Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Original Licensing
Deficiencies: 0
Jun 18, 2025
Visit Reason
The purpose of this visit was to conduct a change of ownership (CHOW) inspection at the facility.
Findings
The inspection began on 2025-06-18 and ended on 2025-06-25. No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2024
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00252189.
Findings
No rule violations were cited as a result of this visit.
Complaint Details
Investigation started on 2024-12-17 and was completed on 2024-12-23. An onsite visit was made on 2024-12-17.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 10, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242072 with an onsite visit made on 7/10/2024.
Findings
No rule violations were cited as a result of this investigation completed on 7/11/2024.
Complaint Details
Investigation of intake #GA00242072 was conducted with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 4, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237540 regarding allegations of verbal and physical abuse of Resident #1 by staff.
Findings
The facility failed to report a serious incident involving Resident #1 within 24 hours as required. Allegations included that Resident #1 was yelled at and beaten by an agency staff member on 7/23/2023, but no law enforcement was notified. Interviews revealed conflicting statements among staff about the abuse and reporting.
Complaint Details
The investigation was triggered by intake #GA00237540 alleging that Resident #1 was verbally and physically abused by an agency staff member. The complaint was not substantiated as staff gave conflicting accounts, and no law enforcement was notified.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report to the Department within 24 hours a serious incident involving a resident as required by regulation. | SS= D |
Report Facts
Incident date: Jul 23, 2023
Report date: Oct 4, 2023
Number of sampled residents: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 29, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00219873 and GA00220094 with an on-site visit conducted on 12/29/2021.
Findings
The facility failed to ensure that one registered professional nurse, licensed practical nurse, or certified medication aide was on-site at all times in the memory care unit. Observations and interviews revealed that on 12/29/21, no qualified nurse or medication aide was present in the memory care unit during the inspection.
Complaint Details
The visit was complaint-related, investigating intakes GA00219873 and GA00220094. The investigation was closed on 01/04/2022.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure one registered professional nurse, licensed practical nurse, or certified medication aide on-site at all times in the memory care unit. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Medication Aide (CMA) | Interviewed and observed working on 1st floor Assisted Living Unit and going back and forth between AL and Memory Care unit. |
| Staff E | Licensed Practical Nurse (LPN) | Interviewed and stated helping to cover 1st floor Assisted Living Unit and noted Staff C was not a CMA or licensed caregiver. |
Inspection Report
Complaint Investigation
Census: 18
Deficiencies: 5
Nov 17, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00218939 and conduct the compliance inspection at the assisted living facility.
Findings
The facility failed to ensure adequate staffing with trained caregivers on each occupied floor, lacked a memory care certificate for the memory care unit, did not have proper physician physical examination reports reflecting dementia diagnosis for residents, failed to involve residents' families in care plan development, and did not secure quarterly pharmacist reviews for certified medication aides.
Complaint Details
The visit was complaint-related, investigating intake GA00218939. The investigation was completed on 11/18/2021.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure at least two trained staff present at all times with one on each occupied floor. | D |
| Failed to obtain and display a memory care certificate for the memory care unit. | D |
| Failed to ensure residents have a physician's physical examination report completed within 30 days prior to admission reflecting dementia diagnosis. | D |
| Failed to ensure resident's family participated in the development of the resident's written care plan. | D |
| Failed to secure quarterly pharmacist reviews of drug regimens for certified medication aides. | D |
Report Facts
Residents on first floor: 6
Residents on second floor: 5
Residents in memory care unit: 7
Sampled residents with care plan issues: 2
Sampled staff without quarterly pharmacist review: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding staffing, care plans, memory care certificate, and pharmacist reviews | |
| Staff C | Caregiver on first floor and certified medication aide without quarterly pharmacist review | |
| Staff D | Assigned to second floor but was on lunch break during inspection | |
| Staff F | Certified medication aide without quarterly pharmacist review | |
| Staff G | Scheduled to work in ALF 7:00 a.m. to 3:00 p.m. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 15, 2021
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00216959 and GA00216833 with an onsite visit conducted on 09/15/2021.
Findings
The facility failed to ensure adequate supervision of residents consistent with their needs, resulting in the elopement of Resident #1 from the memory care unit. Additionally, the facility failed to ensure staff demonstrated proper infection control practices, as one staff member was observed not wearing a mask while providing care.
Complaint Details
The investigation was initiated due to complaint intakes #GA00216959 and GA00216833 regarding inadequate supervision leading to Resident #1's elopement and improper infection control practices by staff.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to supervise residents consistent with their needs, resulting in Resident #1 eloping from the memory care unit. | SS= D |
| Failure to ensure staff demonstrated understanding and use of proper infection control practices; Staff D was observed not wearing a mask while providing care. | SS= D |
Report Facts
Sampled residents: 6
Sampled staff: 10
Time of Resident #1 elopement: 1252
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Observed Resident #1 outside the neighboring library and provided interview details about the elopement | |
| Staff F | Held the door open allowing Resident #1 to exit the memory care unit; was new and unaware of the incident | |
| Staff D | Observed not wearing a mask while providing care to residents, violating infection control policies | |
| Staff I | Reviewed security camera footage of the elopement incident | |
| Staff B | Provided information about Staff F and the elopement incident | |
| Staff A | Provided interview regarding video footage and facility mask policy | |
| Staff G | On-duty staff at the memory care unit during the elopement incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00213442. The investigation began on 2021-04-19 and was completed on 2021-04-20.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00213442 with no rule violations found.
Inspection Report
Original Licensing
Deficiencies: 0
Dec 7, 2020
Visit Reason
The purpose of this inspection 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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