Inspection Reports for Addington Place of Alpharetta
762 N Main St, Alpharetta, GA 30009, United States, GA, 30009
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Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2025
Visit Reason
The purpose of this visit was to investigate intake GA50004290 and GA50004022.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation of complaint intakes GA50004290 and GA50004022 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 4
Jul 2, 2025
Visit Reason
The purpose of this visit was to investigate multiple intakes (#GA50003531, GA50002939, GA50002900, GA50002886, GA50003154) concerning resident safety and care at Addington Place of Alpharetta.
Findings
The facility failed to provide adequate oversight and protective care for Resident #2, who eloped twice from the memory care unit in April 2025 without staff awareness. The memory care unit lacked effective safety devices to alert staff of unauthorized exits, and staff did not have proper notification tools. These lapses placed the resident at significant risk of harm and demonstrated critical failures in monitoring and physical security.
Complaint Details
The investigation was triggered by multiple intakes alleging resident elopement and inadequate supervision. The complaint was substantiated based on observations, record reviews, and staff interviews confirming Resident #2 eloped twice without staff awareness and safety lapses in the memory care unit.
Severity Breakdown
D: 3
J: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Governing body failed to provide oversight necessary to ensure compliance, evidenced by Resident #2 eloping twice without staff awareness. | D |
| Facility failed to provide watchful oversight meeting residents' needs, as Resident #2 eloped twice and staff were unaware. | D |
| Memory care unit failed to utilize effective safety devices to alert staff to unauthorized exits; no alarms or audible alerts on exit doors. | D |
| Facility failed to provide adequate, appropriate care and services in compliance with regulations, as Resident #2 eloped twice and supervision was inadequate. | J |
Report Facts
Elopement incidents: 2
Incident report dates: 04/10/2025 and 04/21/2025
Distance from facility: Resident #2 was found about 500 feet to 1 mile from the facility after elopement.
Staff on shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Received EMT call about Resident #2 elopement and confirmed resident supervision needs. | |
| Staff C | Observed Resident #2 in memory care unit before first elopement and unaware of how elopement occurred. | |
| Staff D | Interviewed regarding elopement incident and visitor holding door for Resident #2. | |
| Staff E | Provided written statement about Resident #2 elopement while busy with other residents. | |
| Staff F | Provided written statement about Resident #2 elopement while busy with other residents. | |
| BB | Staff member working during second elopement, confirmed staff were unaware during incident. | |
| DD | Interviewed about circumstances of Resident #2 elopements and facility alarm system deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 21, 2025
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA00252610 and #GA00252758. An unannounced visit was made on 2025-01-15 and the inspection was completed on 2025-01-21.
Findings
No rule violations were cited during the inspection.
Complaint Details
Investigation of intake #GA00252610 and #GA00252758; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 25, 2024
Visit Reason
The visit was conducted to investigate intake #GA00249890.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00249890 resulted in no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 13, 2024
Visit Reason
The visit was conducted to investigate complaint intakes #GA00248967, #GA00249268, and #GA00249380 through an unannounced inspection.
Findings
No rule violations were cited during the inspection completed on 09/13/2024.
Complaint Details
The inspection was complaint-related, investigating three intake numbers. No rule violations were found, indicating no substantiated deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2024
Visit Reason
The purpose of this visit was to investigate intakes #GA00247271 and GA00247830.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intakes #GA00247271 and GA00247830 was conducted from 7/9/2024 to 7/11/2024 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 13, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00244315. An onsite visit was made on 3/13/24 and the inspection was completed on 3/22/24.
Findings
The facility failed to have a volunteer procedure that provided direction for staff and residents on safety and security precautions to protect residents from volunteers, as evidenced by the lack of policy and interviews indicating the volunteer program was suspended.
Complaint Details
Investigation of intake #GA00244315 regarding safety and security precautions related to volunteers. The complaint was substantiated by observations, record review, and interviews.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to have volunteer procedure providing direction for staff and residents on safety and security to protect residents from volunteers for 1 of 3 sampled residents (Resident #1). | SS= D |
Report Facts
Intake number: GA00244315
Date of onsite visit: Mar 13, 2024
Date survey completed: Mar 22, 2024
Resident sample size: 3
Resident #1 admission date: Oct 31, 2022
Volunteer duration: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 12, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243489.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00243489 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00236199. An onsite visit was made to the facility on 7/19/23.
Findings
The investigation was completed on 8/31/23 with no rule violations cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00236199 found no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00235352.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00235352 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00229581 and GA00229406.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaint intakes GA00229581 and GA00229406 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 7, 2022
Visit Reason
The visit was conducted to investigate intake #GA00220786, with the investigation starting on 2022-01-31 and completing on 2022-02-07, including an onsite visit on 2022-02-07.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of intake #GA00220786 was completed with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 3, 2021
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00212210 and #GA00212980.
Findings
No rule violations were cited as a result of this inspection.
Complaint Details
Investigation was completed on 5/3/21 following an onsite visit on 4/21/21; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 11, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00207589, which was started on 2020-09-08 and completed on 2020-09-11.
Findings
The facility failed to protect residents from criminal activity by not reporting abuse to law enforcement for one sampled resident. Resident #1 was observed with multiple bruises and was pulled by staff on video surveillance. Staff B was terminated and abuse training was provided, but law enforcement was not notified as required.
Complaint Details
The investigation was initiated due to intake #GA00207589. The complaint involved allegations of abuse to Resident #1, substantiated by video evidence and bruising. Staff B was observed pulling the resident and was terminated. Law enforcement was not notified as required. Attempts to interview Resident #1 were unsuccessful due to cognitive status.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report abuse to law enforcement authorities for Resident #1 after observing staff verbally aggressive and physically pulling the resident, resulting in bruises. | SS= D |
| Failure to ensure each resident received adequate and appropriate care in compliance with state law and regulations, evidenced by multiple bruises on Resident #1 and inadequate response to suspected abuse. | SS= D |
Report Facts
Intake number: 200207589
Dates of incident reports: Incidents occurred between 2020-08-17 and 2020-09-07
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed verbally aggressive and physically pulling Resident #1; terminated on 2020-08-18; refused interview | |
| Staff A | Interviewed and stated law enforcement was not notified of the incident | |
| Staff E | Observed Resident #1 with bruises but could not determine cause |
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 process.
Findings
The report focuses on monitoring COVID-19 cases and assessing the infection control process at the facility.
Inspection Report
Follow-Up
Deficiencies: 3
Dec 19, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up to the 7/31/19 compliance inspection and investigation.
Findings
The facility failed to maintain required employee training and documentation for 2 of 3 sampled staff, failed to keep the interior carpets clean and in good repair with visible stains in the Memory Care Unit, and failed to report a serious injury (hip fracture) of a resident to the Department within 24 hours as required.
Complaint Details
This was a follow-up visit to a previous compliance inspection and investigation conducted on 7/31/19.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to maintain required employee training and documentation for Staff F and Staff G. | D |
| Failed to keep the interior of the assisted living community clean and in good repair; carpets in Memory Care Unit stained and worn. | E |
| Failed to report a serious injury to a resident (Resident #7) requiring medical attention to the Department within 24 hours. | D |
Report Facts
Number of sampled staff with missing training documents: 2
Size of largest carpet stain: 2.5
Number of sampled residents involved in serious injury reporting deficiency: 1
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 5
Jul 31, 2019
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00198068.
Findings
The facility was found deficient in multiple areas including expired CPR and first aid certification for staff, unsanitary conditions such as stained carpets and furniture, failure to update Medication Assistance Records (MAR) properly, failure to obtain timely medication refills for residents, and insufficient emergency food and water supplies for a three-day emergency use.
Complaint Details
The visit was triggered by intake #GA00198068 and included investigation of compliance with regulations.
Severity Breakdown
D: 3
J: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to ensure staff were re-certified in CPR and first aid for 1 of 5 staff sampled (Staff D) with expired certification dated June 2017. | D |
| Facility failed to keep the interior clean and in good repair; carpet and sofa had stains and black electrical tape was used on carpet edge protector. | D |
| Facility failed to ensure staff updated the Medication Assistance Record (MAR) each time medication was offered or taken for 1 of 6 sampled residents (Resident #4). | J |
| Facility failed to obtain timely refills of prescribed medications for 2 of 6 sampled residents (Resident #4 and Resident #5). | J |
| Facility failed to maintain sufficient supplies of non-perishable food and water for a three-day emergency use; no water supplies were available. | D |
Report Facts
Resident census: 58
Medication deficiencies: 8
Emergency food supply cans: 18
Emergency food supply bags: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in deficiency for expired CPR and first aid certification | |
| Staff A | Interviewed regarding expired certification and emergency food supplies | |
| Staff B | Interviewed regarding carpet stains and cleaning | |
| Staff C | Interviewed regarding MAR documentation and medication refills |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 30, 2018
Visit Reason
The purpose of this visit was to investigate complaint numbers #GA00192272 and #GA00192388.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation of complaints #GA00192272 and #GA00192388 with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2018
Visit Reason
The purpose of this visit was to investigate facility reported incident #GA00190725.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation was conducted with on-site visits on 2018-08-28 and 2018-09-13, completed on 2018-09-14. No violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 1
May 15, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00187939, with the investigation starting on 2018-05-02 and completing on 2018-05-15.
Findings
The facility failed to ensure that residents were treated with dignity, kindness, consideration, and respect, as evidenced by multiple interviews reporting Staff E and Staff F being rude and harsh to memory care residents.
Complaint Details
Complaint #GA00187939 was investigated starting 2018-05-02 and completed 2018-05-15. Multiple interviews confirmed rude and harsh treatment by staff towards residents in the memory care unit.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were treated with dignity, kindness, consideration, and respect, violating residents' rights for 3 of 16 memory care residents. | SS= D |
Report Facts
Memory care residents affected: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 31, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection.
Findings
No rule violations were cited during the annual inspection.
Inspection Report
Follow-Up
Deficiencies: 3
Jul 10, 2017
Visit Reason
The purpose of this visit was to conduct a follow up to the initial inspection conducted on 2/9/17, with an onsite visit on 6/7/17 and completion on 7/10/17.
Findings
The facility failed to conduct fire drills in compliance with fire safety regulations and maintain accurate records of these drills. Additionally, food safety violations were noted including unlabeled and undated food containers and failure to ensure hot foods were served at the proper temperature.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure fire drills were conducted in compliance with fire safety regulations and failure to maintain accurate records of rehearsals including names of participants and times. | SS= D |
| Failure to ensure all foods stored were protected from spoilage and contamination; observed unlabeled and undated food containers. | SS= D |
| Failure to ensure hot foods leave the kitchen for serving at or above 140 degrees Fahrenheit; observed plated food at 138.9 degrees Fahrenheit. | SS= D |
Report Facts
Temperature of plated food: 138.9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Interviewed regarding fire drill documentation and procedures. | |
| Staff C | Interviewed regarding food labeling and temperature monitoring. |
Inspection Report
Original Licensing
Deficiencies: 13
Feb 7, 2017
Visit Reason
The purpose of this visit was to conduct the initial inspection of the assisted living community.
Findings
The inspection found multiple deficiencies related to the failure to develop required policies and procedures, including those for memory care services, staffing plans, refunds, resident wandering, emergency preparedness, and proxy caregivers. Additionally, the administrator did not meet required qualifications, staff training and criminal background checks were incomplete, and medication management deficiencies were identified.
Severity Breakdown
D: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to develop policies and procedures for specialized services including memory care unit. | D |
| Failed to develop policies and procedures for staffing plan to ensure staffing ratios increase proportionally. | D |
| Failed to develop policies and procedures for refunds when a resident is transferred or discharged. | D |
| Failed to develop policies and procedures regarding residents wandering away from the community including Mattie's Call procedures. | D |
| Failed to develop policies and procedures for emergency preparedness, drills, and evacuation requirements. | D |
| Failed to develop policies and procedures for the use and oversight of proxy caregivers. | D |
| Administrator did not meet educational and work experience qualifications. | D |
| Failed to ensure staff providing hands-on personal services completed required continuing education units. | D |
| Failed to obtain satisfactory fingerprint records check for the administrator prior to hire. | D |
| Failed to obtain criminal records check for one staff member prior to employment. | D |
| Admission agreement failed to disclose how and by what level of staff medications are handled. | D |
| Failed to update Medication Assistance Record (MAR) each time medication was offered or taken for one resident. | D |
| Failed to obtain ordered medication refill for one resident, resulting in medication not being available. | D |
Report Facts
Staff sampled: 5
Residents sampled: 4
CEUs required: 16
Date of inspection visit: Feb 7, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Administrator/Executive Director | Did not meet educational and work experience qualifications; lacked fingerprint records check |
| Staff B | Interviewed staff who could not locate policies and procedures or documentation | |
| Staff C | Failed to provide continuing education documentation; failed to update MAR; reported medication refill not obtained | |
| Staff D | Failed to provide continuing education documentation; lacked criminal records check | |
| Staff E | Failed to provide continuing education documentation |
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