The most recent inspection on June 11, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to protective care and watchful oversight, particularly involving residents leaving the Memory Care Unit unsupervised, as well as some issues with facility security such as exit doors not locking properly. Complaint investigations were mostly unsubstantiated except for a few substantiated cases where residents were found outside unsupervised, resulting in injuries or hypothermia. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history suggests some improvement, with no deficiencies noted in the two most recent inspections.
Deficiencies (last 5 years)
Deficiencies (over 5 years)0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of the visit was to investigate intake number #GA00252449, which triggered an onsite investigation on 1/3/2025.
Findings
The facility failed to provide protective care and watchful oversight for one of four sampled residents, as evidenced by an incident where a resident was mistakenly let out of the Memory Care Unit by staff who did not verify the resident's identity.
Complaint Details
Investigation was initiated due to intake #GA00252449. The investigation found rule violations related to protective care and oversight. Staff B admitted to letting Resident #1 out of the Memory Care Unit by mistake.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to provide protective care and watchful oversight for Resident #1, who was let out of the Memory Care Unit by Staff B without verification of residency.
SS= D
Report Facts
Sampled residents: 4Incident date: Nov 1, 2024Documented Education Form date: Nov 8, 2024
Employees Mentioned
Name
Title
Context
Staff B
Admitted to letting Resident #1 out of the Memory Care Unit by mistake
Staff A
Met with Staff B to provide education regarding the incident
The purpose of this visit was to investigate complaint intakes #GA00231812, #GA00231829, and #GA00233061. An onsite visit was made on 4/4/23 and the inspection was completed on 4/13/23.
Findings
The facility failed to provide protective care and watchful oversight for 1 of 3 sampled residents (Resident #1), who was found outside in cold weather for 2.5 hours with hypothermia and injuries after leaving the facility unsupervised in a motorized wheelchair.
Complaint Details
The investigation was triggered by complaint intakes #GA00231812, #GA00231829, and #GA00233061. Resident #1 was found hypothermic and injured after being outside the facility for 2.5 hours in cold weather. The complaint was substantiated based on observations, record review, and staff interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to provide protective care and watchful oversight for Resident #1, who was found outside in cold weather for 2.5 hours with hypothermia and injuries.
The purpose of this visit was to investigate complaint intakes #GA00211456, #GA00211244, and #GA00211354. The inspection started on 2021-01-21 and was completed on 2021-02-09.
Findings
The facility failed to ensure that staff maintained awareness of each resident's normal appearance and intervened appropriately, resulting in Resident #1 being missing and not recognized by staff when found at the hospital. The facility also failed to ensure the community was designed and maintained to provide for the health, safety, and well-being of residents, as exit doors on the Memory Care Unit did not latch and lock properly, allowing Resident #1 to exit unsupervised.
Complaint Details
The visit was complaint-related, investigating intakes #GA00211456, #GA00211244, and #GA00211354. The complaint involved Resident #1 being missing from the facility, staff not recognizing the resident when found at the hospital, and issues with exit doors on the Memory Care Unit. Substantiation status is not explicitly stated.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Facility failed to ensure staff maintained awareness of residents' normal appearance and intervened appropriately, leading to Resident #1 being missing and unrecognized by staff.
SS= D
Facility failed to ensure the community was designed, constructed, arranged, and maintained to provide for health, safety, and well-being of residents; specifically, exit doors on the Memory Care Unit did not latch and lock properly.
SS= D
Report Facts
Number of sampled residents: 14Date of incident: Jan 10, 2021Time of arrival back to facility: 1215Medication dosage: 5
Employees Mentioned
Name
Title
Context
Staff B
Interviewed regarding Resident #1 missing incident and hospital visit; did not recognize Resident #1 initially
Staff A
Interviewed about exit doors on Memory Care Unit not latching and locking properly
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