The most recent inspection on September 10, 2025, found no deficiencies during complaint investigations. Earlier inspections showed a mixed record, with some deficiencies related mainly to staff health screenings, criminal background checks, resident rights, and supervision. Prior reports cited issues such as missing tuberculosis screenings for staff, incomplete background checks, failure to protect residents’ rights regarding sitter agency choices, and inadequate oversight leading to resident elopements and falls. Complaint investigations were mostly unsubstantiated except for a few substantiated cases involving staffing, resident safety, and documentation. The facility’s recent inspections indicate improvement, with no deficiencies noted in the latest visits after earlier issues.
Deficiencies (last 8 years)
Deficiencies (over 8 years)0.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake #GA00248278. The onsite visit was made on 9/4/24 and the inspection was completed on 9/4/24.
Findings
The facility failed to ensure that staff health examinations and tuberculosis screenings were completed for 2 of 4 sampled staff members. Specifically, Staff C and Staff D did not have documentation of a physical examination or tuberculosis screening within twelve months prior to providing care.
Complaint Details
Investigation of intake #GA00248278. The deficiency was substantiated by record review and interviews confirming missing physical examinations and tuberculosis screenings for two staff members.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to ensure staff health examinations and tuberculosis screenings were completed for Staff C and Staff D within twelve months prior to providing care.
SS= D
Report Facts
Number of sampled staff missing required screenings: 2Number of sampled staff reviewed: 4
The purpose of this visit was to investigate intake #GA00233477 and #GA00. An administrative review began on 2023-03-13 and was completed on 2023-04-06.
Findings
The facility failed to ensure that direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 1 of 1 sampled staff (Staff B). The facility did not have a copy of a GCHEX background check for Staff B nor was Staff B found in the GCHEX system.
Complaint Details
Investigation of intake #GA00233477 and #GA00. Administrative review conducted from 2023-03-13 to 2023-04-06.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement in the position for 1 of 1 sampled staff (Staff B).
SS= D
Employees Mentioned
Name
Title
Context
Staff B
Direct care staff missing required criminal background check.
Staff A
Provided email stating no approved GCHEX background check for Staff B.
The purpose of this inspection was to investigate intake #GA00207732, conducted from 2020-09-08 to 2020-09-16.
Findings
The facility failed to have enough staff to meet the specific resident ongoing health and safety needs, resulting in delayed responses to emergency pendants for 8 of 12 sampled residents. Additionally, multiple residents experienced falls resulting in fractures and injuries, indicating inadequate care and safety measures.
Complaint Details
Investigation was complaint-related, intake #GA00207732. The complaint was substantiated based on findings of inadequate staffing and care leading to delayed emergency response and resident falls with injuries.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Facility failed to have enough staff to meet resident ongoing health and safety needs, causing delayed response times to emergency pendants for multiple residents.
SS= D
Facility failed to ensure each resident received adequate and appropriate care and services, evidenced by multiple resident falls and injuries.
SS= D
Report Facts
Response time to emergency pendants: 397Number of sampled residents with delayed response: 8Number of residents sampled: 12Fall incidents: 8Minutes for acceptable emergency call response: 15
The purpose of this visit was to investigate complaint GA00193400.
Findings
The facility failed to protect residents' rights to make choices about significant aspects of their lives, specifically regarding the selection of sitter agencies. It was found that a staff member owned a private sitter agency and residents were not given various choices as required.
Complaint Details
The visit was complaint-related to investigate complaint GA00193400. The complaint involved failure to protect residents' rights to choose sitter agencies, with substantiation indicated by findings of conflict of interest and policy violation by staff.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to protect each resident's rights to make choices about aspects of his or her life in the assisted living community that are significant to the resident.
SS= D
Employees Mentioned
Name
Title
Context
Staff D
Owned a private home care agency providing sitter services to Resident #1, involved in conflict of interest violation.
Staff C
Former employee who referred residents to Staff D's sitter agency.
Staff A
Interviewed and stated unawareness of conflict of interest and violation of facility policy by Staff D and Staff C.
The purpose of this visit was to investigate complaint intakes #GA00189504 and #GA00189177 involving incidents of residents eloping from the facility.
Findings
The facility failed to provide necessary oversight and protective care, resulting in two residents eloping multiple times and being found offsite, including at a local gym, urgent care center, and a river across the facility. Staff interviews and record reviews confirmed inadequate supervision and failure to report behaviors that could have prevented incidents.
Complaint Details
The investigation was triggered by complaint intakes #GA00189504 and #GA00189177 regarding residents eloping from the facility. The complaints were substantiated based on record reviews and staff interviews.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Failure to provide necessary oversight and operate in compliance with licensing and state regulations, evidenced by residents eloping from the facility.
SS= D
Failure to provide protective care and watchful oversight for residents, resulting in elopements and unsafe conditions.