Inspection Report Summary
The most recent inspection on December 16, 2024, found no deficiencies. Earlier inspections also generally showed no deficiencies, with complaint investigations consistently resulting in no rule violations. However, prior reports identified issues mainly related to medication administration errors, narcotic diversion oversight, and staff training deficiencies. One substantiated complaint involved a medication error causing harm to a resident, and another involved failure to honor a DNR order during a choking incident. The facility’s inspection history shows improvement over time, with no deficiencies noted in recent years and no enforcement actions listed in the available reports.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 16, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00252236.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00252236 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2023
Visit Reason
A visit was made to the facility to investigate intake #GA 002339591.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA 002339591 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 31, 2023
Visit Reason
The visit was conducted to investigate intake #GA00234695 with an onsite visit made on 5/31/23 and the investigation completed on 6/8/23.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of intake #GA00234695; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2023
Visit Reason
The purpose of this visit was to investigate intake GA0023088, GA00232068, and GA0023069.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA0023088, GA00232068, and GA0023069 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 16, 2022
Visit Reason
The purpose of this visit was to investigate intake# GA00225748.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation of intake# GA00225748 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 11, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00220573.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00220573; no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 20, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00217841 and #GA00217855.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2021-10-06 and was completed on 2021-12-20. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 1, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00216787 and #GA00216614, with an on-site visit conducted on 2021-08-24 and the investigation completed on 2021-09-01.
Findings
The facility failed to provide medication administration services in accordance with physicians' orders and resident needs, resulting in a medication error where Resident #3 was given an overdose of Methadone causing hospitalization and subsequent death. The facility also failed to ensure adequate and appropriate care and services for Resident #3 in compliance with state law and regulations.
Complaint Details
The investigation was complaint-driven based on intakes #GA00216787 and #GA00216614. Resident #3 received an accidental overdose of Methadone on 2021-08-05, was hospitalized, and later died from COVID-19. Staff interviews revealed the overdose was due to a medication administration error by Staff C, who measured 10 ml instead of 1 ml of Methadone. The facility failed to provide adequate monitoring and care following the error.
Severity Breakdown
G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide medication administration services in accordance with physicians' orders, resulting in Resident #3 receiving an incorrect Methadone dosage causing hospitalization. | G |
| Failed to ensure each resident received adequate, appropriate care and services in compliance with state law and regulations for Resident #3. | G |
Report Facts
Medication dosage error: 10
Medication dosage prescribed: 1
Date of overdose incident: Aug 5, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Administered incorrect Methadone dosage causing overdose to Resident #3. | |
| Staff A | Received report of medication error and communicated with family and hospice nurse. | |
| Staff B | Supervised Staff C after retraining following medication error. | |
| EE | Expressed hesitation in prescribing Methadone to Resident #3 and was notified of the medication error. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 26, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00215802.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2021-07-26 and was completed on 2021-06-29. No rule violations were found.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 31, 2021
Visit Reason
The purpose of this visit was to conduct an annual inspection and investigate intake #GA00209804, GA00209805, and #GA00213236.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2021-03-29 and was completed on 2021-03-31. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00207683.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began on 2020-09-04 and was completed on 2020-09-09. No rule violation was found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 11, 2020
Visit Reason
The visit on 8/11/20 was conducted to investigate intake #GA00206690 and was completed on 8/13/20.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00206690 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 8, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205170.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began on 2020-05-29 and was completed on 2020-06-08. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00204835.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began 2020-05-04 and was completed 2020-05-13. No rule violations were found.
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: 3
Dec 3, 2019
Visit Reason
The visit was conducted to investigate intake #GA00201041 regarding potential narcotic diversion at the assisted living facility.
Findings
The facility failed to provide necessary oversight to prevent narcotic diversion, including improper narcotic reconciliation, failure to report termination of a medication aide to the registry, and failure to properly inventory controlled substances. A sleeve of 30 Oxycodone pills was missing, and staff did not follow required counting procedures.
Complaint Details
The investigation was initiated due to a complaint regarding theft of narcotics. The complaint was substantiated by findings of missing narcotics and procedural failures in narcotic handling and reporting.
Severity Breakdown
D: 2
J: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide necessary oversight to prevent narcotic diversion, including improper narcotic reconciliation and counting procedures. | D |
| Failure to report termination of a certified medication aide to the Georgia Certified Medication Aide Registry. | D |
| Failure to properly inventory controlled substances to prevent narcotic diversion. | J |
Report Facts
Missing narcotic tablets: 30
Prescribed quantity: 150
Medication frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Certified Medication Aide | Terminated for falsification of medication records and failure to report termination to registry. |
| Staff A | Reported missing narcotics and was notified of potential theft. | |
| Staff D | Had narcotic keys and failed to reconcile narcotics properly. | |
| Staff F | Did not count narcotics on the third floor as required. | |
| Staff G | Noted narcotic sheets were not numbered sequentially. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Nov 14, 2019
Visit Reason
The purpose of this visit was to investigate intake GA00200573 with an on-site visit conducted on 11/14/19 and investigation completed on 11/27/19.
Findings
The facility failed to ensure that staff hired to provide hands-on personal services to residents received required training within the first 60 days of employment. Specifically, one of nine sampled staff (Staff F) did not have current certification in emergency first aid or cardiopulmonary resuscitation (CPR).
Complaint Details
Investigation was conducted based on intake GA00200573. The complaint was substantiated as the facility failed to ensure required staff training for emergency first aid and CPR for one staff member.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff F did not have documentation of current certification in emergency first aid within the first 60 days of employment. | SS= D |
| Staff F did not have documentation of current certification in cardiopulmonary resuscitation (CPR) within the first 60 days of employment. | SS= D |
Report Facts
Number of sampled staff: 9
Number of deficient staff: 1
Staff F hire date: Sep 11, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in findings for lack of emergency first aid and CPR certification |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 14, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00200068.
Findings
The facility failed to ensure all staff received required training on medical and social needs of the resident population, specifically hospice care. Additionally, the facility failed to honor a signed Do Not Resuscitate (DNR) order for Resident #1 during a choking incident, resulting in inappropriate resuscitation efforts.
Complaint Details
The investigation was triggered by intake #GA00200068 concerning failure to honor a DNR order and inadequate staff training related to hospice care. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure all staff have training in medical and social needs and characteristics of the resident population, including hospice care (Staff D). | SS= D |
| Facility failed to honor signed medical orders impacting end of life care, specifically the DNR order for Resident #1 during a choking incident. | SS= D |
Report Facts
Date of choking incident: Nov 13, 2019
Number of staff involved in Heimlich maneuver: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Failed to receive training on hospice care and involved in CPR during choking incident | |
| Staff G | Called to Resident #1's room during choking incident, performed Heimlich maneuver, discovered DNR after EMS arrival | |
| Staff E | Interviewed regarding the incident and staff actions during choking event | |
| Staff C | Called 911 during choking incident | |
| Staff F | Provided information about EMT call for Resident #1 | |
| Staff B | Gave EMTs the DNR form when Resident #1 was transferred |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00196869.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00196869 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00195466.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00195466 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 21, 2019
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00193156, #GA00194677, and #GA00194571 with onsite visits conducted on 2/20/19 and 2/21/19 and the investigation completed on 3/21/19.
Findings
The facility failed to maintain updated medication administration records (MAR) for residents, specifically Resident #8, where medication changes were not timely updated or documented. Additionally, the facility failed to obtain new prescriptions within 48 hours for Resident #2, resulting in medication not being available and administered as ordered.
Complaint Details
The investigation was complaint-driven based on concerns reported in an incident report dated 2/8/19 about residents not receiving prescribed medications, receiving discontinued medications, and medication changes not being updated timely.
Severity Breakdown
SS= D: 1
SS= J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to maintain an updated medication administration record (MAR) for Resident #8, including failure to document medication changes and administration of eye drops. | SS= D |
| Failed to obtain new prescriptions within 48 hours of notice for Resident #2, resulting in medication not being available or administered. | SS= J |
Report Facts
Sampled residents: 11
Medication not given days: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding medication administration and pharmacy communication for Residents #8 and #2 | |
| Staff C | Interviewed regarding administration of Travatan eye drops to Resident #8 without documentation | |
| Staff D | Interviewed regarding unavailability of Cartia XT medication for Resident #2 | |
| MM | Interviewed and stated pharmacy never received prescription or order for Resident #2's medication |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 20, 2018
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00191524, #GA00191964, #GA00192684, and #GA00192977 with on-site visits conducted on 10/10/18 and 11/20/18.
Findings
The facility failed to immediately take appropriate actions in response to a sudden adverse change in condition for Resident #1, specifically failing to notify the resident's family/representative of an open sacral wound. The nurse responsible was terminated for failure to report the pressure ulcer.
Complaint Details
Investigation was conducted based on complaint intakes #GA00191524, #GA00191964, #GA00192684, and #GA00192977. The complaint was substantiated as the facility failed to notify Resident #1's family of a pressure ulcer and failed to take immediate appropriate action.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately take actions appropriate to a sudden adverse change in Resident #1's condition, including failure to notify family/representative of an open sacral wound. | SS= D |
Report Facts
Complaint intakes investigated: 4
Dates of on-site visits: 10/10/2018 and 11/20/2018
Resident #1 admission date: 1/30/2017
Dates of skin assessments: 9/22/2018, 9/24/2018, 9/30/2018
Date Resident #1 moved out: 9/30/2018
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00192207.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00192207 was investigated and found to have no violations.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
Oct 10, 2018
Visit Reason
The purpose of this visit was to investigate self-reported incidents #GA00191524 and #GA00191964 related to resident care concerns.
Findings
The facility failed to inform the legal representative of a change in the resident's condition for 1 of 75 residents (Resident #2), specifically regarding a wound on the resident's buttock area. Staff attempted to obtain a doctor's order for home health care but did not receive a response.
Complaint Details
The visit was complaint-related, investigating self-reported incidents #GA00191524 and #GA00191964. The complaint was substantiated as the facility failed to notify the legal representative about the resident's wound.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to inform the legal representative of a change in the resident's condition for Resident #2 regarding a wound. | J |
Report Facts
Residents present: 75
Incident numbers linked: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 10, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate self-reported incident #GA00190291, with onsite visits on 8/7/18 and 8/8/18, and investigation completed on 8/10/18.
Findings
The facility failed to ensure that hot water temperatures in 5 of 6 sampled bathroom sinks did not exceed 120 degrees Fahrenheit, with recorded temperatures ranging from 124 to 128 degrees Fahrenheit.
Complaint Details
Investigation was conducted related to self-reported incident #GA00190291.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Hot water temperatures in 5 of 6 sampled bathroom sinks exceeded 120 degrees Fahrenheit, ranging from 124 to 128 degrees F. | SS= D |
Report Facts
Hot water temperature: 126
Hot water temperature: 126
Hot water temperature: 128
Hot water temperature: 125
Hot water temperature: 124
Hot water temperature: 127.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Interviewed regarding hot water temperature testing and measurement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2018
Visit Reason
The purpose of this visit was to investigate a self-reported incident GA#00185143.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of self-reported incident GA#00185143 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 18, 2017
Visit Reason
The purpose of this visit was to investigate complaint GA00179302.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint GA00179302 was investigated and found to have no rule violations.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 9, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 22, 2017
Visit Reason
The purpose of this visit was to conduct a follow-up to the 8/24/16 complaint investigation.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Follow-up to the 8/24/16 complaint investigation; no rule violations cited.
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