Inspection Reports for The Mansions at Alpharetta Assisted Living and Memory Care
3675 Old Milton Pkwy, Alpharetta, GA 30005, GA, 30005
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 13, 2024, cited a deficiency related to the facility’s failure to ensure a resident’s right to be free from physical abuse, though the specific allegation was not substantiated. Earlier inspections showed a pattern of deficiencies involving resident care, including inadequate supervision and safety measures leading to an elopement, failure to provide appropriate care for pressure wounds, and medication administration errors. Prior reports also noted issues with timely reporting of incidents and abuse, as well as lapses in emergency preparedness and staff background checks at the facility’s opening. Complaint investigations included both substantiated and unsubstantiated findings, with the most notable substantiated cases involving inadequate care and medication errors. The inspection history shows ongoing challenges with resident care and safety, with some issues recurring over time and no clear pattern of sustained improvement.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51 residents
Based on a January 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2024
Visit Reason
The purpose of this visit was to investigate intake GA 00251791 regarding an allegation of physical abuse of a resident.
Complaint Details
The complaint involved an allegation that Staff C physically abused Resident #1 by grabbing and squeezing the resident's testicles during a shower. The facility conducted an internal investigation, suspended Staff C, notified the police (case #2410-0279), and informed the resident's spouse. The case remained open pending further investigation. Ultimately, the allegation was not substantiated.
Findings
Based on observation, record review, and interviews, the allegation of physical abuse by Staff C against Resident #1 was not substantiated.
Deficiencies (1)
Facility failed to ensure each resident had the right to be free from physical abuse for 1 of 1 sampled residents (Resident #1).
Report Facts
Case number: 24100279
Staff C hire date: Oct 8, 2024
Staff C termination date: Oct 17, 2024
Resident #1 admission date: Jan 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in physical abuse allegation | |
| Staff A | Received abuse report, conducted investigation, suspended Staff C, and informed resident's spouse | |
| Staff B | Witnessed alleged abuse and assessed Resident #1 | |
| BB | Involved in assessment and investigation of the incident | |
| CC | Investigator who stated case remained open and Staff C might be charged |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 24, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00243108 with an onsite visit made on 2/24/24 to assess the facility's compliance related to the complaint.
Complaint Details
Investigation of intake #GA00243108 regarding Resident #3's care and pressure wounds. The complaint was substantiated by findings of pressure wounds and inadequate care.
Findings
The facility failed to provide adequate and appropriate care for Resident #3, who was hospitalized with bilateral pressure wounds on the heels and a small pressure wound on the back. Interviews and record reviews revealed conflicting reports about the presence of pressure wounds prior to hospitalization and noted the resident's physical and cognitive decline.
Deficiencies (1)
Failure to provide adequate and appropriate care resulting in bilateral pressure wounds on Resident #3's heels and a small pressure wound on the back.
Report Facts
Resident sample size: 3
Date of survey completion: Feb 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Provided statements regarding Resident #3's hospitalization and condition | |
| Staff D | Cared for Resident #3 and provided statements about pressure wounds | |
| EE | Conducted assessments on Resident #3 and provided statements | |
| DD | Took photographs of pressure wounds and provided statements | |
| AA | Provided statements about Resident #3's emergency room visit and pressure wounds |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 5
Date: Jan 30, 2024
Visit Reason
The purpose of this visit was to investigate intake #GA00242026, which started on 2024-01-16 and was completed on 2024-01-30.
Complaint Details
Investigation of intake #GA00242026 regarding Resident #1's elopement and related safety concerns.
Findings
The facility failed to provide adequate oversight and supervision for Resident #1, an 89-year-old resident diagnosed with dementia who eloped from the assisted living section and was found outside in cold weather with injuries. The facility lacked effective safety devices on exits, had insufficient staffing to meet Resident #1's needs, and had no policy for frequent resident checks in assisted living.
Deficiencies (5)
Governing body failed to provide necessary oversight to ensure compliance with state laws and regulations for Resident #1 who eloped and was found outside with injuries.
Facility failed to maintain adequate staffing to meet Resident #1's ongoing health and safety needs, including fall risk and supervision.
Assisted living community failed to provide protective care and watchful oversight meeting the needs of residents, including Resident #1 who eloped.
Facility failed to utilize effective safety devices to prevent elopement; exits opened without alarms or locks allowing Resident #1 to leave unsupervised.
Facility failed to provide adequate, appropriate care and services in compliance with state law for Resident #1, including lack of policy for assisted living checks and insufficient supervision.
Report Facts
Resident census: 51
Staffing: 4
Resident age: 89
Temperature: 37
Incident time: 310
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and confirmed Resident #1 eloped, exits opened with a push and no locks or alarms. | |
| Staff B | Interviewed and stated Resident #1 was moved from memory care to assisted living; no policy for assisted living checks; signed policy page. | |
| Staff C | Interviewed and stated assisted living residents did not receive supervision or frequent checks. | |
| Staff D | Interviewed and stated assisted living residents did not receive supervision or frequent checks. | |
| Staff E | Interviewed and stated assisted living residents did not receive supervision or frequent checks. | |
| Staff G | Interviewed and stated assisted living residents did not receive supervision or frequent checks. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 12, 2023
Visit Reason
The visit was conducted to investigate complaint intakes #GA00233545 and #GA00234043.
Complaint Details
Investigation of complaint intakes #GA00233545 and #GA00234043 with no rule violations cited.
Findings
The investigation was completed on 2023-05-10 and no rule violations were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2023
Visit Reason
The purpose of this visit was to investigate intake #GA00233144 and #GA00233450.
Complaint Details
Investigation of intake #GA00233144 and #GA00233450 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 18, 2022
Visit Reason
The purpose of this visit was to conduct the compliance inspection and investigate intake #GA00226945. An onsite visit was made on 10/18/22 and the inspection was completed on 10/21/22.
Complaint Details
The visit was complaint-related, investigating intake #GA00226945. The complaint involved failure to provide adequate care and failure to report a serious incident timely. Substantiation status is not explicitly stated.
Findings
The facility failed to provide adequate and appropriate care and services for 1 of 3 sampled residents (Resident #1), including failure to notify the responsible party when the resident refused showers for 3 weeks and failure to report a serious incident involving a resident within 24 hours after it occurred.
Deficiencies (2)
Failed to provide adequate and appropriate care and services for Resident #1, including lack of notification to responsible party when resident refused showers for 3 weeks.
Failed to report a serious incident involving Resident #1 within 24 hours after the incident occurred.
Report Facts
Date of incident: Oct 12, 2022
Date of care plan: Mar 5, 2021
Date of home health note: Sep 20, 2022
Date of admission: Jan 6, 2018
Duration of shower refusal: 21
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 1
Date: Jun 7, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00224266 and intake #GA00224415. An onsite visit was made on 6/7/22 and the investigation was completed on 6/14/22.
Complaint Details
The investigation was triggered by intake #GA00224266 and intake #GA00224415. The complaint involved failure to administer prescribed medication Eliquis to Resident #1, resulting in hospitalization. Staff interviews revealed confusion over medication lists and withholding of Eliquis. No discontinuation order was confirmed.
Findings
The facility failed to provide medication administration services in accordance with physician's orders for 1 of 3 sampled residents (Resident #1). Specifically, Eliquis medication was withheld multiple times, leading to Resident #1 being hospitalized with chest pain and other symptoms.
Deficiencies (1)
Failed to provide medication administration services in accordance with physician's orders for Resident #1, including withholding Eliquis medication multiple times.
Report Facts
Residents observed: 22
Staff observed: 10
Medication doses withheld: 17
Previous violation date: Nov 23, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed regarding medication withholding and facility retraining | |
| Staff C | Interviewed regarding medication list and retraining by pharmacy | |
| Staff D | Interviewed regarding medication administration and communication with EMS | |
| Staff E | Interviewed regarding medication reconciliation and supply | |
| Staff F | Interviewed regarding medication supply and administration oversight | |
| AA | Interviewed regarding notification of Resident #1 hospitalization and medication error |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake #GA00218883 with an onsite visit made on 11/15/21.
Complaint Details
Investigation of intake #GA00218883 regarding medication administration issues for Resident #4. The complaint was substantiated based on record review and interviews.
Findings
The facility failed to provide medication administration services to 1 of 4 sampled residents (Resident #4) in accordance with physician's orders, with missed medications documented and interviews revealing a system glitch affecting medication pass records.
Deficiencies (1)
Failed to provide medication administration services to Resident #4 in accordance with physician's orders, including missed doses of multiple medications.
Report Facts
Missed medication doses: 4
Sampled residents: 4
Medication doses: 2
Scheduled hours: 36
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 8, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00210370.
Complaint Details
Investigation started on 2020-01-04 and was completed on 2020-01-08. No rule violations were found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 26, 2020
Visit Reason
The purpose of this inspection was to investigate intake #GA00205505, starting on 2020-06-15 and completed on 2020-06-26.
Complaint Details
Investigation was complaint-related based on intake #GA00205505. The complaint was substantiated as the facility failed to timely report abuse of Resident #1.
Findings
The facility failed to follow the Long Term Care Resident Abuse Reporting Act by not timely reporting an incident of abuse involving Resident #1. Staff B reported the incident late to law enforcement after the investigation started.
Deficiencies (1)
Failure to report abuse of Resident #1 to law enforcement in a timely manner as required by the Long Term Care Resident Abuse Reporting Act.
Report Facts
Residents involved: 3
Inspection start date: Jun 15, 2020
Inspection completion date: Jun 26, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Interviewed regarding late reporting of abuse incident | |
| Staff F | Reported to Staff B that Staff C slapped Resident #1 | |
| Staff C | Alleged to have slapped Resident #1 |
Inspection Report
Monitoring
Deficiencies: 0
Date: 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
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2019
Visit Reason
The purpose of this visit was to conduct the compliance inspection and to investigate intake #GA00199706.
Complaint Details
Investigation of intake #GA00199706 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 1, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00196213.
Complaint Details
Investigation of intake #GA00196213 with no rule violations found.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 17, 2019
Visit Reason
The purpose of this visit was to conduct a follow-up inspection to the initial inspection.
Findings
No rule violations were cited as a result of this inspection.
Inspection Report
Original Licensing
Deficiencies: 3
Date: Sep 26, 2018
Visit Reason
The purpose of this visit was to conduct the initial inspection of the assisted living community.
Findings
The facility failed to obtain proper criminal history background checks for 5 sampled staff, did not maintain a 3-day emergency water supply sufficient for drinking and food preparation, and failed to ensure adequate care and documentation for one resident regarding blood pressure and weight checks.
Deficiencies (3)
Failed to obtain a criminal records check determination in compliance with O.C.G.A 31-7-250 for 5 of 5 sampled staff.
Failed to maintain a 3-day emergency water supply sufficient for drinking and food preparation.
Failed to ensure each resident received adequate care and services; no documentation of blood pressure and weight checks for Resident #6 as ordered.
Report Facts
Number of staff with improper criminal record checks: 5
Dates of staff hiring with improper checks: Staff B hired 9/26/17, Staff C hired 9/13/18, Staff D hired 9/26/17, Staff E hired 2/27/18, Staff F hired 6/26/18
Date order for Resident #6 blood pressure and weight checks written: Order written on 9/6/18 for blood pressure daily for one week and weight twice a week for one month
Date range with no documentation for Resident #6: No documentation from 9/6/18 to 9/13/18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiency for improper criminal record check and failure to locate blood pressure and weight checks for Resident #6 | |
| Staff C | Named in deficiency for improper criminal record check | |
| Staff D | Named in deficiency for improper criminal record check | |
| Staff E | Named in deficiency for improper criminal record check | |
| Staff F | Named in deficiency for improper criminal record check | |
| Staff G | Interviewed regarding lack of emergency water supply | |
| Staff A | Interviewed regarding plans to resolve criminal record check issue |
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