Inspection Reports for The Retreat at Loganville
580 Tommy Lee Fuller Dr, Loganville, GA 30052, United States, GA, 30052
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 12, 2025, found no deficiencies. Earlier inspections showed a mix of results, with several complaint investigations over the years resulting in no violations, but some prior reports cited deficiencies related to resident care, communication with families, and safety measures. Inspectors noted issues such as failure to notify representatives about changes in condition, inadequate care for a resident’s wound, and insufficient safety device functioning to prevent a cognitively impaired resident from leaving the facility unsupervised. There were no fines, immediate jeopardy findings, or license actions listed in the available reports, and most complaint investigations were unsubstantiated. The inspection history suggests improvement over time, with recent inspections consistently free of deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 12, 2025
Visit Reason
The purpose of this visit was to investigate intake# GA50004911. The survey began on 2025-08-28 and concluded on 2025-09-05.
Complaint Details
Investigation of intake# GA50004911 with no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001194, #GA50000412, #GA50000442, and #GA50000661.
Complaint Details
Investigation was initiated based on multiple intakes and completed on 3/19/25 with no violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2024
Visit Reason
The purpose of this visit was to investigate intakes GA00249899 and GA00250197.
Complaint Details
Investigation of intakes GA00249899 and GA00250197; no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
The purpose of this visit was to investigate intake# GA00248742 and conduct the compliance inspection.
Complaint Details
Investigation of intake# GA00248742; no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 2, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00234434 with an onsite visit conducted on 6/2/2023.
Complaint Details
Investigation of complaint #GA00234434 resulted in no rule violations being cited.
Findings
The investigation was completed on 6/2/2023 and no rule violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2023
Visit Reason
The purpose of this visit was to investigate intake# GA00229698. The investigation began on 2023-03-02 and ended on 2023-03-03.
Complaint Details
Investigation of intake# GA00229698; no rule violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 15, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00224576. An on-site visit was made to the facility on 6/15/22. The investigation started on 6/13/22 and was completed on 7/7/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00224576. The complaint involved failure to notify resident's representative and doctor about a resident's sore and failure to provide adequate care.
Findings
The facility failed to provide oversight to ensure compliance with regulations, including failure to notify resident's representative of an accident or change in condition, failure to involve residents and families in care plan development, and failure to provide adequate care and services for Resident #1 who had a dark red open sore on the left third toe. The facility also failed to notify the resident's doctor and responsible party timely about the sore and did not document incident reports related to the sore.
Deficiencies (4)
Failure to notify resident's representative of an accident or change in resident's condition.
Failure to provide evidence of resident and family involvement in care plan development for 3 sampled residents.
Failure to ensure adequate care and services for Resident #1 with a dark red open sore on left third toe.
Failure to take appropriate actions during sudden adverse change in Resident #1's condition, including notification of representative and documentation.
Report Facts
Sampled residents: 3
Dates of skin integrity review forms: 5/26/22, 5/31/22, 6/14/22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding policy on notification and care plan review; stated would update policy and ensure notifications. | |
| Staff B | Interviewed regarding care plan updates and notification of resident's sore; stated unaware of sore and would notify responsible party and doctor. | |
| BB | Resident #1's responsible party; stated not notified by facility about sores and had to provide antibiotic ointment and band aids. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 19, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223720. An on-site visit was made to the facility on 5/19/22.
Complaint Details
Investigation started on 5/16/22 and was completed on 5/19/22. No rule violations were cited.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Routine
Deficiencies: 0
Date: Feb 18, 2022
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 10, 2021
Visit Reason
The purpose of this inspection was to investigate complaint intakes #GA0020481, #GA00204465, and #GA00204291, with investigations started on 2020-04-27 and completed on 2021-02-10.
Complaint Details
The investigation was complaint-driven, focusing on intake numbers #GA0020481, #GA00204465, and #GA00204291. Resident #1 was a transferred resident from another facility that closed down, tested negative for COVID-19 prior to admission, but was not quarantined as recommended. The facility had 39 residents with positive COVID-19 test results and 5 deaths from COVID-19 between April and December 2020.
Findings
The facility failed to ensure that policies and procedures provided adequate direction for staff and residents on infection control, work and return to work policies, food borne illnesses, and reportable diseases, specifically regarding quarantine protocols for newly admitted residents with underlying conditions related to COVID-19. Resident #1 was not quarantined appropriately upon admission despite testing negative for COVID-19, and wandered outside his/her room during lockdown.
Deficiencies (1)
Failure to ensure policies and procedures provided direction on health and hygiene issues related to infection control, work and return to work policies, food borne illnesses, and reportable diseases for 1 of 3 sampled residents (Resident #1).
Report Facts
Residents with positive COVID-19 test results: 39
Residents who died of COVID-19: 5
Quarantine period: 14
Quarantine period alternative 1: 10
Quarantine period alternative 2: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided information about Resident #1's transfer and COVID-19 testing status | |
| DD | Interviewed regarding Resident #1 wandering outside his/her room during COVID-19 lockdown | |
| EE | Interviewed regarding Resident #1's quarantine status and behavior |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 3, 2021
Visit Reason
The investigation was conducted to investigate complaint #GA00208642 regarding the safety and care of Resident #1, who was found missing from the facility and outside in a puddle of water.
Complaint Details
Investigation started on 2020-10-20 and completed on 2021-02-03. Resident #1 was missing from his/her room on 2020-09-20 at approximately 6:00 a.m., found outside at 6:28 a.m. lying in a puddle of water, cold and wet. The resident had Alzheimer's and other diagnoses. Staff failed to take the resident's temperature with a device and did not adequately secure the exit door. EMS was called and resident was transported to hospital with no significant injury found. Resident was discharged the same day.
Findings
The facility failed to ensure safety devices were properly working to prevent a cognitively impaired resident from leaving the facility unsupervised. Resident #1 was found outside on a walking trail, cold and wet, after staff failed to monitor and secure exit doors adequately. The resident had a fall but sustained no significant injury. The facility also failed to provide adequate care and services in compliance with federal and state regulations for Resident #1.
Deficiencies (2)
Facility failed to ensure safety devices were properly working to prevent Resident #1 from leaving the facility unsupervised.
Facility failed to ensure each resident received adequate and appropriate care and services in compliance with applicable laws for Resident #1.
Report Facts
Date survey completed: Feb 3, 2021
Incident date: Sep 20, 2020
Time resident found outside: 628
911 call time: 637
EMS arrival time: 659
Resident vital signs: 97
Resident vital signs: 14568
Resident vital signs: 64
Temperature range: 52
Temperature range: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Notified staff of missing resident, conducted room checks, alerted Staff D, called 911, and cared for Resident #1 | |
| Staff D | Conducted security check outside, found Resident #1, placed jackets and blankets on resident, remained with resident until paramedics arrived | |
| Staff A | Interviewed and aware of findings | |
| AA | Interviewed regarding notification of missing resident |
Inspection Report
Monitoring
Deficiencies: 0
Date: 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 measures.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 12, 2019
Visit Reason
The purpose of this visit was to conduct an initial inspection.
Findings
No rule violations were cited as a result of this inspection.
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