Inspection Report Summary
The most recent inspection on September 10, 2024, found a deficiency related to the facility’s failure to enforce its pet policy, which resulted in a resident falling and breaking an arm due to an unleashed dog. Earlier inspections showed a pattern of deficiencies involving staff training, abuse prevention, medication management, and policy enforcement, with substantiated complaints including physical and verbal abuse of residents and missing controlled medications. Complaint investigations were mostly unsubstantiated except for several substantiated cases involving abuse by staff, inadequate staff training, and failure to follow screening policies for private sitters. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The inspection history shows ongoing challenges with staff oversight and policy enforcement, with no clear trend of consistent improvement or worsening.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
69% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 10, 2024
Visit Reason
The purpose of this visit was to investigate complaints #GA00250136 and #GA00248743 related to facility compliance and safety concerns.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving an unleashed dog causing a resident fall and multiple observations of the dog off leash. The complaint was substantiated by observations, interviews, and video review.
Findings
The facility failed to enforce its pet policy requiring pets to be leashed or physically restrained in common areas. A dog was observed off leash multiple times, including an incident where a resident fell and broke an arm due to the unleashed dog. Staff and residents confirmed the policy was not strictly followed.
Deficiencies (1)
Facility failed to ensure policies and procedures were effective and enforced regarding pet restraint, resulting in a dog being off leash in common areas and causing a resident fall.
Report Facts
Dates of incidents and observations: Resident #1 fall on 2024-08-12; Resident #1 discharged 2024-08-27; multiple observations of unleashed dog on 2024-08-29, 2024-09-04, and 2024-09-10
Number of times dog observed off leash: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding pet policy enforcement and observations of unleashed dog | |
| Staff B | Observed dog off leash and instructed resident to leash dog | |
| AA | Interviewed about resident fall and observations of unleashed dog | |
| BB | Interviewed and reviewed video footage of incident | |
| CC | Observed dog running off leash outside facility door | |
| DD | Viewed video footage and confirmed dog running freely |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00248165.
Complaint Details
Investigation was completed with no rule violations cited.
Findings
No rule violation was cited as a result of this investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The purpose of this visit was to conduct a follow up to the 4/19/2023 inspection.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake GA00238537 at the facility.
Complaint Details
Investigation was initiated on 10/25/2023 and completed on 11/15/2023 with no violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 14, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235652 with an on-site visit conducted on 7/14/23 and the investigation completed on 7/21/23.
Complaint Details
The investigation was complaint-related based on intake #GA00235652. The complaint was substantiated by video evidence showing rough handling and verbal abuse of Resident #1 by Staff C and Staff D. Interviews confirmed lack of training and missing background check documentation for Staff D.
Findings
The facility failed to ensure that staff received required training on residents' rights and abuse reporting, failed to provide documentation of a satisfactory criminal background check for one staff member, and failed to provide adequate and appropriate care to a resident as evidenced by rough handling and verbal abuse captured on video.
Deficiencies (3)
Failure to ensure staff received training within the first 60 days on residents' rights and abuse reporting requirements for Staff D.
Failure to provide documentation of a satisfactory criminal background check for Staff D.
Failure to provide adequate and appropriate care to Resident #1, including rough handling and verbal abuse by Staff C and Staff D as shown in video evidence.
Report Facts
Date of video recording: Mar 24, 2023
Number of sampled staff with missing documentation: 1
Number of sampled residents with care deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiencies for missing training and background check, and involved in rough handling of Resident #1 | |
| Staff C | Involved in rough handling and verbal abuse of Resident #1 | |
| Staff A | Interviewed and unable to present documentation of training for Staff D | |
| Staff B | Interviewed and unable to present documentation of training for Staff D | |
| Staff E | Interviewed regarding facility procedures and reporting | |
| Staff F | Interviewed regarding facility procedures and reporting | |
| Staff G | Interviewed regarding facility procedures and reporting | |
| BB | Interviewed and described video evidence of abuse |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 29, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00233146, with an onsite visit made on 3/29/23 and the investigation completed on 4/19/23.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00233146. The complaint involved allegations of physical abuse of Resident #1 by Staff C, substantiated by video evidence and multiple staff interviews. Staff C was terminated and charged with simple battery of a person 65 years and older. Staff D was cited for failure to report a crime.
Findings
The facility failed to ensure the governing body implemented policies supporting dignity, respect, and safety for residents, specifically failing to prevent physical abuse of Resident #1 by Staff C. Evidence included video footage and staff interviews showing Staff C pulling, pushing, and kicking Resident #1, resulting in Staff C's termination and law enforcement charges.
Deficiencies (2)
Failure to ensure policies, procedures, and practices support dignity, respect, choice, independence, and privacy of residents in a safe environment for Resident #1.
Failure to ensure each resident had the right to be free from physical abuse for Resident #1, including documented physical abuse by Staff C.
Report Facts
Dates of incident and investigation: Mar 29, 2023
Dates of incident and investigation: Apr 19, 2023
Resident admission date: Jan 30, 2020
Staff C hire date: Jul 2, 2021
Termination date: Mar 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in physical abuse findings and termination | |
| Staff D | Recorded video footage and cited for failure to report a crime | |
| Staff A | Interviewed and aware of findings | |
| Staff F | Witnessed abuse and interviewed | |
| Staff G | Witnessed abuse, interviewed, and fearful of retaliation | |
| Staff I | Provided written statement about video | |
| Staff J | Provided written statement about video | |
| AA | Interviewed regarding Staff C admission and warrants |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2022
Visit Reason
The visit was conducted to investigate intake GA00220673.
Complaint Details
Investigation was started on 2022-01-20 and completed on 2022-02-24. No violations were found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00219378 and GA00219336, which were opened on 2021-11-30 and completed on 2021-12-09.
Complaint Details
The investigation was complaint-related, focusing on allegations that a private paid sitter took $600 daily from Resident #1's bank account and failed to comply with facility screening and sign-in policies. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to ensure policies and procedures were implemented to support residents' core values in a safe environment. Specifically, a private paid sitter took $600 daily from a resident's bank account without proper facility screening or sign-in as required by policy.
Deficiencies (1)
Failure to implement policies ensuring private duty sitters submit criminal background checks, provide negative TB screenings, and sign in/out as required.
Report Facts
Amount taken daily: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding facility policies and compliance of private duty sitters |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 16, 2021
Visit Reason
The purpose of the visit was to investigate intake #GA00218901, with an onsite visit made on 11/16/21 and the investigation completed on 12/2/21.
Complaint Details
The visit was complaint-related to intake #GA00218901. The complaint involved missing controlled medications. The investigation included interviews, record reviews, and law enforcement involvement. The case was closed with a waiver of prosecution after the facility decided not to proceed further.
Findings
The facility failed to ensure staff followed medication management protocols and professional oversight, resulting in missing controlled medications (Oxycodone and Tylenol with Codeine) for two residents. The investigation revealed unsecured medication storage, failure to verify narcotic counts, and missing narcotics unaccounted for in controlled drug forms. Law enforcement was notified but no suspects were identified, and the case was closed with a waiver of prosecution.
Deficiencies (2)
Failure to ensure staff followed medication management and professional oversight, resulting in missing controlled medications from locked medication cart.
Failure to store residents' medications securely and inventory appropriately to prevent loss and unauthorized use for 2 sampled residents.
Report Facts
Missing tablets: 71
Missing tablets: 64
Medication cards missing: 2
Medication cards missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding notification of missing medications, internal investigation, family and law enforcement notification, and police reports. | |
| Staff B | Interviewed about narcotic count and shift details on 10/30/21. | |
| Staff C | Interviewed about narcotic count and key exchange on 10/30/21. | |
| Staff F | Interviewed about medication administration and narcotic count verification failure on 10/30/21. | |
| Staff H | Interviewed about observation of medication room door propped open and unsecured medication cart on 10/30/21. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217672.
Complaint Details
Investigation of intake #GA00217672 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 29, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00217121, with the investigation starting on 2021-09-23 and completing on 2021-09-29.
Complaint Details
Investigation of intake #GA00217121 was completed with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 9, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00212823 and conduct the compliance inspection. The investigation began on 2021-03-23 and was completed on 2021-04-09.
Complaint Details
Investigation of intake GA00212823; no violations found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The inspection was conducted to investigate intake #GA00211733 initiated on 2021-02-08.
Complaint Details
The inspection was complaint-related based on intake #GA00211733. No deficiencies or rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
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 process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Sep 10, 2019
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rule violations were cited as a result of this inspection.
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