Inspection Reports for The Phoenix at Milton
13943 GA-9, Alpharetta, GA 30004, United States, GA, 30004
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 4, 2025, found no deficiencies during the complaint investigation. Earlier inspections showed a mixed pattern, with some citations related to environmental conditions, resident care, and infection control. Main issues included failure to maintain safe indoor temperatures, inadequate notification of changes in resident condition, unsanitary conditions linked to pneumonia, infection control lapses during COVID-19, and neglect in resident supervision and property protection. Several complaints were substantiated, including neglect and inadequate safeguards, but many investigations found no violations. The facility’s record shows some recurring themes but also periods of compliance, with no enforcement actions or fines listed in the available reports.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 4, 2025
Visit Reason
The purpose of this survey was to investigate complaint intake numbers GA50004761 and GA50004964 with an onsite visit conducted on 9/4/25.
Complaint Details
Investigation of complaint intake numbers GA50004761 and GA50004964 resulted in no rule violations.
Findings
The investigation was completed on 9/4/25 with no rule violations cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 24, 2025
Visit Reason
The inspection visit was conducted to investigate multiple intakes (#GA50004737, #GA50004739, #GA50004748, #GA50004749) related to complaints about the facility.
Complaint Details
The visit was complaint-related, investigating multiple intakes. The complaints included failure to maintain adequate temperature control and failure to notify responsible parties of changes in resident condition. The substantiation status is not explicitly stated.
Findings
The facility failed to maintain indoor temperatures below 85 degrees Fahrenheit during the day, resulting in heat-related issues for residents, including heat exhaustion. Additionally, the facility failed to notify the responsible party of a change in condition for one resident who sustained a skin tear and bruise after a fall.
Deficiencies (2)
Facility failed to ensure temperatures did not exceed 85 degrees Fahrenheit during the day, with temporary cooling units failing and generator running out of fuel.
Facility failed to notify the responsible party of a change in condition for Resident #1 after a fall resulting in a skin tear and bruise.
Report Facts
Temperature recorded in resident rooms: 90
Temperature recorded in common areas: 90
Temperature recorded in resident rooms: 86
Date of generator fuel outage: Jul 4, 2025
Date of resident fall: Jul 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Sent emails to resident families regarding air conditioning issues and notifications; involved in communication about generator failure and temperature monitoring. | |
| AA | Received notice of air conditioning failure; involved in notification process related to resident condition. | |
| BB | Visited Resident #1; reported not being notified about resident's fall and injury. | |
| CC | Visited Resident #1 and reported heat exhaustion and fatigue due to high temperatures. | |
| DD | Reported hallways and dining room were unbearably hot. | |
| Staff E | Reported vendor attempts to fix air conditioning and temperature readings. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The purpose of this visit was to complete the compliance inspection and investigate intake #GA50002256 and #GA50002608. An unannounced visit was made on 2025-05-06 and the inspection was completed on 2025-05-13.
Complaint Details
Investigation of complaint intakes #GA50002256 and #GA50002608 with no rule violations cited.
Findings
No rule violations were cited during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2023
Visit Reason
The purpose of this survey was to investigate complaint #GA00234138.
Complaint Details
Investigation of complaint #GA00234138 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 25, 2022
Visit Reason
The purpose of this visit was to investigate intake #GA00227672 with an onsite visit made on 10/25/22 and the investigation completed on 10/28/22.
Complaint Details
Investigation of intake #GA00227672; no rule violations were found.
Findings
No rule violations were cited during the investigation.
Report Facts
Intake number: 227672
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2022
Visit Reason
The purpose of this survey was to investigate complaints #GA00225832 and GA00225860, with the investigation starting on 2022-07-12 and completed on 2022-08-10.
Complaint Details
Investigation was complaint-driven based on complaints #GA00225832 and GA00225860. The complaint was substantiated by findings related to unsanitary conditions and failure to maintain air filters, contributing to Resident #7's pneumonia diagnosis.
Findings
The facility failed to ensure that the interior was free of unsanitary or unsafe conditions posing a health or safety risk to residents, specifically Resident #7, whose room air filter had not been changed since August 2020. This was linked to Resident #7's diagnosis of pneumonia and related health issues.
Deficiencies (1)
Facility failed to change the air filter in Resident #7's room since August 2020, despite the resident being diagnosed with pneumonia.
Report Facts
Filters purchased: 84
Hospital stay duration: 9
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 22, 2022
Visit Reason
The purpose of this visit was to conduct a compliance inspection and investigate intake GA#00218655.
Complaint Details
Investigation of complaint intake GA#00218655 with no rule violations cited.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 4, 2021
Visit Reason
The purpose of this visit was to investigate intake #GA00211990. The investigation began on 2021-02-22 and was completed on 2021-03-04.
Complaint Details
Investigation of intake #GA00211990 with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
The purpose of this inspection was to investigate intake #GA00210638, which was started on 2021-01-11 and completed on 2021-01-14.
Complaint Details
Investigation of intake #GA00210638 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 10, 2020
Visit Reason
The purpose of this visit was to investigate intake #GA00209898. The investigation began on 2020-11-30, with an unannounced visit on 2020-12-10 and completed on 2020-12-14.
Complaint Details
Investigation was complaint-related for intake #GA00209898. The complaint was substantiated based on observations, record review, and interviews showing infection control deficiencies.
Findings
The facility failed to have an effective infection control program, specifically staff not demonstrating proper infection control practices such as hand hygiene after caring for COVID-19 positive residents. Multiple residents and staff tested positive for COVID-19, with one resident death reported.
Deficiencies (1)
Failure to have an effective infection control program including staff not properly washing hands after caring for COVID-19 positive residents.
Report Facts
Residents tested positive for COVID-19: 23
Resident deaths: 1
Staff tested positive for COVID-19: 4
Active positive COVID-19 residents observed: 1
Residents tested positive per facility incident report: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Observed failing to wash hands after caring for COVID-19 positive resident and interviewed about hand hygiene | |
| Staff D | Interviewed regarding proper hand hygiene practices after PPE removal |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 16, 2020
Visit Reason
An onsite visit was made to the facility on 11/16/20 to investigate intake #GA00209547.
Complaint Details
Investigation of intake #GA00209547; no violations found.
Findings
No violations were cited as a result of this inspection.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
The purpose of this visit was to investigate intakes #GA00207658, #GA00207525, and #GA00207944. The investigation began on 2020-08-27 and was completed on 2020-10-01.
Complaint Details
Investigation of three intakes (#GA00207658, #GA00207525, and #GA00207944) with no rule violations found.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Monitoring
Deficiencies: 0
Date: Apr 7, 2020
Visit Reason
The purpose of this review is to monitor COVID 19 cases and assess infection control process.
Findings
No specific findings or deficiencies are detailed in the report beyond the stated purpose to monitor COVID-19 cases and infection control.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA0000201086 with an onsite visit on 2019-12-04 and investigation completion on 2019-12-12.
Complaint Details
Investigation of complaint #GA0000201086 found substantiated neglect by Staff D who refused to assist Resident #1 to the bathroom on 11/20/19, was placed on administrative leave, and terminated the next day. Police were notified but found no crime committed.
Findings
The facility failed to provide protective care and watchful oversight for one sampled resident, as evidenced by staff refusing to assist the resident to the bathroom, leaving the resident unassisted despite needing help, resulting in staff suspension and termination.
Deficiencies (1)
Facility failed to provide protective care and watchful oversight for Resident #1 who required assistance transferring from chair to wheelchair; staff refused to assist and left resident unassisted.
Report Facts
Date of incident: Nov 20, 2019
Date of staff termination: Nov 21, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Named in neglect finding for refusing to assist Resident #1 and subsequently suspended and terminated | |
| Staff B | Reported incident to facility after family forwarded video | |
| Staff C | Called by Staff D after Resident #1 stood up unassisted |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 16, 2019
Visit Reason
The purpose of this visit was to investigate intake #GA00198345.
Complaint Details
Investigation of intake #GA00198345 found no rule violations.
Findings
No rule violations were cited as a result of this investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2019
Visit Reason
The purpose of this visit was to investigate complaint #GA00196376 regarding a resident wandering incident.
Complaint Details
Investigation of complaint #GA00196376 regarding Resident #1 wandering off the facility and being found outside unsupervised. The complaint was substantiated by interviews and record review.
Findings
The facility failed to ensure adequate and appropriate care for Resident #1, who was diagnosed with Lewy Body Dementia and was found outside the facility unsupervised. Staff had prior knowledge of the resident's wandering behavior but did not implement measures to prevent elopement.
Deficiencies (1)
Facility failed to ensure that each resident received care and services which were adequate, appropriate, and in compliance with state law and regulations for Resident #1 who wandered off the premises.
Report Facts
Date of incident: Apr 25, 2019
Number of sampled residents: 3
Resident admission date: Mar 18, 2019
Physician Evaluation Form date: Jan 13, 2019
Health Assessment date: Mar 6, 2019
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 5, 2019
Visit Reason
The visit was conducted to investigate intake #GA00194258 regarding allegations of theft involving a resident's missing cash and gold bracelet.
Complaint Details
The complaint involved allegations that Staff C took $120 cash and a gold bracelet from Resident #1 by gaining the resident's trust. Multiple theft incidents were reported at the facility, but the facility failed to properly document or investigate these incidents.
Findings
The facility failed to ensure proper investigation and reporting of abuse, neglect, and exploitation, failed to enforce policies and procedures related to incident reporting, and failed to safeguard residents' personal property. Multiple theft incidents were reported, and the facility lacked documentation and internal investigations to address these issues.
Deficiencies (3)
Failure to ensure policies and procedures provided direction for investigation and reporting of abuse, neglect, and exploitation.
Failure to enforce policies and procedures related to incident reporting and documentation.
Failure to ensure residents' rights to reasonable safeguards for protection and security of personal property.
Report Facts
Cash missing: 120
Number of theft incidents reported: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Named in allegation of theft of cash and gold bracelet from Resident #1 | |
| Staff A | Aware of theft incidents but failed to document or investigate | |
| Staff B | Unaware of theft incident until reported by AA; did not receive incident report from Staff C |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 18, 2018
Visit Reason
The purpose of this visit was to conduct the annual inspection and to investigate complaints #GA00193374.
Complaint Details
Complaint #GA00193374 was investigated during this visit.
Findings
No rule violations were cited as a result of this inspection.
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