Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2025
Visit Reason
The purpose of this survey was to investigate intake #GA50004807, with the investigation beginning on 2025-10-08 and an onsite visit made the same day.
Findings
No rule violations were cited as a result of the inspection.
Complaint Details
Investigation was complaint-related under intake #GA50004807 and was completed on 2025-10-08 with no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 28, 2025
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate intake #GA50001725 and GA50001790.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes #GA50001725 and GA50001790; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 8, 2024
Visit Reason
The purpose of this survey was to investigate complaints #GA00250661, #GA00250659, #GA00250697, and #GA00250642. The onsite visit occurred on 2024-10-08.
Findings
The facility failed to operate in a manner that respected the personal dignity and human rights of one resident (Resident #1) as evidenced by an incident on 2024-08-14 where Resident #1 was observed inappropriately interacting with Resident #2 in the bathroom. Both residents had memory impairments and could not recall the incident. Staff intervened and instructed Resident #1 that the behavior was inappropriate.
Complaint Details
The investigation was triggered by complaints #GA00250661, #GA00250659, #GA00250697, and #GA00250642. The incident involved inappropriate behavior observed on 8/14/24 between Resident #1 and Resident #2. Both residents had cognitive impairments and could not recall the event.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to respect the personal dignity and human rights of Resident #1 during an incident involving Resident #2 in the bathroom on 8/14/24. | Level D |
Report Facts
Complaint numbers investigated: 4
Incident date: Aug 14, 2024
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 8, 2024
Visit Reason
The purpose of this survey was to investigate complaints #GA00250661, #GA00250659, #GA00250697, and #GA00250642. The onsite visit occurred on 2024-10-08.
Findings
The facility failed to operate in a manner that respected the personal dignity and human rights of one resident. An incident on 2024-08-14 involved Resident #1 and Resident #2 inappropriately positioned in a bathroom, with staff intervening and instructing Resident #1 that such assistance was inappropriate.
Complaint Details
The investigation was triggered by complaints #GA00250661, #GA00250659, #GA00250697, and #GA00250642. Interviews with Residents #1 and #2 indicated memory impairments preventing recall of the incident. Staff interviews confirmed the observations and inappropriate assistance by Resident #1.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to respect the personal dignity and human rights of Resident #1 as evidenced by an incident where Resident #1 was observed behind Resident #2 with Resident #2's pants and brief pulled down, purportedly helping Resident #2 to the toilet. | D |
Report Facts
Complaint numbers investigated: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D and Staff E provided observations and interviews related to the incident but no full names were provided. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 14, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00243446.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00243446 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2023
Visit Reason
The visit was conducted to perform a compliance inspection and to investigate intake #GA00241412 at the facility.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00241412 was conducted onsite from 12/19/23 to 12/20/23 with no rule violations found.
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 3
Aug 22, 2023
Visit Reason
The visit was conducted to investigate intake #GA00237822 with an on-site visit made on 8/22/23 and the investigation completed on 8/24/23.
Findings
The facility failed to maintain minimum staffing requirements of at least one RN, LPN, or CMA on-site at all times in memory care, with no nurse observed during the visit and no current LPN or RN on staff. Additionally, medications were provided by proxy caregivers who had not completed required training and skills checklists prior to August 2023.
Complaint Details
Investigation was initiated based on intake #GA00237822. The investigation included review of staffing schedules, resident census, staff interviews, and medication assistance records.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to maintain minimum staffing requirements of at least one RN, LPN, or CMA on-site at all times in memory care. | D |
| Facility failed to provide one RN or LPN on-site at all times for a minimum of 16 hours per week for memory care with 13 to 30 residents. | D |
| Facility failed to ensure medications for memory care residents were provided by a trained proxy caregiver in accordance with requirements for 1 of 1 sampled residents. | D |
Report Facts
Memory care resident census: 18
Deficiencies cited: 3
Dates medication assistance provided: 10
Minimum hours per week for nurse coverage: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staffing difficulties and knowledge of requirements | |
| Staff C | LPN | Had separation notice dated 6/9/23; no replacement hired |
| Staff F | Medication Tech | Provided medication assistance without completed proxy caregiver skills checklist or training prior to August 2023 |
| Staff J | Medication Tech | Provided medication assistance without completed proxy caregiver skills checklist or training prior to August 2023 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 5, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00229288.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00229288 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 29, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00226005.
Findings
The facility failed to ensure that refills of prescribed medications were obtained timely, resulting in interruption of routine dosing for 1 of 4 sampled residents (Resident #4). Specifically, Resident #4 missed multiple doses of Tramadol HCL 100 mg due to medication not being available while waiting for a refill.
Complaint Details
Visit was complaint-related, investigating intake #GA00226005.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure timely refills of prescribed medications, causing interruption in routine dosing for Resident #4. | D |
Report Facts
Missed medication doses: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 8/29/22 regarding missed medication doses for Resident #4. |
Inspection Report
Complaint Investigation
Census: 19
Capacity: 22
Deficiencies: 1
Apr 22, 2022
Visit Reason
The purpose of this survey was to investigate complaint #GA00222060, with the investigation starting on 2022-03-29, onsite visit on 2022-04-22, and completion on 2022-06-01.
Findings
The facility failed to provide one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times in the memory care unit. Staff observed were not listed as med-techs and were not found in the CMA registry.
Complaint Details
Investigation of complaint #GA00222060 started on 2022-03-29, with onsite visit on 2022-04-22 and completed on 2022-06-01.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times in the memory care unit. | D |
Report Facts
Resident census: 19
Total capacity: 22
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 23, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and to investigate complaint intake #GA00216218, which was initiated on 2021-08-12 and completed on 2021-09-23.
Findings
The facility failed to update the medication assistance record (MAR) for 11 of 31 sampled residents, indicating medications were signed off as given but were found unused in sealed packages. Additionally, the facility failed to maintain an effective system for medication storage, with unsecured medications and unattended medication carts observed during the inspection.
Complaint Details
The investigation was initiated due to complaint intake #GA00216218. Staff E was found to have signed off on medication administration that was not actually given, leading to termination on 2021-08-02.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update the medication assistance record (MAR) each time medication was offered or taken for 11 out of 31 sampled residents. | SS= D |
| Failure to have an effective system to manage medications including storing medications under lock and key or other secure system to prevent unauthorized access at all times. | SS= D |
Report Facts
Residents with MAR errors: 11
Date of investigation start: Aug 12, 2021
Date of investigation completion: Sep 23, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Proxy caregiver terminated for signing off medication administration that was not given. | |
| Staff B | Discovered medications in trash and confirmed MAR discrepancies. | |
| Staff F | Observed medication cart unattended and unlocked; was in training. | |
| Staff C | Left medication unsecured on medication cart. | |
| Staff A | Reported termination of Staff E for medication errors. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2020
Visit Reason
The purpose of this visit was to investigate complaint #GA00205350.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation began on 2020-06-09 and was completed on 2020-06-23. No rule violations were found.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
May 26, 2020
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00203410 and GA00203822, which started on 2020-03-04 and were completed on 2020-05-26.
Findings
The facility failed to document medication administration on the Medication Assistance Record for one resident and failed to notify the resident's representative of an accident involving the resident. Resident #1 fell and later passed away during a breathing treatment. The facility did not inform the family about the fall or properly document medication administration.
Complaint Details
The investigation was initiated due to complaint intakes #GA00203410 and GA00203822. The complaint involved failure to document medication administration and failure to notify the resident's family of an accident. Resident #1 was found on the floor after a fall, received a breathing treatment, and passed away. The facility did not inform the family about the fall or properly document the medication administration.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document on the Medication Assistance Record (MAR) when a breathing treatment was administered to Resident #1. | Level D |
| Failed to notify the resident's representative or legal surrogate of an accident involving Resident #1. | Level D |
Report Facts
Residents present during inspection: 72
Residents involved in deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Direct caregiver responsible for administering breathing treatment to Resident #1 and involved in documentation deficiency | |
| Staff E | Staff who assisted Resident #1 after fall and involved in incident report | |
| GG | CNA | Provided written statement and assisted with Resident #1 after passing |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 12, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00204731, starting on 2020-05-04 and completed on 2020-05-12.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00204731 was completed with no rule violations found.
Inspection Report
Monitoring
Deficiencies: 0
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 procedures.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 5, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00194516, beginning with an onsite visit on 2019-02-22 and completed on 2019-03-05.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00194516 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 7
Sep 24, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint # GA00190476. On-site visits were made on 2018-08-16 and 2018-08-17, with the investigation completed on 2018-09-24.
Findings
The facility failed to obtain satisfactory criminal records checks for 4 of 6 sampled staff, failed to retain only ambulatory residents capable of self-preservation for 1 of 8 sampled residents, and failed to ensure timely medication refills and prescription management for multiple residents. Additionally, medications were not always stored securely, and the facility failed to provide adequate care and reporting for one resident who suffered multiple falls and injuries.
Complaint Details
The visit was complaint-related, investigating complaint # GA00190476. The complaint involved issues such as failure to obtain proper criminal background checks, inadequate resident care, medication management deficiencies, and failure to report serious incidents.
Severity Breakdown
D: 6
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to obtain a satisfactory criminal records check prior to employment for 4 of 6 sampled staff. | D |
| Failed to retain only ambulatory residents capable of self-preservation with minimal assistance for 1 of 8 residents sampled (Resident #7). | E |
| Failed to ensure timely refills of prescribed medications for 2 of 8 residents sampled (Residents #1 and #3). | D |
| Failed to obtain new prescriptions within 48 hours for 1 of 6 residents sampled (Resident #4). | D |
| Failed to have all medications stored under lock and key; medication cart was found unlocked. | D |
| Failed to ensure each resident received adequate and appropriate care; Resident #1 had multiple falls resulting in injury. | D |
| Failed to report a serious incident involving Resident #1 to the Department within 24 hours. | D |
Report Facts
Sampled staff with failed criminal records check: 4
Residents sampled for ambulatory status: 8
Residents sampled for medication refills: 8
Residents sampled for prescription management: 6
Residents sampled for care adequacy: 6
Residents involved in serious incident reporting failure: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding use of third party company for criminal records checks and incident reporting misunderstandings. | |
| Staff B | One of the staff members without satisfactory criminal records check. | |
| Staff C | One of the staff members without satisfactory criminal records check. | |
| Staff E | One of the staff members without satisfactory criminal records check. | |
| Staff F | One of the staff members without satisfactory criminal records check. | |
| Staff G | Interviewed regarding medication availability and storage. | |
| Staff H | Interviewed regarding missing medications for Resident #1. |
Inspection Report
Annual Inspection
Deficiencies: 2
Jun 19, 2017
Visit Reason
The purpose of this visit was to conduct an annual inspection of the facility.
Findings
The facility failed to ensure that it retained only ambulatory residents capable of self-preservation with minimal assistance, as evidenced by one resident who was non-ambulatory and required one-to-one assistance. Additionally, the facility failed to ensure that medication administration records were properly updated each time medication was offered or taken for one resident.
Severity Breakdown
D: 1
E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility retained a non-ambulatory resident who required one-to-one assistance, contrary to admission requirements. | D |
| Staff failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for one resident. | E |
Report Facts
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Named in medication administration record deficiency | |
| Staff C | Interviewed regarding medication administration record deficiency | |
| Staff A | Interviewed regarding waiver applications for residents |
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