Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 20, 2025
Visit Reason
The purpose of this visit was to conduct a complaint inspection (GA50006245 and GA50006455).
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint inspection conducted with no rule violations cited.
Inspection Report
Original Licensing
Deficiencies: 0
Mar 26, 2025
Visit Reason
The purpose of this visit was to conduct a change of ownership inspection.
Findings
No rule violations were cited as a result of this inspection. The facility was closed during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2024
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake # GA00244773.
Findings
No rule violations were cited as a result of this inspection and investigation.
Complaint Details
Investigation of intake # GA00244773 with no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235626 and #GA00235632 with an on-site visit made to the facility on 6/27/23. The investigation started on 6/27/23 and was completed on 6/28/23.
Findings
The facility failed to ensure a written admission agreement was entered into between the governing body and the resident for 1 of 4 residents sampled (Resident #3). A review of Resident #3's file showed no admission agreement documents, and staff was unaware of this omission.
Complaint Details
Investigation of intake #GA00235626 and #GA00235632. The investigation was complaint-related and conducted on-site from 6/27/23 to 6/28/23.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a written admission agreement was entered into between the governing body and the resident for Resident #3. | D |
Inspection Report
Complaint Investigation
Census: 11
Deficiencies: 5
Nov 30, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00228006 and #GA00229687 with onsite visits conducted on 11/29/22 and 11/30/22.
Findings
The facility was found deficient in multiple areas including failure to maintain clean and well-repaired floors, walls, and ceilings; inadequate hot water supply; failure to retain residents requiring restraints properly; insufficient staffing levels; and a non-operational kitchen with broken dishwasher, ice machine, and juice machine.
Complaint Details
The visit was complaint-related, investigating intakes #GA00228006 and #GA00229687. The investigation was completed on 11/30/22.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to keep floors, walls, and ceilings clean and in good repair, including large black areas on bedroom floors, peeling paint, missing doorknobs, and debris on floors. | D |
| Facility failed to ensure an adequate hot water system supplying heated water comfortable to the touch, with water temperatures measured at 83.4°F and 84.2°F, and resident complaints of insufficient hot water. | D |
| Facility failed to not retain residents who required restraints properly, with improper use of side rails on Resident #9's bed. | D |
| Facility failed to maintain minimum staffing requirements, with only one CMA on multiple shifts and two staff present during night shifts for 11 residents. | D |
| Facility failed to have a fully operational kitchen; dishwasher, ice machine, and juice machine were not working for over 90 days. | D |
Report Facts
Water temperature: 83.4
Water temperature: 84.2
Facility census: 11
Duration dishwasher broken: 90
Inspection Report
Monitoring
Deficiencies: 0
Jun 23, 2022
Visit Reason
The purpose of the visit was to monitor services at the facility.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 20, 2021
Visit Reason
The purpose of this inspection was to conduct the annual inspection and investigate intake #GA00213368 and #GA00213271.
Findings
No rule violations were cited as a result of this inspection and investigation.
Complaint Details
Investigation started on 2021-04-06 and was completed on 2021-04-20; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 4, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00209049.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began on 2020-10-30 and was completed on 2020-11-04. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 15, 2020
Visit Reason
The purpose of this inspection was to investigate intake GA00208012.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began on 2020-09-29 and was completed on 2020-10-15. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2020
Visit Reason
The purpose of this survey was to investigate complaint intakes #GA00206675 and #GA00207036.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation was initiated on 2020-07-29 and completed on 2020-10-08. No deficiencies 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: 5
Aug 27, 2019
Visit Reason
The purpose of this visit was to investigate intake numbers GA00198876, GA00198869, and GA00199075.
Findings
The facility, licensed as a personal care home but not as an assisted living community, was found to be providing assisted living care and misrepresenting itself as an assisted living community. Additionally, multiple workforce qualification deficiencies were identified, including lack of current emergency first aid and CPR certifications for several staff, failure to obtain satisfactory criminal records checks prior to employment, and inadequate response times to resident call lights.
Complaint Details
The visit was complaint-related, investigating intake numbers GA00198876, GA00198869, and GA00199075.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility licensed as a personal care home but providing assisted living care and misrepresenting as an assisted living community. | D |
| Failed to ensure 3 of 4 sampled staff had current certification in emergency first aid. | D |
| Failed to ensure 2 of 4 sampled staff had current certification in cardiopulmonary resuscitation (CPR). | D |
| Failed to obtain satisfactory criminal records check prior to employment for 4 of 4 sampled staff. | D |
| Failed to ensure each resident received adequate and appropriate care and services in compliance with applicable laws and regulations. | D |
Report Facts
Calls with response time 10 minutes or greater: 234
Pendant pushes: 70
Calls with response time 10 minutes or greater: 68
Pendant pushes: 83
Staff sampled for training and background checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings for lack of emergency first aid certification, CPR certification, and criminal records check. | |
| Staff C | Named in findings for lack of emergency first aid certification and criminal records check. | |
| Staff D | Named in findings for lack of emergency first aid certification, CPR certification, and criminal records check. | |
| Staff B | Named in findings for lack of criminal records check. | |
| Staff E | Interviewed staff who was unaware of deficiencies related to certifications and response times. | |
| AA | Resident who reported delayed response times to call lights and buzzer. |
Inspection Report
Routine
Deficiencies: 0
Aug 23, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection.
Findings
No rule violations were written as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 1, 2019
Visit Reason
The visit was conducted to investigate intake #GA00194276 following a complaint regarding medication administration and supervision.
Findings
The facility failed to ensure non-nursing staff properly supervised self-administration of medications for 1 of 2 sampled residents, resulting in Resident #1 ingesting another resident's medication mixed in applesauce, leading to an emergency room visit.
Complaint Details
The complaint investigation was substantiated by findings that Resident #1 ingested medications not prescribed to them, resulting in altered mental status and an emergency room visit. Staff interviews confirmed improper medication supervision and administration practices.
Severity Breakdown
SS= D: 1
SS= J: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure non-nursing staff supervised self-administration of medications as required, leading to Resident #1 ingesting medications belonging to Resident #2. | SS= D |
| Failure to ensure each resident received adequate and appropriate care and services in compliance with applicable laws for Resident #1. | SS= J |
Report Facts
Incident date: Jan 21, 2019
Incident report date: Jan 22, 2019
Medication administration time: 1700
Resident #2 medications: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed staff who placed Resident #2 medications in applesauce and did not supervise consumption | |
| Staff A | Interviewed staff who received call about Resident #1 emergency and confirmed incident details | |
| Staff C | Staff who observed Resident #1 convulsing and called 911 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 1, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00191610 regarding failure to notify a resident's representative after an accident.
Findings
The facility failed to notify the representative or legal surrogate of Resident #1 after a fall resulting in bruises and bleeding. Staff did not follow proper protocol to notify family or management immediately. Resident #1 was later taken to the emergency room and diagnosed with multiple conditions and subsequently expired.
Complaint Details
Investigation of complaint GA00191610 found that the facility did not notify Resident #1's family after a fall on 9-10-18. Staff C failed to call supervisor and family as required. Resident #1 was taken to emergency room by family and later expired on 9-22-19.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the representative or legal surrogate in case of an accident or sudden adverse change in a resident's condition. | D |
Report Facts
Date of resident fall: Sep 10, 2018
Date of survey completion: Oct 1, 2018
Date of resident admission: Jan 9, 2016
Date of resident death: Sep 22, 2019
Date of corrective action form: Sep 11, 2018
Time resident found with injuries: 521
Time family called: 701
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in finding for failing to notify supervisor and family after resident accident | |
| Staff A | Interviewed regarding Staff C's actions during resident accident | |
| GG | Interviewed about resident fall and family notification |
Inspection Report
Original Licensing
Deficiencies: 1
Sep 13, 2018
Visit Reason
The purpose of this visit was to conduct an initial inspection and investigate intake #GA00191127.
Findings
The facility failed to ensure adequate and appropriate care when Staff B gave the wrong medications prescribed for Resident #2 to Resident #1, resulting in a medication error. Staff C, who trained Staff B, resigned following the incident.
Complaint Details
The visit was triggered by an intake complaint #GA00191127 regarding a medication error involving Resident #1 and Resident #2.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident received adequate and appropriate care as Staff B gave wrong medications prescribed for Resident #2 to Resident #1. | D |
Report Facts
Date of medication error: Aug 28, 2018
Date of inspection visit: Sep 13, 2018
Date survey completed: Sep 14, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Gave wrong medications to Resident #1 | |
| Staff C | Trained Staff B and gave wrong instructions leading to medication error; resigned from position | |
| Staff A | Interviewed and reported on medication error |
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