Deficiencies per Year
4
3
2
1
0
Moderate
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2025
Visit Reason
The purpose of this visit was to investigate intake #GA50005976 with an on-site visit conducted on 10/8/2025.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation started and completed on 10/8/2025 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 7, 2024
Visit Reason
The purpose of this visit was to investigate intake # GA00248532.
Findings
An onsite visit was made on 2024-08-07 and the investigation was completed on 2024-08-13. There were no rule violations cited as a result of this survey.
Complaint Details
Investigation of intake # GA00248532 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 25, 2024
Visit Reason
The visit was conducted to investigate multiple complaint intakes numbered GA00246963, GA00246908, GA00246917, GA00246960, and GA00246964.
Findings
The investigation was completed with no rule violations cited as a result of this visit.
Complaint Details
Investigation of complaint intakes #GA00246963, #GA00246908, #GA00246917, #GA00246960, and #GA00246964 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 7, 2023
Visit Reason
The purpose of this visit was to investigate complaint intakes GA00240197 and GA00240369 with an on-site visit conducted on 11/7/23 and completed on 11/8/23.
Findings
The facility failed to ensure the assisted living community operated in a manner that respects the personal dignity and human rights of residents, as evidenced by video showing Staff C forcibly handling Resident #1, causing distress and potential harm. Staff C was suspended and retrained following the incident.
Complaint Details
The investigation was initiated due to complaint intakes GA00240197 and GA00240369. The complaint was substantiated by video evidence showing Staff C's inappropriate conduct towards Resident #1. Staff C was suspended and retrained. Police reviewed the video and did not find signs of abuse.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to operate in a manner that respects the personal dignity and human rights of residents, including forcibly handling Resident #1 causing distress and potential harm. | D |
Report Facts
Date of incident: Oct 16, 2023
Date of admission: Feb 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in findings for inappropriate conduct towards Resident #1 and subject of corrective action and suspension | |
| Staff A | Involved in reviewing video evidence and calling police | |
| Staff B | Involved in reviewing video evidence and suspension decision | |
| AA | Witness who observed video and reported incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 8, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237626. An onsite visit was made to the facility on 9/8/23 to conduct the investigation.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Investigation was started and completed on 9/8/23 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 17, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00216686 and #GA00216597, including an unannounced visit and investigation completed on 09/17/2021.
Findings
The facility failed to ensure that one resident was free from mental, verbal, and physical abuse. Specifically, Staff C pinched the ear of Resident #1 and raised his/her voice during an attempt to weigh the resident, who was combative. Staff C was subsequently removed from employment.
Complaint Details
The investigation was initiated based on complaint intakes #GA00216686 and #GA00216597. The complaint was substantiated by interviews and incident reports confirming abuse by Staff C against Resident #1 on 08/04/2021.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure each resident had the right to be free from mental, verbal, and physical abuse for 1 of 6 residents in the sample. | SS= D |
Report Facts
Residents in sample: 6
Incident report date: Aug 4, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in abuse incident involving Resident #1; pinched resident's ear and raised voice; subsequently removed from facility. | |
| Staff A | Witnessed abuse incident, reported to police, and confirmed Staff C was escorted from facility. | |
| Staff B | Witnessed abuse incident and described resident's combative behavior. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 14, 2020
Visit Reason
The inspection was conducted to investigate intake #GA00207283, which began on 2020-09-03 and was completed on 2020-10-14.
Findings
The assisted living community failed to utilize appropriate safety devices to protect residents at risk of eloping, specifically Resident #1, who exited the building due to a door locking mechanism failure and staff leaving the door propped open with a piece of paper.
Complaint Details
The investigation was complaint-related, triggered by intake #GA00207283 regarding Resident #1 eloping from the facility due to door and wander guard system failures. The complaint was substantiated based on record review, video evidence, and staff interviews.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to utilize appropriate effective safety devices to protect residents at risk of eloping, resulting in Resident #1 exiting the building due to door locking mechanism failure and staff propping door open. | D |
Report Facts
Incident date: Jul 8, 2020
Investigation start date: Sep 3, 2020
Investigation completion date: Oct 14, 2020
Resident admission date: Oct 28, 2012
Residents at risk: 2
Residents involved: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in relation to leaving door propped open and allowing Resident #1 to exit | |
| Staff A | Completed progress note and investigation related to Resident #1 incident | |
| Staff B | Wrote note regarding Resident #1 and reported on door incident | |
| AA | Interviewed regarding Resident #1 eloping incident and door issues |
Inspection Report
Monitoring
Deficiencies: 0
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 evaluating the facility's infection control measures.
Inspection Report
Routine
Deficiencies: 1
Nov 14, 2018
Visit Reason
The purpose of this visit was to conduct the compliance inspection.
Findings
The facility failed to ensure that staff received a tuberculosis screening within 12 months prior to providing care to residents for 1 of 3 staff sampled (Staff C).
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure staff received a tuberculosis screening within 12 months prior to providing care to residents for 1 of 3 staff sampled (Staff C). | SS= D |
Report Facts
Staff sampled: 3
Staff with missing TB screening: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 6, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA00190224.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint GA00190224 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Aug 2, 2018
Visit Reason
The purpose of this visit was to investigate self reported incident #GA00189635 involving a resident injury during transfer.
Findings
The facility failed to ensure protection from avoidable injury for 1 of 52 residents when Staff B dropped Resident #1 during a transfer from wheelchair to bed, resulting in a fractured right leg.
Complaint Details
Investigation of self reported incident #GA00189635 confirmed that Resident #1 was dropped by staff during transfer, resulting in injury and fracture.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure each resident was protected from avoidable injury for 1 of 52 residents (Resident #1) who was dropped during transfer resulting in a fracture. | SS= D |
Report Facts
Residents present: 52
Incident date: Jun 24, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named as staff who dropped Resident #1 during transfer | |
| Staff A | Provided interview details about the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 17, 2018
Visit Reason
An onsite visit was made to the facility on 7/17/18 and 7/18/18 to investigate complaints #GA0000189805, #GA00189544 and a self-reported incident #GA00189305.
Findings
The facility failed to ensure all residents made choices about aspects of their life that were significant to them. Specifically, Resident #1 complained about being put to bed earlier than their preferred time, and there was no documentation indicating the resident's preferred bedtime.
Complaint Details
The investigation was complaint-related, triggered by complaints #GA0000189805, #GA00189544 and a self-reported incident #GA00189305. The complaint about Resident #1 was substantiated regarding bedtime preferences not being respected.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents made choices about significant aspects of their life, including bedtime preferences. | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 17, 2018
Visit Reason
The purpose of this visit was to investigate complaint GA#00188118. The investigation began on 2018-04-30, with an on-site visit on 2018-05-01, and was completed on 2018-05-17.
Findings
The facility failed to obtain new prescriptions within 48 hours of receipt of notice of the prescription for 1 of 1 sampled residents (Resident #1). Resident #1 did not receive prescribed medications from hospital discharge on 2018-03-30 until 2018-04-07 due to delays in processing and communication with the pharmacy and physician.
Complaint Details
Complaint GA#00188118 was investigated. The complaint involved delayed medication procurement for Resident #1, which was substantiated by record reviews and interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to obtain new prescriptions within 48 hours of receipt of notice of the prescription for Resident #1. | SS= D |
Report Facts
Days delay in medication administration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding medication procurement delays and communication with pharmacy and physician. | |
| CC | Confidential interviewee who stated Resident #1 was discharged with prescriptions but did not receive medications for one week. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 5, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00185589.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00185589 was investigated and no rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 17, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00180609 with an on-site visit made to the community on 10/17/17.
Findings
No rule violations were cited as a result of the investigation.
Complaint Details
Complaint #GA00180609 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 15, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00178252 and #GA00178423.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaints #GA00178252 and #GA00178423 with no rule violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 12, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00175745.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00175745 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 31, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00175287.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00175287 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 27, 2017
Visit Reason
The purpose of this visit was to investigate complaint #GA00170662.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Complaint #GA00170662 was investigated and found to have no rule violations.
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