The most recent inspection on June 5, 2025, found no deficiencies. Earlier inspections generally showed no rule violations, with only a few substantiated deficiencies related to staff training, medication management, and resident care documented in reports from 2019 to early 2023. Inspectors cited issues such as missing medication training documentation, incomplete criminal background checks, delays in medication refills, and failure to provide timely resident care. Complaint investigations were mostly unsubstantiated, with the exception of a few substantiated cases involving staff neglect and documentation lapses. The overall trend suggests improvement, as recent inspections have consistently found no deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)1.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The purpose of this visit was to investigate intake # GA50003448 through an unannounced onsite visit conducted on 2025-06-04 and completed on 2025-06-05.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake # GA50003448 found no rule violations.
The purpose of this investigation was to investigate intake numbers GA00250164, GA00250183, GA00149819, and GA00249905 with an on-site visit conducted from 2024-09-23 to 2024-10-01.
Findings
No rule violation was cited as a result of this investigation.
Complaint Details
Investigation was related to multiple intake numbers; no rule violations were found.
The purpose of this visit was to investigate complaint intakes #GA00232293 and #GA00231956 with an on-site visit made on 3/1/23 and the investigation completed on 3/3/23.
Findings
The facility failed to have documentation of medication training for 2 of 3 staff reviewed (Staff B and Staff C) and failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement for 2 of 3 sampled staff (Staff B and Staff D).
Complaint Details
Investigation of complaint intakes #GA00232293 and #GA00231956. The findings were substantiated based on record review and staff interviews.
Severity Breakdown
D: 2
Deficiencies (2)
Description
Severity
Facility failed to have documentation of medication training for 2 of 3 staff reviewed (Staff B and Staff C).
D
Facility failed to ensure direct care staff hired after October 1, 2019 had the required criminal background check upon employment or prior to placement for 2 of 3 sampled staff (Staff B and Staff D).
D
Report Facts
Staff reviewed: 3Staff without medication training documentation: 2Staff without criminal background check: 2
Employees Mentioned
Name
Title
Context
Staff A
Interviewed staff who provided information about medication training and fingerprint background check issues
Staff B
Staff member lacking medication training documentation and fingerprint background check
Staff C
Staff member lacking medication training documentation
The purpose of this inspection was to investigate intake #GA00212109. An on-site visit was made on 2/24/21 and the investigation was completed on 3/11/21.
Findings
The facility failed to ensure that only ambulatory residents capable of self-preservation with minimal assistance were admitted and retained, as evidenced by one resident who required nursing home placement and was unable to ambulate or propel his/her wheelchair independently.
Complaint Details
Investigation was complaint-related, intake #GA00212109. Resident #1 was found not capable of self-preservation and required nursing home placement. The complaint was substantiated based on observation, record review, and interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure the home admitted and retained only ambulatory residents capable of self-preservation with minimal assistance for 1 of 8 sampled residents (Resident #1).
SS= D
Report Facts
Number of sampled residents: 8Date of incident report: Feb 11, 2021Date of discharge notice: Dec 21, 2020
The purpose of this inspection was to investigate complaint intakes GA00209193, GA00209408, GA00209732, and GA00209910. The investigation began on 2020-11-02 and was completed on 2021-01-28.
Findings
The facility failed to ensure that residents received adequate and appropriate care and services in compliance with federal and state regulations. Specifically, Staff B neglected to respond to calls for assistance from Resident #1, resulting in delayed care and eventual termination of Staff B.
Complaint Details
The investigation was complaint-driven based on multiple intakes. Staff B was found neglectful for not responding to resident calls and not completing required two-hour checks. Staff B was terminated due to these complaints.
Severity Breakdown
SS= D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure each resident received adequate and appropriate care and services; Staff B did not respond to Resident #1's call for assistance, resulting in Resident #1 waiting over an hour for help.
SS= D
Report Facts
Residents involved: 5Date investigation began: 2020-11-02 (not numeric but date)
Employees Mentioned
Name
Title
Context
Staff B
Named in deficiency for neglecting resident calls and terminated for this reason
Staff C
Provided interview information regarding Staff B's neglect and termination
AA
Provided interview information about Staff B not responding to calls
The purpose of this visit was to investigate intake #GA00199737.
Findings
The facility failed to ensure timely refills of prescribed medications resulting in interruptions in routine dosing for 2 of 3 sampled residents. Additionally, the facility failed to ensure a written plan of care for proxy caregiver services was current for 2 of 3 sampled residents.
Complaint Details
The visit was complaint-related to intake #GA00199737. Staff interviews confirmed medication refills did not arrive timely, resulting in residents not receiving medications as ordered. Resident #2 did not receive medication for 2 to 3 days between September and October 2019.
Severity Breakdown
J: 1D: 1
Deficiencies (2)
Description
Severity
Refills of prescribed medications were not obtained timely, causing interruptions in routine dosing for Resident #1 and Resident #2.
J
The facility failed to ensure a written plan of care for proxy caregiver services was developed and updated for Resident #1 and Resident #2.
D
Report Facts
Medication administration omissions: 26Resident admission dates: Resident #1 admitted 2017-06-11; Resident #2 admitted 2017-06-17.Plan of care date: Written plans of care for Residents #1 and #2 dated February 2018.
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00198079 with an onsite visit made on 7/22/19.
Findings
The facility failed to maintain evidence of trainings, skills competency, and recertification for 6 sampled staff. Additionally, the facility failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 6 sampled residents and failed to have physician's orders for all medications for 1 of 6 sampled residents.
Complaint Details
The visit was conducted to investigate intake #GA00198079.
Severity Breakdown
SS= D: 3
Deficiencies (3)
Description
Severity
Failed to maintain evidence of trainings, skills competency, and recertification as required by the Rules for Proxy Caregivers for 6 sampled staff.
SS= D
Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 6 sampled residents (Resident #2 and Resident #3).
SS= D
Failed to have physician's orders for all medications for 1 of 6 sampled residents (Resident #6).
SS= D
Report Facts
Sampled staff: 6Sampled residents: 6Residents with MAR update issues: 2Resident with missing physician orders: 1