Deficiencies per Year
4
3
2
1
0
Moderate
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 2, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50005106 and #GA50005751. An on-site visit was made to the facility on 9/2/2025 at 10:30 am.
Findings
The report documents the initiation of an investigation based on complaint intakes. No specific findings or deficiencies are detailed in the provided page.
Complaint Details
Investigation was initiated based on complaint intakes #GA50005106 and #GA50005751.
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 19, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50004356 and #GA50004372, which involved an onsite investigation of an assisted living facility regarding a resident elopement incident.
Findings
The facility failed to obtain necessary medical information to determine if a resident continued to meet retention requirements after a significant change in condition, failed to provide adequate protective care and watchful oversight for a resident who eloped, and failed to report the initiation and discontinuation of a Mattie's call to the Department within 30 minutes as required.
Complaint Details
The investigation was initiated due to complaints/intakes #GA50004356 and #GA50004372 concerning Resident #1 who eloped from the facility on 6/11/2025. The resident was missing for about 30 minutes and was found unharmed by law enforcement. The facility failed to meet regulatory requirements related to medical reevaluation, protective care, and timely reporting of the elopement.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to obtain medical information necessary to determine that the resident continues to meet retention requirements after a significant change in condition. | SS= D |
| Failed to provide protective care and watchful oversight meeting the needs of the resident, resulting in elopement. | SS= D |
| Failed to report the initiation and discontinuation of a Mattie's call to the Department within 30 minutes of communication with law enforcement regarding resident elopement. | SS= D |
Report Facts
Resident missing duration: 30
Date of resident elopement: Jun 11, 2025
Date of investigation onsite visit: Jul 22, 2025
Date survey completed: Aug 19, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding resident elopement and reporting procedures; stated family refused memory care placement and 24-hour sitter. | |
| Staff B | Interviewed regarding facility staffing and resident search. | |
| AB | Interviewed regarding search for Resident #1 and telehealth appointment. | |
| BC | Interviewed regarding search for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 2, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50003353.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2025-06-02 with an on-site visit at 10:00 am and completed the same day. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50002521 and #GA50002101.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was unannounced and completed on 4/10/2025. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 26, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint intakes #GA50001538 and #GA50001124.
Findings
No rule violations were cited as a result of this inspection and investigation.
Complaint Details
Investigation of complaint intakes #GA50001538 and #GA50001124 was completed with no rule violations found.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Aug 21, 2024
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00249205, #GA00249573, and #GA00247935, focusing on resident safety and compliance with regulations.
Findings
The investigation found that the facility failed to utilize appropriate safety devices to prevent elopement for a resident at risk, failed to obtain a required physician's report within 30 days prior to memory care unit admission for one resident, and failed to ensure a resident's right to be free from physical restraints, resulting in staff termination.
Complaint Details
The investigation was initiated due to complaint intakes #GA00249205, #GA00249573, and #GA00247935. Resident #2 was found missing from the facility and was located offsite after leaving due to being upset with staff. Resident #1 was physically restrained by staff despite no clinical indication, leading to staff termination. The allegations of physical abuse were unsubstantiated but confirmed policy violations.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to utilize appropriate effective safety devices to protect residents at risk of elopement. | D |
| Failed to obtain a physician's report of physical examination within 30 days prior to admission to the memory care unit. | D |
| Failed to ensure residents' rights to be free from actual or threatened physical or chemical restraints. | E |
Report Facts
Census: 32
Census: 12
Date of incident: 10
Date of staff termination: 13
Distance: 0.3
Distance: 0.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Employee who physically restrained Resident #1 and was terminated for violating resident rights | |
| Staff A | Supervisor of Staff C and investigator of restraint incident | |
| Staff B | Staff who assessed Resident #1 and commented on missing physician's report | |
| Staff F | Staff who found Resident #2 missing during safety monitoring check | |
| Staff G | Staff who conducted safety monitoring checks when Resident #2 was found missing |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00248617 and #GA00248706.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00248617 and #GA00248706 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 18, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00247603.
Findings
An onsite visit was made on 6/18/2024. Investigation started and was completed on 6/18/2024. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00247603 was completed with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 11, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00245198.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00245198 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 5, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244035 with an onsite visit made to the facility on 3/5/24.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00244035 resulted in no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 3, 2023
Visit Reason
The purpose of this visit was to investigate intakes #GA00231865, #GA00232239, and #GA00233098.
Findings
The facility failed to ensure that a resident was free from physical restraints when Staff C blocked the resident's apartment door with a heavy chair for about five minutes. Staff C's employment was terminated, and the resident was discharged to a psychiatric center due to aggressiveness and difficulty managing.
Complaint Details
The visit was complaint-related, investigating allegations of restraint involving Resident #1. The allegation was substantiated as Staff C confirmed the incident and was terminated. Resident #1 was discharged due to aggressiveness and difficulty managing.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that each resident has the right to be free from actual or threatened physical or chemical restraints and the right to be free from isolation, corporal, or unusual punishment including interference with the daily functions of living for 1 of 4 sampled residents. | SS= D |
Report Facts
Incident duration: 5
Incident date: Jan 12, 2023
Incident report submission date: Jan 26, 2023
Staff C hire date: Jun 18, 2014
Resident #1 admission date: Apr 19, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Staff member who restrained Resident #1 and was terminated | |
| Staff A | Interviewed staff who terminated Staff C and provided information about the incident | |
| Staff D | Witnessed the incident and reported it to Staff A |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 24, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00226467.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00226467 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224410.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00224410 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00224983.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake GA00224983 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00223937 and conduct the compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00223937; no rule violations were found.
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