The most recent inspection on August 26, 2025, found no deficiencies. Earlier inspections generally showed no deficiencies, with complaint investigations consistently resulting in no rule violations. Some prior reports cited issues related to resident care and admission practices, including retaining residents not capable of self-preservation and inadequate safety measures that led to an elopement incident in 2020. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility’s inspection history indicates improvement over time, with recent inspections free of cited deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this survey was to investigate intake # GA00204198 related to the care and safety of Resident #1.
Findings
The facility failed to ensure that Resident #1, who required specialized memory care, was admitted or retained appropriately. Resident #1 eloped from the facility on 4/5/20 due to unsecured exit doors and lack of safety devices, and staff were unaware of the resident's condition changes and elopement until notified by the police.
Complaint Details
Investigation of intake # GA00204198 found no rule violations cited as a result of the investigation, but identified deficiencies related to Resident #1's care and safety, including elopement and inappropriate admission.
Severity Breakdown
D: 2
Deficiencies (2)
Description
Severity
Facility admitted or retained a resident who did not need care beyond which the home is permitted to provide (Resident #1 required specialized memory care).
D
Facility failed to ensure each resident received adequate and appropriate care, evidenced by Resident #1's elopement due to unsecured exit doors and lack of safety devices.
D
Report Facts
Incident date: Apr 5, 2020Resident admission date: Nov 12, 2019Resident discharge date: Apr 22, 2020Physician evaluation date: Sep 9, 2019Incident report review period start: Mar 1, 2020Incident report review period end: Apr 30, 2020Weather high temperature: 80Weather low temperature: 59
Employees Mentioned
Name
Title
Context
Staff B
Interviewed regarding Resident #1's admission, condition, and elopement
Staff A
Interviewed regarding Resident #1's condition changes and admission oversight
BB
Interviewed regarding Resident #1's dementia diagnosis and elopement awareness
DD
Interviewed regarding Resident #1's behavior and elopement
CC
Interviewed regarding Resident #1's exit seeking behaviors and facility exit door security
EE
Interviewed regarding Resident #1's exit seeking behaviors and elopement notification
The purpose of this visit was to investigate incident #GA00197887 with an onsite visit made on 7/15/19 and the investigation completed on 7/17/19.
Findings
The facility failed to keep floors in good repair, with uneven carpeted flooring and indentations reported by residents and staff. Additionally, the facility admitted and retained a non-ambulatory resident who was incapable of self-preservation without a waiver, which is against admission requirements.
Complaint Details
Investigation was triggered by incident #GA00197887. The complaint was substantiated based on observations and interviews confirming facility deficiencies.
Severity Breakdown
D: 2
Deficiencies (2)
Description
Severity
Facility failed to keep floors in good repair; uneven carpeted flooring with indentations in multiple areas.
D
Facility admitted and retained a resident incapable of self-preservation without a waiver, contrary to admission requirements.
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The facility failed to ensure that retained residents were capable of self-preservation with minimal assistance for 2 of 4 sampled residents, both of whom were on hospice and required total assistance.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
The home admitted and retained residents who were not capable of self-preservation with minimal assistance, specifically 2 residents on hospice needing total assistance.
The purpose of this visit was to investigate complaint GA00182670.
Findings
The facility failed to ensure that Resident #1 received adequate and appropriate care in compliance with federal and state regulations. Specifically, Resident #1 was not assessed upon re-admission from the rehabilitation center and staff were unaware that the resident had an intravenous catheter in place.
Complaint Details
The visit was complaint-related, investigating complaint GA00182670. The complaint involved failure to provide adequate care to Resident #1, including lack of assessment after re-admission and unawareness of an intravenous catheter.
Severity Breakdown
D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure each resident received adequate and appropriate care; Resident #1 was not assessed after re-admission and staff were unaware of an intravenous catheter.
D
Report Facts
Incident dates: Falls occurred on 2017-11-07 and 2017-12-02
Employees Mentioned
Name
Title
Context
Staff B
Interviewed regarding Resident #1's care and lack of assessment after re-admission
Staff C
Interviewed and contacted rehabilitation staff about Resident #1's intravenous catheter