Mentioned as missing personnel file | |
| II | Interviewed regarding medical treatment advice for Resident #2 | |
| HH | Family member concerned about Resident #2; provided information about fall and injuries | |
| KK | Submitted complaint report regarding serious injury of Resident #2 | |
| EE | Submitted complaint report regarding serious injuries requiring medical attention | |
| FF | Submitted complaint report regarding serious injuries requiring medical attention | |
| GG | Submitted complaint report regarding serious injuries requiring medical attention |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 3
Mar 19, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001185 through an unannounced onsite visit conducted on 3/19/2025 and completed on 3/20/2025.
Findings
The facility failed to maintain personnel files for all employees, lacked a licensed nurse on-site as required for the resident census, and did not maintain individual resident files for sampled residents. These deficiencies were supported by observations, record reviews, and interviews.
Complaint Details
The visit was complaint-related, investigating intake #GA50001185. The complaint was substantiated by findings of missing personnel and resident files and lack of licensed nursing staff.
Severity Breakdown
E: 2
D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain personnel files for 3 of 3 sampled staff (Staff C, Staff D, Staff E). | E |
| Failed to ensure a registered professional nurse or licensed practical nurse was on-site to support care and oversight for 25 residents. | D |
| Failed to maintain individual resident files for 3 of 3 sampled residents (Resident #1, Resident #2, Resident #3). | E |
Report Facts
Residents present: 25
Staff missing personnel files: 3
Residents missing files: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding absence of personnel and resident files and facility nursing staff | |
| Staff B | Interviewed regarding management of staff and resident files and nursing staff absence | |
| Staff C | Sampled staff missing personnel file | |
| Staff D | Sampled staff missing personnel file | |
| Staff E | Sampled staff missing personnel file and present during onsite visit |
Inspection Report
Complaint Investigation
Deficiencies: 4
Jan 27, 2025
Visit Reason
The purpose of this investigation was to investigate intake # GA50000617 and complete a compliance inspection, conducted on-site from January 27, 2025 to January 29, 2025.
Findings
The facility failed to ensure that staff received required initial and ongoing training, including current certification in emergency first aid, tuberculosis screening and physical examinations within twelve months, and satisfactory fingerprint background checks for direct access employees. Documentation was missing for multiple staff files.
Complaint Details
Investigation was initiated based on intake # GA50000617 to assess compliance with training, health screenings, and background checks.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure staff received initial training within the first 60 days of employment, including current certification in emergency first aid for 1 of 3 sampled staff (Staff A and Staff C). | Level D |
| Failure to ensure ongoing staff training of at least sixteen hours annually for 3 of 3 sampled staff (Staff A, Staff C, and Staff AA). | Level D |
| Failure to maintain documentation of tuberculosis screening and physical examination within twelve months for 1 of 3 sampled staff (Staff A). | Level D |
| Failure to obtain satisfactory fingerprint record check for 1 of 3 sampled staff (Staff B). | Level D |
Report Facts
Number of sampled staff with training deficiencies: 3
Number of sampled staff with fingerprint check deficiency: 1
Number of sampled staff with missing physical exam and TB screening: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in deficiencies related to missing first aid certification, ongoing training, physical examination, and tuberculosis screening. | |
| Staff B | Named in deficiency related to missing fingerprint record check. | |
| Staff C | Named in deficiencies related to missing first aid certification and ongoing training. | |
| Staff AA | Named in deficiency related to missing ongoing training documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 3, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00247690 with an onsite visit conducted from 7/3/2024 to 7/9/2024.
Findings
The facility failed to maintain personnel files for 3 sampled staff members and individual resident files for 3 sampled residents, with no files available for review as of 7/3/2024 and no files received by the Department as of 7/9/2024.
Complaint Details
Investigation of intake # GA00247690. The deficiencies were substantiated based on record review and interviews.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain personnel files for each employee and for three years following departure for 3 of 3 sampled staff (Staff B, Staff C, and Staff D). | D |
| Failure to maintain individual resident files for each resident for 3 of 3 sampled residents (Resident #1, Resident #2, and Resident #3). | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 7/3/2024 and stated inability to provide files due to being out sick and needing to 'get them together'. | |
| Staff B | Personnel file missing as part of deficiency. | |
| Staff C | Personnel file missing as part of deficiency. | |
| Staff D | Personnel file missing as part of deficiency. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2024
Visit Reason
The visit was conducted to investigate intake #GA00244088 with an onsite visit on 3/19/2024 and investigation completion on 3/22/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00244088 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA00242865.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake GA00242865; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 21, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237209.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00237209 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 process.
Findings
No specific findings or deficiencies are detailed in the report.
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 25, 2020
Visit Reason
The visit was conducted to review documentation submitted by the facility to verify correction of violations cited during the previous compliance inspection on 2019-12-04.
Findings
The review confirmed that the violation(s) cited on the 2019-12-04 compliance inspection have been corrected.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00201666.
Findings
No rules violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint #GA00201666 with no violations found.
Inspection Report
Routine
Deficiencies: 8
Dec 4, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection of the assisted living community.
Findings
The facility failed to ensure that staff received required training within the first 60 days of employment in areas including Residents' Rights, emergency preparedness, emergency first aid, CPR, and medical and social needs of residents. Additionally, the facility did not comply with fire safety rules regarding fire drills, failed to ensure physical examinations were completed prior to admission for some residents, and did not report a serious injury incident to the Department within 24 hours as required.
Severity Breakdown
D: 6
E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure staff received training within the first 60 days on Residents' Rights for 2 of 3 sampled staff (Staff B and Staff C). | D |
| Failed to ensure staff received training within the first 60 days on emergency preparedness for 2 of 3 sampled staff (Staff B and Staff C). | D |
| Failed to ensure staff hired to provide hands-on personal services received emergency first aid training within the first 60 days for 1 of 3 sampled staff (Staff B). | D |
| Failed to ensure staff hired to provide hands-on personal services received CPR training within the first 60 days for 1 of 3 sampled staff (Staff B). | D |
| Failed to ensure staff were trained in medical and social needs and characteristics of the resident population for 2 of 3 sampled staff (Staff B and Staff C). | D |
| Failed to comply with fire safety rules requiring one fire drill per quarter per shift; only 2 drills conducted since facility opened. | E |
| Failed to ensure all residents had a physical examination by a licensed provider dated within 30 days prior to admission for 2 of 4 sampled residents (Resident #1 and Resident #2). | E |
| Failed to report a serious injury requiring medical attention to the Department within 24 hours for 1 of 4 sampled residents (Resident #4). | D |
Report Facts
Fire drills conducted: 2
Residents sampled: 4
Staff sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in multiple training deficiencies including Residents' Rights, emergency preparedness, emergency first aid, CPR, and medical/social needs training; certifications expired. | |
| Staff C | Named in training deficiencies for Residents' Rights, emergency preparedness, and medical/social needs training. | |
| Staff A | Interviewed staff who confirmed training deficiencies and lack of reporting. |
Inspection Report
Complaint Investigation
Deficiencies: 6
May 13, 2019
Visit Reason
The purpose of this visit was to investigate complaint # GA00196426.
Findings
The facility failed to meet multiple regulatory requirements including fire safety due to expired fire extinguisher tags and lack of fire drills, unsanitary conditions such as feces on resident's floor and walls, failure to document tuberculosis screening prior to admission for one resident, failure to administer prescribed medication properly, improper food labeling, and inadequate resident care as evidenced by a resident's soaked mattress and delayed staff response to call buttons.
Complaint Details
The visit was complaint-related, investigating complaint # GA00196426.
Severity Breakdown
D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Fire extinguisher in the kitchen had an expired tag dated 04/03/18 and no documentation of fire drills since facility opening in November 2018. | D |
| Interior and exterior of the community were not free of unsanitary or unsafe conditions; Resident #1 had feces on floor and walls. | D |
| No documentation of tuberculosis screening prior to admission for Resident #1. | D |
| Staff failed to administer prescribed antifungal cream daily to Resident #1 as ordered. | D |
| Food in refrigerator was not labeled. | D |
| Resident #1's mattress was soaked with urine and stained with feces; staff delayed response to call button and inadequate care provided. | D |
Report Facts
Date of expired fire extinguisher tag: Apr 3, 2018
Date of admission for Resident #1: Jan 24, 2019
Weight of Resident #1: 650
Date of inspection: May 13, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding fire extinguisher inspection, fire drills, cleaning of unsanitary conditions, medication administration, food labeling, and resident care |
Inspection Report
Original Licensing
Deficiencies: 0
Oct 29, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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