The most recent inspection on July 14, 2025, found no deficiencies. Earlier inspections showed a generally clean record with several complaint investigations resulting in no rule violations. However, prior reports from 2023 noted deficiencies related to resident care, including delayed response times and improper restraint use, as well as staff training issues. One investigation in October 2023 involved staff termination and law enforcement due to resident mistreatment, but no fines or license actions were listed in the available reports. The facility’s inspection history suggests improvement over time, with recent inspections showing no cited deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake #GA50002042, GA50002725, GA50002079, and GA50002704.
Findings
An on-site visit was made to the facility on 5/5/25 and the investigation was completed on 5/5/25. No rule violations were found as a result of the inspection.
Complaint Details
Investigation of four intakes: #GA50002042, GA50002725, GA50002079, and GA50002704. No rule violations found.
The purpose of this visit was to investigate complaint intakes #GA00239816 and #GA00239342 through an on-site visit conducted on 10/12/2023 and completed on 10/13/2023.
Findings
The facility failed to ensure adequate and appropriate care for residents, including delayed response times to resident calls and improper treatment of Resident #2, who was placed in a padded laundry cart by staff, resulting in staff termination and law enforcement involvement. Resident #1 experienced long wait times for assistance, and the facility was found to have violated residents' rights regarding freedom from restraints and punishment.
Complaint Details
The investigation was triggered by complaint intakes #GA00239816 and #GA00239342. Staff B, Staff C, and Staff D were terminated and reported to law enforcement case #2023-10-0085 for elderly abuse towards Resident #2. Resident #1 reported retaliation concerns due to contacting the Ombudsman and 911. Family member AA expressed dissatisfaction with the laundry cart incident but was satisfied with the facility's handling.
Severity Breakdown
SS= D: 2
Deficiencies (2)
Description
Severity
Facility failed to ensure each resident received adequate and appropriate care and services in compliance with state law for 2 of 3 sampled residents, including 16 incidents with response times over 20 minutes.
SS= D
Facility failed to ensure residents' right to be free from actual or threatened physical or chemical restraints and unusual punishment for 1 of 3 sampled residents (Resident #2) who was placed in a padded laundry cart by staff.
SS= D
Report Facts
Incidents with response time over 20 minutes: 16Response time to Resident #1 pendant call: 34Sampled residents: 3
Employees Mentioned
Name
Title
Context
Staff A
Interviewed staff who reported on incidents involving Residents #1 and #2 and staff terminations
Staff B
Staff involved in placing Resident #2 in a padded laundry cart and subsequently terminated
Staff C
Staff involved in placing Resident #2 in a padded laundry cart and subsequently terminated
Staff D
Staff involved in placing Resident #2 in a padded laundry cart and subsequently terminated
AA
Family member interviewed by telephone regarding Resident #2 incident and facility care
The purpose of this visit was to investigate intake #GA00234984 with an onsite visit conducted from 6/6/23 to 6/9/23.
Findings
The facility failed to ensure that staff received required training within the first 60 days of employment for 2 of 5 sampled staff, specifically Staff D and Staff E, as there was no documentation of abuse, neglect, or exploitation training.
Complaint Details
The visit was complaint-related, investigating intake #GA00234984.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Failure to ensure staff received abuse, neglect, or exploitation training within the first 60 days of employment for 2 of 5 sampled staff (Staff D and Staff E).
SS= D
Report Facts
Number of sampled staff with training deficiency: 2Sample size of staff reviewed: 5
Employees Mentioned
Name
Title
Context
Staff D
Named in training deficiency finding
Staff E
Named in training deficiency finding
Staff B
Interviewed and stated he/she would get staff trained