Inspection Reports for The Residence at Oak Grove
135 Market St, Thomasville, GA 31792, United States, GA, 31792
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Inspection Report
Complaint Investigation
Census: 2
Deficiencies: 4
Aug 13, 2025
Visit Reason
The purpose of this visit was to conduct a complaint investigation for complaint GA50005014, initiated on 2025-08-13 with an onsite visit on the same day and completed on 2025-08-25.
Findings
The facility failed to have a full-time licensed Administrator, maintain personnel files for all sampled staff, provide medication administration services according to physician orders for one resident, and maintain individual resident files for two of three sampled residents. Documentation requests were made multiple times but not fulfilled by survey conclusion.
Complaint Details
Complaint investigation for GA50005014 initiated on 2025-08-13 with onsite visit and completed on 2025-08-25.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to have a full-time Administrator with a valid license posted. | D |
| Failed to maintain personnel files for 4 of 4 sampled staff (Staff A, B, C, D). | D |
| Failed to provide medication administration services in accordance with physician orders for 1 of 3 residents (Resident #3). | D |
| Failed to maintain individual resident files for 2 of 3 sampled residents (Resident #1 and Resident #2). | D |
Report Facts
Medication bubble pack count: 14
Sampled residents: 3
Sampled staff: 4
Census: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Administrator | Named as Administrator without valid license and required assistance to gather documentation |
| Staff A | Provided care during visit and involved in medication administration finding |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004282 through an unannounced visit made on 2025-07-07 at 10:00 a.m., with the investigation completed on 2025-07-08.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA50004282 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50002020 and #GA50001890.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was unannounced, conducted starting 3/17/2025 at 12:30 p.m. and completed on 3/19/2025. No violations found.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 5, 2025
Visit Reason
The purpose of this visit on 3/5/25 was to conduct an annual inspection and investigate complaint #GA50001316.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 18, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245901.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00245901 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 8, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244606. An unannounced visit was made on 4/8/2024 at 3:00 p.m. and the investigation was completed on 4/11/2024.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00244606 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00241305 with an onsite visit made to the facility on 12/21/23 and the investigation completed on 12/26/23.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00241305 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 19, 2023
Visit Reason
A visit was made to the facility on 10/19/23 to investigate intake #GA 002238123.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA 002238123 completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236812 with an onsite visit made to the facility on 8/23/23.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 8/23/23 and completed on 9/6/23. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 26, 2023
Visit Reason
The visit on 4/26/2023 was conducted to investigate complaint intakes GA00215452, GA00232471, GA00233521, and GA00233578.
Findings
The investigation was completed on 4/27/2023 with no rule violations cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00215452, GA00232471, GA00233521, and GA00233578 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 6, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00219874.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00219874 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 1, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00215231, #GA00215452, #GA00215233, and #GA00215168, related to allegations of physical abuse.
Findings
The facility failed to ensure that each resident was free from physical abuse for 1 of 5 sampled residents (Resident #1). Staff C was witnessed hitting Resident #1 in the face and arm on 6/13/21, was immediately removed from the schedule, and terminated. The incident was reported to local police and the Department.
Complaint Details
The investigation was initiated due to multiple complaint intakes alleging physical abuse of Resident #1 by Staff C. The abuse was substantiated based on witness statements and video evidence.
Severity Breakdown
G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from physical abuse; Staff C physically abused Resident #1. | G |
Report Facts
Number of sampled residents: 5
Date of incident: Jun 13, 2021
Date of hire: Feb 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Alleged abuser of Resident #1 | |
| Staff A | Reported Staff C abuse and removed Staff C from schedule | |
| Staff B | Witnessed Staff C hit Resident #1 | |
| Staff E | Witnessed Staff C hit Resident #1 and reported incident |
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 5, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00210885 and #GA00210898, with the investigation starting on 2021-01-27 and completing on 2021-02-05.
Findings
The facility was found to have failed to ensure residents received adequate and appropriate care, including incidents of staff being rude to a resident causing distress, forcing food into a resident's mouth causing gagging, administering medication improperly by giving dropped medication to a resident, and refusing to provide pain medication as needed. Staff B was terminated for violating resident rights and facility policy prohibiting abuse and neglect.
Complaint Details
The investigation was initiated due to complaints regarding Staff B's rude behavior towards Resident #1, causing emotional distress, and improper care including forced feeding and medication errors. The complaints were substantiated based on interviews, resident and family statements, and staff witness accounts.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff B was rude to Resident #1, causing the resident to cry twice and feel afraid. | SS= D |
| Staff B forced a large amount of food into Resident #2's mouth, causing gagging and coughing. | SS= D |
| Staff B dropped Resident #2's medication on the floor and then gave it to the resident, violating medication administration policy. | SS= D |
| Staff B refused to provide pain medication to Resident #1 despite complaints of sharp leg cramps, requiring intervention by another medication technician. | SS= D |
Report Facts
Investigation start date: Jan 27, 2021
Investigation completion date: Feb 5, 2021
Staff B hire date: Nov 9, 2020
Resident #1 admit date: Dec 15, 2020
Incident date - forced feeding: Dec 27, 2020
Incident date - yelling: Dec 29, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in multiple findings including rude behavior, forced feeding, medication errors, and refusal to provide pain medication | |
| Staff A | Interviewed regarding complaints and facility expectations; reported family member complaint and described lunch served | |
| Staff C | Witnessed Staff B drop medication and give it to Resident #2; heard Resident #1 complain of leg cramps | |
| Staff D | Witnessed forced feeding incident involving Staff B and Resident #2 | |
| Staff E | Provided written statement about Staff B yelling at Resident #1 and making him/her cry |
Inspection Report
Original Licensing
Deficiencies: 0
Nov 3, 2020
Visit Reason
The purpose of this inspection was to conduct an initial inspection for licensing.
Findings
No rule violations were cited as a result of this inspection.
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