The most recent inspection on April 22, 2025, found no deficiencies. Earlier complaint investigations over the past several years also consistently identified no rule violations. Prior reports from 2020 and 2021 noted deficiencies related to resident safety and abuse, including substantiated cases involving elopement risks and resident harm, but no enforcement actions such as fines or license suspensions were listed in the available reports. Complaint investigations since those events have been unsubstantiated, indicating no ongoing regulatory issues. The inspection history shows improvement with no recent deficiencies noted in complaint investigations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA00212727, which was started on 2021-03-25 and completed on 2021-04-06.
Findings
The facility failed to implement policies and procedures to ensure the safety of residents at risk of elopement, specifically Resident #1 who eloped from the facility on 2021-03-06. The facility lacked alarms on exit doors, did not have a current photo of the resident in the emergency binder, and failed to conduct a specific elopement risk assessment. Staff interviews and record reviews confirmed these deficiencies and the resident was found outside the facility and taken to a hospital.
Complaint Details
The investigation was initiated due to intake #GA00212727 regarding Resident #1 eloping from the facility on 2021-03-06. The complaint was substantiated based on observations, record reviews, interviews, and law enforcement reports confirming the resident left the facility unaccompanied and was found by a passing driver and taken to a hospital.
Severity Breakdown
J: 3D: 1
Deficiencies (4)
Description
Severity
Failed to implement policies, procedures, and practices supporting dignity, respect, choice, independence, and privacy for Resident #1, who eloped from the facility.
J
Failed to utilize appropriate effective safety devices to protect residents at risk of eloping; exit doors lacked alarms or alerts.
J
Failed to retain current pictures of residents at risk of elopement on file for Resident #1.
D
Failed to ensure each resident received adequate and appropriate care and services in compliance with state law for Resident #1.
J
Report Facts
Resident sample size: 5Resident #1 admission date: Mar 3, 2021Temperature at time of elopement: 49Distance from facility: 0.2Time of elopement: 331Time law enforcement notified: 350Time family member picked up resident: 630
Employees Mentioned
Name
Title
Context
Staff A
Interviewed regarding lack of elopement risk assessment and oversight of resident safety
Staff B
Interviewed regarding perimeter door locking and resident behavior before elopement
Staff C
Interviewed regarding resident behavior and discovery of elopement
Staff D
Interviewed regarding search efforts and door alarms
Staff G
Interviewed regarding door locking and video monitoring
AA
Interviewed regarding resident placement and door locking times
The purpose of this visit was to investigate intake #GA00208784, which involved allegations of abuse and failure to provide adequate care to Resident #3.
Findings
The facility failed to implement policies and procedures to protect Resident #3 from abuse and failed to provide adequate care after the resident fell. Staff B was observed on security footage forcibly removing his/her arm from Resident #3, causing the resident to fall and sustain injuries. Staff B failed to immediately assist the resident and did not report the incident as required. Staff B was arrested for aggravated battery and elder abuse. Multiple staff interviews confirmed failures in reporting and care.
Complaint Details
The investigation was initiated due to a complaint alleging that Resident #3 was pushed by a staff member (Staff B), causing a fall and injury. Law enforcement was involved, and Staff B was arrested for aggravated battery and elder abuse. The complaint was substantiated based on interviews, incident reports, security footage, and medical records.
Severity Breakdown
SS=J: 3
Deficiencies (3)
Description
Severity
Failure to implement policies and procedures supporting dignity, respect, and safety of residents, resulting in abuse of Resident #3.
SS=J
Failure to ensure each resident received adequate and appropriate care, including failure to assist Resident #3 after a fall.
SS=J
Failure to ensure each resident was free from abuse, with substantiated abuse of Resident #3 by Staff B.
SS=J
Report Facts
Date survey completed: Oct 30, 2020Incident report date: Oct 6, 2020Incident date: Oct 2, 2020Arrest date: Oct 6, 2020
Employees Mentioned
Name
Title
Context
Staff B
Named in abuse and neglect findings; observed on security footage causing Resident #3 to fall and failing to assist or report the incident; arrested for aggravated battery and elder abuse.
Staff A
Interviewed regarding incident awareness and reporting failures; reviewed security footage.
Staff C
Interviewed; worked with Staff B during incident shift; attempted to assist Resident #3 after fall.
Staff D
Interviewed; on duty during incident; not notified by Staff B of incident.
Staff E
Interviewed; observed Resident #3 post-incident with injuries; called 911 and completed incident report.
FF
Interviewed; spoke with Resident #3 who reported being pushed by staff; noted injuries consistent with abuse.