Inspection Reports for Tapestry House Assisted Living
2725 Holcomb Bridge Rd, Alpharetta, GA 30022, United States, GA, 30022
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 28, 2023, identified a deficiency related to the facility’s failure to thoroughly clean and sanitize a resident’s room after discharge. Earlier inspections showed a mixed pattern, with some investigations finding no violations while others cited deficiencies involving resident care, staffing, and environmental cleanliness. Common themes included inadequate response to resident needs, issues with staff training and staffing ratios, and problems with maintaining a clean and safe environment. Complaint investigations were mostly unsubstantiated, though some substantiated cases involved failure to provide timely care after a resident fall and verbal mistreatment of residents by staff. The facility’s inspection history shows ongoing challenges in care and housekeeping, with no clear trend of consistent improvement or worsening.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
51% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 28, 2023
Visit Reason
The purpose of this visit was to investigate intake GA00238072 with an onsite visit made to the facility on 9/28/23 completed on 9/29/23.
Findings
The facility failed to thoroughly clean and sanitize Resident #3's room after the resident moved out, as evidenced by dirty carpet, trash scattered on the floor, old food, dirty utensils and clothes, overflowed trash, knats in the trash can, and an unpleasant urine smell. Staff acknowledged no directives were given to housekeeping to clean the room after the resident moved out.
Complaint Details
Visit was complaint-related to intake GA00238072; substantiation status not explicitly stated.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to thoroughly clean and sanitize Resident #3's room after the resident moved out. | SS= D |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 23, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00237730.
Findings
No violations were cited as a result of this survey.
Complaint Details
Investigation of intake #GA00237730; no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2023
Visit Reason
The visit was conducted to investigate complaint intakes #GA00230738, #GA00231547, and #GA00232105 with an onsite visit made on 3/6/23 and investigation completed on 3/24/23.
Findings
No rule violations were cited during the investigation.
Complaint Details
Investigation of complaint intakes #GA00230738, #GA00231547, and #GA00232105; no violations found.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 16, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00228782 and #GA00228783, with an onsite visit made on 2022-11-30 and the investigation completed on 2022-12-16.
Findings
The facility failed to provide adequate and appropriate care for one of three sampled residents (Resident #1), who fell and lay on the floor unattended for approximately 8 hours overnight. Staff failed to respond to the resident's emergency call and did not check the resident every 2 hours as required.
Complaint Details
Investigation was complaint-related, triggered by intake #GA00228782 and #GA00228783. Resident #1 reported falling and lying on the floor for 8 hours without response to emergency pendant. Staff B confirmed finding the resident on the floor at 7:00 a.m. after the fall. Agency staff were working the night of the fall and were subsequently fired. Staff failed to check the resident every 2 hours as required.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate and appropriate care for Resident #1 who fell and lay unattended on the floor for 8 hours overnight. | SS= D |
Report Facts
Deficiencies cited: 1
Hours resident lay on floor: 8
Date of incident: Sep 7, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Found Resident #1 on the floor at 7:00 a.m. after fall; stated agency staff worked the night of the fall | |
| AA | Interviewed on 12/16/22; stated staff failed to check resident every 2 hours and agency staff were fired |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00225608, GA00225926, and GA00226338.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was complaint-related for intake GA00225608, GA00225926, and GA00226338; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 26, 2022
Visit Reason
The purpose of this visit was to investigate intake GA00223109, with an onsite visit made to the facility on 4/26/22.
Findings
The facility failed to ensure that two sampled residents were treated with dignity, kindness, and respect, and failed to protect them from verbal and mental abuse by staff. Multiple interviews and record reviews indicated that Staff D yelled at and intimidated residents at the receptionist desk, causing emotional distress.
Complaint Details
The investigation was complaint-driven based on intake GA00223109. Interviews with residents and staff revealed allegations of staff yelling and mistreating residents, specifically Staff D. Residents reported feeling intimidated and fearful. Staff D denied the allegations. Staff C acknowledged asking residents to leave the receptionist desk but denied yelling or mistreatment. Resident complaints were not acted upon by Staff C.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were treated with dignity, kindness, consideration, and respect. | D |
| Facility failed to ensure residents had the right to be free from verbal and mental abuse. | D |
Report Facts
Number of sampled residents: 2
Date of onsite visit: Apr 26, 2022
Date survey completed: May 5, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in findings for inappropriate behavior, yelling, and intimidation of residents | |
| Staff C | Mentioned in relation to asking residents to leave receptionist desk and failure to intervene in Staff D's behavior |
Inspection Report
Renewal
Deficiencies: 0
Mar 17, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00221865 and conduct the re-licensure inspection.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was related to intake #GA00221865; no violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 12, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00220421 and #GA00220669.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation was conducted for two intakes (#GA00220421 and #GA00220669) with no rule violations found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 18, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00214107.
Findings
No rule violations were cited as a result of this investigation.
Complaint Details
Investigation began 05/17/21, site visit conducted on 05/18/21, and investigation completed on 06/29/21. No rule violations were found.
Inspection Report
Complaint Investigation
Deficiencies: 5
Apr 28, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00213309, with the survey starting on 2021-04-19 and completed on 2021-04-30.
Findings
The facility failed to keep the interior and exterior of the assisted living community clean, in good repair, and free of unsanitary or unsafe conditions posing health or safety risks to residents and staff. Observations included tripping hazards, discarded trash and cleaning items improperly stored, broken fixtures, and medical equipment stored inappropriately.
Complaint Details
Investigation was initiated due to intake #GA00213309. The survey was conducted as a compliance inspection related to this complaint.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Computer cable laying on the floor across two doorways creating a potential tripping hazard. | D |
| Housekeeping closet had discarded trash, empty bottle, mop on the floor, and used cleaning gloves on a rollator seat. | D |
| Laundry room ceiling light fixture had no cover over the long tube bulbs. | D |
| Laundry room had a broken cabinet door hanging by one hinge. | D |
| Laundry room floor had discarded dryer sheets and white powder substance; medical equipment stored in front of washing machine. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Interviewed regarding housekeeping staffing and temporary placement of computer cable. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 6, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00209985. This investigation started on 2020-12-14 and was completed on 2021-01-06.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00209985 was conducted and completed with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 18, 2020
Visit Reason
An onsite visit was made to the facility on 10/18/20 to investigate intake #GA00209467.
Findings
No violations were cited as a result of this inspection.
Complaint Details
Investigation of intake #GA00209467 with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00208291 and #GA00208041.
Findings
No rule violation was cited as a result of this inspection.
Complaint Details
Investigation began on 2020-09-22 and was completed on 2020-09-29. No rule violations were found.
Inspection Report
Monitoring
Deficiencies: 0
Apr 6, 2020
Visit Reason
The purpose of this review was to monitor COVID 19 cases and assess infection control processes.
Findings
The report focused on monitoring COVID-19 cases and evaluating infection control measures at the facility.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2020
Visit Reason
The purpose of this investigation was to investigate intake #GA00203305, starting on 2020-03-16 and completed on 2020-03-27.
Findings
No violations were cited as a result of this investigation.
Complaint Details
Investigation was complaint-related intake #GA00203305; no violations were found.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Oct 9, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate complaint #GA00199740.
Findings
The facility failed to maintain adequate staffing ratios to meet residents' health and safety needs, resulting in delayed staff response times and inadequate assistance during transfers. Additionally, the facility failed to document and respond appropriately to a resident's fall and injury involving a broken closet mirror door.
Complaint Details
Complaint #GA00199740 was investigated, focusing on staffing adequacy and response to resident needs, including a fall incident involving Resident #5. The complaint was substantiated based on findings of insufficient staffing and failure to document and respond to the resident's fall.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to staff above the minimum on-site staff to resident ratio to meet residents' ongoing health, safety, and care needs. | SS= D |
| Failed to include an incident report related to change in resident condition and take immediate actions appropriate to the specific circumstances to address the needs of the resident. | SS= D |
Report Facts
Staff coverage third shift: 3
Staff coverage second shift: 4
Staff coverage first shift: 5
Census: 58
Residents requiring assistance with transfer: 6
Residents requiring maximum assistance during transfer: 6
Residents unable to transfer on their own: 7
Time delay for staff response: 30
Time delay for staff response: 90
Time delay for lunch service: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Mentioned in relation to staff response times and lack of knowledge about resident fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 3
Aug 15, 2019
Visit Reason
The purpose of this visit was to investigate complaint GA00198615. An on-site visit was made on 8/15/19 and the investigation was completed on 8/22/19.
Findings
The facility failed to update the Medication Assistance Record (MAR) for 2 of 6 sampled residents, failed to obtain ordered medications for one resident, and failed to ensure timely response to emergency pendants, with delays ranging from 5 minutes to over 45 minutes or no response at all.
Complaint Details
Complaint GA00198615 triggered the investigation. The complaint involved failure to maintain medication records, failure to obtain medications, and inadequate response to emergency pendants.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to update the Medication Assistance Record (MAR) each time medication was offered or taken for 2 of 6 sampled residents. | SS= D |
| Failed to obtain ordered medications for 1 of 6 sampled residents (Resident #2). | SS= D |
| Failed to provide adequate and timely response to emergency pendants, with delays up to 45 minutes or no response. | SS= D |
Report Facts
Sampled residents: 6
Residents with MAR deficiencies: 2
Residents with medication procurement failure: 1
Emergency pendant response times: 30
Emergency pendant response time: 45
Emergency pendant response time: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Interviewed and stated he/she forgot to sign the MARs for Residents #1 and #2 | |
| Staff F | Interviewed and stated Resident #2 did not have Polyeth GLYC powder and that medications in Resident #1's room were not from the facility | |
| Staff A | Interviewed and stated facility staff were to answer emergency pendants within 7 to 10 minutes | |
| HH | Interviewed and stated it took facility staff 45 minutes to respond to pendants |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 13, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00193782 with on-site visits made on 2/5/19 and 2/13/19, and the investigation completed on 2/13/19.
Findings
The facility failed to ensure staff received required training within the first 60 days of employment specific to assigned job duties, and failed to maintain adequate staffing ratios to meet residents' ongoing health, safety, and care needs, resulting in delayed responses to call buttons and resident injuries.
Complaint Details
Investigation of intake #GA00193782 with substantiated findings of training deficiencies and staffing shortages impacting resident care and safety.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff hired to provide hands-on personal services received training within the first 60 days of employment specific to assigned job duties including medication assistance and dementia-related behaviors. | SS= D |
| Failure to maintain minimum on-site staff to resident ratios to meet specific residents' ongoing health, safety, and care needs, causing delayed response times to call buttons. | SS= D |
Report Facts
Dates of on-site visits: 2
Wait time for call button response: 45
Staff response time to call buttons: 2
Staff response time to call buttons: 3
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2018
Visit Reason
The purpose of this visit was to conduct a compliance inspection and to investigate complaint #GA00186645.
Findings
An on-site visit was made on 4/3/18 and inspection/investigation was completed on 4/4/18. There were no rule violations cited.
Complaint Details
Complaint #GA00186645 was investigated and found to have no rule violations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 12, 2018
Visit Reason
The purpose of this visit was to investigate complaint #GA00184430, with onsite visits made on 2018-01-30 and 2018-02-08, and the investigation completed on 2018-02-12.
Findings
The facility failed to allow a resident to associate and communicate freely and privately with persons of the resident's choice without censorship by staff, specifically restricting communication between Resident #1 and an individual named CC during August and September 2017 based on a Power of Attorney's request.
Complaint Details
Complaint #GA00184430 was investigated with substantiation implied by the deficiency found regarding residents' rights violations.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to allow the resident to have the right to associate and communicate freely and privately with persons and groups of the resident's choice without being censored by staff for 1 resident. | SS= D |
Inspection Report
Annual Inspection
Deficiencies: 0
May 24, 2017
Visit Reason
The purpose of this visit was to conduct the annual inspection of the facility.
Findings
No violations were cited as a result of this inspection.
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