Inspection Reports for Towne Club Windermere Assisted Living
3950 TOWNE CLUB PARKWAY, CUMMING, GA, 30041
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 28, 2025, identified deficiencies related to staff certifications in emergency first aid and CPR, care plan updates, and emergency food supply rotation. Earlier inspections showed a mix of findings, including prior issues with food safety, resident record access, and safety procedures, but several complaint investigations found no violations. Main themes of deficiencies have involved staff training and certification, care planning, and food safety practices. Complaint investigations were mostly unsubstantiated except for a substantiated case in December 2022 involving menu substitutions and resident record access. The pattern of findings suggests ongoing challenges in these areas, with some repeated issues over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 28, 2025
Visit Reason
The purpose of this survey was to conduct a compliance inspection and investigate complaints #GA50001107 and #GA50002280.
Complaint Details
The inspection was conducted to investigate complaints #GA50001107 and #GA50002280.
Findings
The facility failed to ensure staff had current certifications in emergency first aid and cardiopulmonary resuscitation (CPR). Additionally, the facility did not provide evidence of care plans being updated at least annually or reviewed quarterly for residents, and failed to rotate emergency food supplies according to shelf life, resulting in expired canned food found on site.
Deficiencies (5)
Staff failed to have current certification in emergency first aid.
Staff failed to have current certification in cardiopulmonary resuscitation (CPR).
Facility failed to provide evidence of care plan being updated at least annually for Resident #2.
Facility failed to review care plan at least quarterly for Resident #1 in memory care.
Facility failed to rotate emergency food supply in accordance with shelf life, resulting in expired canned food.
Report Facts
Staff hire date: Jun 1, 2024
Resident admission date: Dec 27, 2021
Resident admission date: Jul 23, 2024
Expired food date: Sep 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Named in findings for lacking current first aid and CPR training. | |
| Staff B | Interviewed regarding staff training and care plan updates. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 14, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243095.
Complaint Details
Investigation of intake #GA00243095 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Monitoring
Capacity: 181
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
The purpose of this visit was to conduct a monitoring inspection to increase capacity from 128 to 181 residents.
Findings
No rule violations were cited as a result of this visit.
Report Facts
Capacity increase: 128
Capacity increase: 181
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00238800.
Complaint Details
Investigation of intake #GA00238800; no violations were found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 23, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00234953. The onsite visit was made on 5/23/23.
Complaint Details
Investigation of intake #GA00234953; no violations were found.
Findings
No violations were cited as a result of this survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 8, 2022
Visit Reason
The purpose of this visit was to investigate complaint #GA00227999. An on-site visit was made to the facility on 12/8/22 and the investigation was completed on 12/16/22.
Complaint Details
Complaint #GA00227999 was investigated with findings that the facility did not note menu substitutions and denied access to requested resident documentation. The complaint was substantiated based on record review, observations, and interviews.
Findings
The facility failed to ensure that menu substitutions were noted before the meal was served, and failed to ensure that residents had the right to obtain copies of all records pertaining to them. Specifically, a meal served was not on the menu and documentation requested by a resident's family was not provided.
Deficiencies (2)
Facility failed to ensure that menu substitutions were noted before the meal was served.
Facility failed to ensure that each resident has the right to make a copy of all records pertaining to the resident on the premises or obtain a copy from the community.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D, hired 3/29/21, stated that the meal served was not on the menu. | ||
| Staff B, hired 5/10/22, stated Resident #4's family was denied access to daily notes documenting changes in behavior. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00226785, GA00226837, GA00227523, GA00227523.
Complaint Details
Investigation of multiple intakes GA00226785, GA00226837, GA00227523, GA00227523 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Aug 3, 2022
Visit Reason
The purpose of this visit was to investigate complaint intakes #GA00225086, #GA00225740, and #GA00226098 with an onsite visit conducted on 8/3/22 and survey completion on 8/10/22.
Complaint Details
The visit was complaint-related, investigating intake numbers #GA00225086, #GA00225740, and #GA00226098. Interviews revealed some expired items had been removed, and some expired salad dressing was delivered but not served.
Findings
The facility failed to ensure that all foods were stored, prepared, and served in a manner that protected them from spoilage and contamination, posing a risk to human consumption. Observations included moldy celery, expired leftovers, unsealed raw chicken, and expired salad dressings.
Deficiencies (8)
One bag of celery with large amounts of mold growth.
Leftovers covered with saran wrap with dates of 7/18/22, 7/27/22, 7/28/22.
One shelf of leftovers with food that was covered loosely and left unsealed.
One container of unsealed raw chicken.
Two large containers of caesar/ranch salad dressing with expiration dates of 7/1/22 and 6/2/22.
One large container of balsamic vinaigrette dressing with an expiration of 7/12/22.
One bottle of lime juice with an expiration of 11/4/21.
One large pan of black eyed peas with a date of 8/1/22 and a 'use by' date of 8/3/22.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2021
Visit Reason
The purpose of this visit was to investigate intake GA00219660.
Complaint Details
Investigation of intake GA00219660 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 27, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate Intake #GA00212557 and GA00211404.
Complaint Details
Investigation of Intake #GA00212557 and GA00211404; no violations found.
Findings
No rule violations were cited as a result of this visit.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 6, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00206055, which involved an elopement incident of Resident #1 from the facility.
Complaint Details
Investigation of intake #GA00206055 regarding Resident #1 eloping from the facility on 6/20/2020. The resident was found by law enforcement walking on a nearby road and returned unharmed. The investigation included interviews with staff and review of incident and 911 reports.
Findings
The facility failed to implement policies and procedures to ensure resident safety, resulting in Resident #1 eloping through an unsecured back/side exit door without an alarm or camera. Resident #1 was found and returned by law enforcement unharmed. The facility did not provide adequate protective care and watchful oversight for this resident with cognitive deficits.
Deficiencies (3)
Failure to implement policies and procedures supporting resident dignity, respect, choice, independence, and privacy in a safe environment.
Failure to provide protective care and watchful oversight for Resident #1, who eloped from the facility.
Failure to utilize appropriate effective safety devices to prevent elopement without impeding resident rights or violating fire safety standards.
Report Facts
Date of elopement incident: Jun 20, 2020
Temperature: 82
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 processes.
Findings
The report focuses on monitoring COVID-19 cases and assessing infection control processes at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 3, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA002026589.
Complaint Details
Investigation of intake #GA002026589 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 7, 2019
Visit Reason
The purpose of this visit was to increase the facility capacity and to complete a compliance inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 30, 2018
Visit Reason
The purpose of this visit was to investigate a self-reported incident # GA00188528.
Complaint Details
Investigation of self-reported incident # GA00188528 with no rule violations found.
Findings
No rule violation was cited as a result of this investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 27, 2018
Visit Reason
The visit was conducted to review documentation submitted by the facility regarding violations cited at the 4/11/18 relicensure inspection.
Findings
The violations cited at the 4/11/18 relicensure inspection have been corrected based on the documentation review.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 11, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection of Towne Club Windermere Assisted Living.
Findings
The facility failed to ensure that staff had current certification in emergency first aid and cardiopulmonary resuscitation (CPR) within the first 60 days of employment for 1 of 4 sampled staff (Staff A).
Deficiencies (2)
Facility failed to ensure staff had current certification in emergency first aid training within the first 60 days of employment for 1 of 4 sampled staff (Staff A).
Facility failed to ensure staff had current certification in cardiopulmonary resuscitation (CPR) within the first 60 days of employment for 1 of 4 sampled staff (Staff A).
Report Facts
Sampled staff: 4
Staff with deficiencies: 1
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