Deficiencies per Year
12
9
6
3
0
Severe
Moderate
Inspection Report
Renewal
Deficiencies: 0
Jul 29, 2025
Visit Reason
The purpose of this visit was to conduct a re-licensure and a complaint inspection (GA50004151).
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Complaint inspection GA50004151 was conducted with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 21, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50001650 through an unannounced visit on 4/21/2025 at 9:10 a.m.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA50001650 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 26, 2025
Visit Reason
The purpose of this visit was to investigate intakes #GA50000402 and GA50000548.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted on 2/26/2025 and completed on 2/27/2025 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242072 with an onsite visit to the facility.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00242072; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 21, 2023
Visit Reason
The purpose of this visit was to investigate intakes# GA00235601 and GA00235980.
Findings
An on-site visit was made on 6/21/2023. No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intakes# GA00235601 and GA00235980 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 25, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00231018.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00231018 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 21, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00228060.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00228060 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 26, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00226362, which involved allegations of possible sexual assault and other incidents involving residents.
Findings
The facility failed to ensure adequate and appropriate care for 1 of 7 sampled residents, with incidents involving Resident #2 wandering into other residents' rooms, including an alleged sexual assault on Resident #1. The facility made a report to law enforcement and implemented some changes, but family and staff reported ongoing concerns about inadequate response and monitoring.
Complaint Details
The investigation was initiated due to intake #GA00226362 concerning an alleged sexual assault on 7/13/22 involving Resident #2 and Resident #1. The complaint was substantiated with findings of Resident #2 wandering into other residents' rooms multiple times and inappropriate behavior. Family and staff interviews indicated dissatisfaction with the facility's response and monitoring.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure each resident received care and services which were adequate, appropriate, and in compliance with state law and regulation for 1 of 7 sampled residents related to incidents of possible sexual assault and wandering. | D |
Report Facts
Number of sampled residents: 7
Date of alleged incident: Jul 13, 2022
Date report made to law enforcement: Jul 26, 2022
Number of documented wandering incidents: 6
Date investigation started: Aug 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding the incident and facility response; provided details about Resident #2's behavior and facility actions |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 9
Apr 6, 2022
Visit Reason
The inspection was conducted to perform a compliance inspection and investigate complaint intakes #GA00222704 and #GA00222966.
Findings
The facility failed to ensure required criminal background checks, emergency first aid and CPR certifications, memory care certification, adequate staff training, medication aide licensing, and sufficient emergency water supply. Additionally, the facility failed to provide adequate care for Resident #4, who fell and was not promptly assisted.
Complaint Details
The inspection was complaint-related, investigating intakes #GA00222704 and #GA00222966. The complaint involved failure to provide adequate care, staff training deficiencies, and licensing issues.
Severity Breakdown
SS= D: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure direct care staff hired after October 1, 2019 had required criminal background checks upon employment or prior to placement for 2 of 6 sampled staff (Staff C and Staff E). | SS= D |
| Failed to ensure staff hired to provide hands-on personal services received current certification in emergency first aid for 1 of 6 sampled staff (Staff C). | SS= D |
| Failed to ensure staff hired to provide hands-on personal services received current certification in cardiopulmonary resuscitation (CPR) for 1 of 6 sampled staff (Staff C). | SS= D |
| Failed to obtain a memory care certification. | SS= D |
| Failed to ensure staff in the memory care unit received adequate trainings for 1 of 6 sampled staff (Staff C). | SS= D |
| Failed to provide general orientation and trainings for 2 of 6 sampled staff (Staff C and Staff E). | SS= D |
| Failed to check the registry and ensure medication aides were in good standing for 1 of 2 staff required to have a license (Staff E). | SS= D |
| Did not have a sufficient quantity of 3 day emergency water (53 gallons on hand; 180 gallons needed based on census of 60). | SS= D |
| Failed to provide adequate care for Resident #4 who fell and was found on the floor for about two hours without staff knowledge. | SS= D |
Report Facts
Census: 60
Emergency water on hand: 53
Emergency water needed: 180
Sampled staff: 6
Residents sampled: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in multiple findings including lack of criminal background check, missing emergency first aid and CPR certifications, inadequate memory care training, and involved in resident incident | |
| Staff E | Named in findings related to missing criminal background check, lack of general orientation training, and inactive CNA and CMA licenses | |
| Staff A | Interviewed regarding staff certifications and training deficiencies | |
| Staff H | Interviewed regarding incident involving Resident #1 and Staff C | |
| Staff D | Interviewed regarding systems failure related to Resident #4 fall and medication administration | |
| Staff I | Interviewed regarding Resident #4 fall and lack of shift report | |
| Staff J | Interviewed regarding emergency water supply |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00219944.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00219944 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00218058.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation started on 2021-10-26 and was completed on 2021-10-29. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 6
Sep 3, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00216525 and #GA00216719, with an onsite visit made on 2021-08-25 and investigation completed on 2021-09-03.
Findings
The facility failed to implement proper medication management policies for 3 of 7 sampled residents, including medication omissions, lack of timely medication refills, and a medication administration error. Additionally, the facility failed to maintain accurate staffing schedules, keep medications in original containers, and ensure residents received adequate care and services as ordered by physicians.
Complaint Details
The visit was complaint-related, investigating intakes #GA00216525 and #GA00216719. The investigation included review of medication management, staffing schedules, medication administration errors, and medication storage practices.
Severity Breakdown
L: 3
D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to implement medication management policies for 3 of 7 sampled residents, including lack of documentation for medication administration and timely refill notifications. | L |
| Failed to develop and maintain monthly work schedules for all employees and retain completed schedules for at least one year. | D |
| Failed to provide medication administration services in accordance with physicians' orders for 1 of 7 sampled residents, including a medication error where Hydrocodone/Acetaminophen was given instead of Tylenol. | D |
| Failed to obtain medication refills timely for 3 of 7 sampled residents, resulting in interruptions in routine dosing. | L |
| Failed to ensure medications were kept in original containers with original labels for 3 of 7 sampled residents. | D |
| Failed to provide adequate and appropriate care and services in compliance with state law for 3 of 7 sampled residents, including failure to administer medications as ordered. | L |
Report Facts
Sampled residents: 7
Residents with medication management issues: 3
Medication administration error: 1
Insulin flex pens observed: 5
Missing work schedules: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding medication ordering practices, awareness of medication errors, and staffing schedules | |
| Staff H | Administered incorrect medication to Resident #6 and reported the error |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 3, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00215487.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation started on 2021-08-02 and was completed on 2021-08-03. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 29, 2021
Visit Reason
The visit was conducted to perform a compliance inspection and investigate intake #GA00213540.
Findings
No rule violations were cited as a result of this inspection and investigation.
Complaint Details
Investigation started on 2021-04-22 and was completed on 2021-04-29. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 19, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210897 and #GA00211243.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation started on 2021-01-26 and was completed on 2021-02-19. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Feb 18, 2021
Visit Reason
The purpose of this visit was to investigate complaints #GA00208576 and #GA00208608, with the investigation starting on 2020-10-29 and completed on 2021-02-18.
Findings
The facility failed to ensure adequate care and services for residents, including failure to provide continuous medical or nursing care for Resident #9, inadequate wound care for Resident #2, failure to treat Resident #1 with dignity and respect, and improper use of physical restraints for Resident #9. Multiple interviews and record reviews revealed neglect, insufficient staffing, and failure to follow hospice care plans.
Complaint Details
The investigation was complaint-driven, focusing on allegations of neglect, inadequate care, physical abuse, and improper use of restraints involving Residents #1, #2, and #9. Substantiation is implied by the findings but not explicitly stated.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure Resident #9 received continuous medical or nursing care, resulting in a large stage IV wound and significant weight loss. | SS=D |
| Facility failed to provide adequate wound care for Resident #2, resulting in worsening wounds and pain. | SS=D |
| Facility failed to ensure Resident #1 was treated with dignity, kindness, and respect, including incidents of physical abuse and verbal disrespect by staff. | SS=D |
| Facility failed to ensure Resident #9 was free from physical restraints, as bedrails were used to prevent falling. | SS=D |
Report Facts
Resident weight loss: 48
Resident sample size: 12
Dates of hospice visits: 11
Dates of hospice visits: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Provided information about Resident #9's discharge and wound care; stated Staff D no longer worked with Resident #1. | |
| Staff D | Accused by Resident #1 and witnesses of physical abuse and verbal disrespect. | |
| FF | Interviewed regarding Resident #9's wound care and staffing issues. | |
| KK | Interviewed about wounds and care for Residents #9 and #2. | |
| MM | Interviewed about wound care and restraint use for Residents #9 and #2. | |
| AA | Interviewed about wound care and staffing issues for Resident #2. | |
| CC | Interviewed about Resident #9's condition and restraint use. | |
| JJ | Called to assist with incontinence care for Resident #9. | |
| OO | Interviewed about Resident #9's admission and wound condition. | |
| II | Provided wound care instructions and discussed staffing for Resident #2. | |
| GG | Interviewed about Resident #2's wound condition and care. | |
| DD | Witnessed Staff D's harsh behavior toward Resident #1. | |
| EE | Reported Resident #1's statements about Staff D's abuse. | |
| NN | Stated hospice nurse visited Resident #9 weekly and staff changed bandages between visits. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2021
Visit Reason
The visit was conducted to investigate intake #GA00209348 and #GA00209048.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was related to two intakes (#GA00209348 and #GA00209048) and was completed with no cited violations.
Inspection Report
Complaint Investigation
Deficiencies: 3
Jan 12, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210048, which was started on 2020-12-10 and completed on 2021-01-12.
Findings
The facility failed to implement policies and procedures to ensure timely medication refills and administration for three sampled residents, resulting in medication omissions and interruptions in routine dosing. Documentation of family notifications and medication deliveries was incomplete or missing.
Complaint Details
Investigation of intake #GA00210048 regarding medication management and care for three residents. The complaint was substantiated with findings of medication omissions and failure to obtain timely refills.
Severity Breakdown
K: 2
L: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement policies supporting dignity, respect, choice, independence, and privacy of residents, including medication management and documentation of medication omissions or refusals. | K |
| Failure to ensure timely medication refills to prevent interruptions in routine dosing for three sampled residents. | K |
| Failure to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations. | L |
Report Facts
Medication omissions: 14
Dates of medication omissions: Specific dates include 11/19/2020, 12/9/2020, 12/12/2020, 12/13/2020, 11/21/2020, 12/5/2020, 12/6/2020, 12/10/2020, 12/28/2020, and 12/9/2020 among others.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed on 2021-01-06 regarding Resident #3's family supplying COQ 10 medication. | |
| Staff B | Interviewed on 2021-01-12 stating a coordinator reorders medication refills and noting Resident #1 was out of Simvastatin on 12/13/2020. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 21, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00207136.
Findings
The facility failed to ensure that policies and procedures were effective and enforced, including failure to complete incident reports for all incidents and accidents, failure to maintain and review safety logs, and failure to update residents' service plans and written care plans quarterly. Specific incidents involving residents were not properly documented, and care plans lacked signatures from all team members providing direct care.
Complaint Details
The inspection was complaint-related, investigating intake #GA00207136. The complaint involved failure to document incidents and falls properly, and failure to update care plans accordingly.
Severity Breakdown
Level D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete incident reports for all incidents and accidents. | Level D |
| Failure to maintain and review safety committee logs for incidents and accidents. | Level D |
| Failure to review and revise resident service plans in conjunction with fall reviews or incidents. | Level D |
| Failure to update residents' written care plans quarterly and include signatures from all team members providing direct care. | Level D |
Report Facts
Incident dates: 3
Care plan dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Interviewed regarding care plans and incident reports; signed care plans and involved in notification of incidents | |
| Staff L | Interviewed about lack of incident report for Resident #3's fall on 8/21/2020 | |
| EE | Reported receiving call about Resident #3's falls on 8/21/2020 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 27, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00205336, which was started on 2020-10-20 and completed on 2020-10-27.
Findings
The facility failed to ensure timely refills of prescribed medication Sertraline for Resident #1, resulting in the resident not receiving the medication on multiple dates in October 2020. Interviews with staff and the resident confirmed the medication was unavailable, causing the resident to experience increased depression. The facility did not notify appropriate staff timely about the medication shortage.
Complaint Details
Investigation of intake #GA00205336 regarding medication management and resident care for Resident #1. The complaint was substantiated based on record review and staff interviews.
Severity Breakdown
J: 2
K: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement policies and procedures to support dignity, respect, choice, independence, and privacy of residents in a safe environment. | J |
| Failure to ensure refills of prescribed medications were obtained timely to prevent interruption in routine dosing for Resident #1. | J |
| Failure to ensure each resident received adequate and appropriate care and services in compliance with state law and regulations for Resident #1. | K |
Report Facts
Missed medication doses: 7
Resident admission date: Nov 27, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Medication Aide (CMA) | Stated Resident #1 did not have Sertraline available on 10/10/2020. |
| Staff B | Notified late about medication shortage; responsible for being notified when resident had 7 pills left. | |
| Staff G | Reported Resident #1 did not have Sertraline on 10/10/2020 and 10/11/2020. | |
| Staff H | Reported Resident #1 did not have Sertraline on 10/8/2020. |
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: 1
Feb 7, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00202426 regarding medication administration concerns.
Findings
The facility failed to follow the physician's medication orders for Resident #1, resulting in missed doses of Keppra and other medications. This led to the resident experiencing mini seizures and subsequent hospitalization, with the resident passing away from pneumonia on 1/28/2020.
Complaint Details
Investigation of intake #GA00202426 found that Resident #1 missed two doses of Keppra resulting in mini seizures. Staff A was suspended and Staff B received a verbal warning. Resident #1 was hospitalized and later died from pneumonia.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to follow the written doctor's order for medication administration for Resident #1, missing doses of Keppra and other medications. | SS= D |
Report Facts
Missed medication doses: 2
Dates of staff actions: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Suspended for rule violation related to medication errors and later separated from employment. | |
| Staff B | Received verbal warning for medication administration errors. | |
| Staff C | Provided interview information regarding medication administration and resident condition. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Dec 17, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00201104, with the investigation starting on 2019-11-26 and completing on 2019-12-17.
Findings
The facility was found to have multiple deficiencies including failure to provide required staff training within the first 60 days of employment in areas such as infection control, emergency preparedness, emergency first aid, medical and social needs of residents, residents' rights, and memory care. The facility also failed to obtain required criminal background checks and physical examinations for staff. Additionally, the facility failed to conduct National Sex Offender Registry searches for some residents. A substantiated allegation of physical abuse was found where a staff member pushed a resident to the floor, and involved staff were terminated for gross misconduct.
Complaint Details
The complaint investigation was initiated due to intake #GA00201104 concerning an allegation of physical abuse of Resident #1 by Staff B, who pushed the resident to the floor on 2019-11-13. The incident was substantiated based on incident reports, video footage, and staff interviews. Staff involved in the abuse and other related misconduct were terminated.
Severity Breakdown
D: 9
J: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure staff received training within the first 60 days on general infection control principles including hand hygiene for 6 of 7 sampled staff. | D |
| Failure to ensure staff received training within the first 60 days on emergency preparedness for 3 of 7 sampled staff. | D |
| Failure to ensure staff hired to provide hands-on personal services received emergency first aid training within the first 60 days for 3 of 7 sampled staff. | D |
| Failure to ensure staff received training in medical and social needs and characteristics of the resident population for 4 of 7 sampled staff. | D |
| Failure to ensure staff received training in residents' rights and individualized care for 1 of 7 sampled staff. | D |
| Failure to obtain satisfactory fingerprint records check for Executive Director prior to serving for 2 staff. | D |
| Failure to obtain criminal records check for 2 of 7 sampled staff. | D |
| Failure to ensure staff received physical examination and TB screening within 12 months of employment for 5 of 7 sampled staff. | D |
| Failure to ensure memory care staff received training in Alzheimer's disease and dementia within 6 months of hire for 3 of 7 sampled staff. | D |
| Failure to conduct National Sex Offender Registry search for 3 of 5 sampled residents. | J |
| Failure to provide adequate and appropriate care resulting in physical abuse of Resident #1 by Staff B, who pushed the resident to the floor; staff involved were terminated. | J |
Report Facts
Sampled staff: 7
Sampled residents: 5
Incident date: Nov 13, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Executive Director | Named in findings related to missing fingerprint records check and staff training deficiencies |
| Staff B | Involved in physical abuse of Resident #1 and multiple training deficiencies; terminated for gross misconduct | |
| Staff C | Mentioned in relation to reporting abuse and missing fingerprint records check | |
| Staff E | Witness to abuse incident and had training deficiencies; terminated for gross misconduct | |
| Staff F | Witness to abuse incident and had training deficiencies; terminated for gross misconduct | |
| Staff G | Witness to abuse incident and had training deficiencies; terminated for gross misconduct |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 9, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00201178, which was an allegation investigated under intake #GA00201104.
Findings
The report does not provide specific findings or conclusions beyond the investigation of the complaint intake.
Complaint Details
Investigation of complaint intake #GA00201178 and related allegation under intake #GA00201104.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 3, 2019
Visit Reason
The purpose of this visit was to complete a compliance inspection and to investigate complaint number GA00199645.
Findings
No rules violation was written as a result of this investigation.
Complaint Details
Investigation of complaint # GA00199645 resulted in no rules violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 30, 2019
Visit Reason
The purpose of this visit was to investigate intake GA00199022 and GA00198789, which were opened on 8/28/19 and completed on 8/30/19.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00199022 and GA00198789; no violations found.
Inspection Report
Original Licensing
Deficiencies: 0
Oct 26, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the facility.
Findings
No rules violation was cited as a result of this inspection.
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