Inspection Report Summary
The most recent inspection on March 28, 2025, found no deficiencies and determined that complaints investigated were unsubstantiated. Earlier inspections showed a mixed record, with the August 15, 2024, survey citing deficiencies related to resident privacy, medication security, care planning for PICC lines, environmental cleanliness, and food storage practices. Prior complaint investigations included two substantiated cases in August 2024 involving similar issues, while other complaints were unsubstantiated. Life Safety Code surveys in 2024 and 2022 noted fire safety and maintenance deficiencies that were later corrected. The facility’s recent inspections indicate improvement, with all previously cited deficiencies addressed and no enforcement actions or fines listed in the available reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
81 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 81
Deficiencies: 0
Mar 28, 2025
Visit Reason
A Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00253259 and GA00254266.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaints GA00253259 and GA00254266 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Dec 17, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00252490.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00252490 was investigated and found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Oct 25, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Cumming Health & Rehab, indicating a regulatory inspection was conducted.
Findings
The report contains only initial comments without detailed findings or deficiencies listed.
Inspection Report
Follow-Up
Census: 83
Deficiencies: 0
Oct 25, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification and Complaint Investigation Survey on August 15, 2024.
Findings
All deficiencies cited in the prior Recertification and Complaint Investigation Survey were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a Complaint Investigation Survey on August 15, 2024.
Inspection Report
Life Safety
Deficiencies: 0
Oct 4, 2024
Visit Reason
A Life Safety Code Revisit was conducted as a Desk Review to verify correction of previously cited Life Safety Code deficiencies.
Findings
The revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 5
Aug 15, 2024
Visit Reason
The inspection was a State Licensure survey conducted from August 13, 2024 through August 15, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy during care, improper medication storage security, incomplete care plans for residents with PICC lines, unsanitary environmental conditions such as dusty HVAC filters, and improper food labeling and expired food items in storage.
Deficiencies (5)
| Description |
|---|
| Failure to provide privacy during incontinent care for one resident, with privacy curtain not fully closed and room door left open. |
| Failure to ensure Schedule IV medication was secured under double lock and key in one medication storage room. |
| Failure to develop a comprehensive person-centered care plan addressing PICC lines for two residents. |
| Failure to maintain a clean and sanitary environment; HVAC unit vents covered with thick grayish white dust particles in multiple resident rooms. |
| Failure to label and date meat products and discard expired snack cookies, improper sanitary conditions of ice machine, and failure to discard expired emergency water supply items. |
Report Facts
Facility census: 81
Sample size: 40
Expired food items: 22
Expired water bottles: 140
Expired water cases: 24
Unlabeled meat products: 48
Rooms with dusty HVAC filters: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nursing Assistant | Named in privacy deficiency during incontinent care observation |
| MM | Regional Manager | Named in food labeling and expired food findings |
| AA | Vice President of Clinical Services | Observed expired snack cookies and dirty ice machine |
| HH | Housekeeping Supervisor | Confirmed cleaning duties and observed dirty ice machine |
| GG | Housekeeper | Described HVAC vent cleaning process and frequency |
Inspection Report
Routine
Census: 81
Deficiencies: 5
Aug 15, 2024
Visit Reason
A standard survey was conducted from August 13 through August 15, 2024, including investigation of four complaint intake numbers, two of which were substantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain resident dignity and privacy, unclean HVAC filters, incomplete care plans for residents with PICC lines, unsecured Schedule IV medications, and unsanitary food storage and expired food and water supplies.
Complaint Details
Complaint Intake Numbers GA00246173 and GA00246882 were substantiated with deficiencies cited; GA00248720 and GA00246538 were unsubstantiated.
Severity Breakdown
D: 2
E: 2
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide privacy during incontinent care for one resident (R132). | D |
| Failed to maintain a clean and sanitary environment; HVAC filters covered with thick dust in multiple resident rooms. | E |
| Failed to develop a comprehensive person-centered care plan addressing PICC lines for two residents (R8 and R59). | D |
| Failed to ensure Schedule IV medication was secured under double lock and key in one of two medication storage rooms. | E |
| Failed to label and date food items properly, discarded expired food and water, and failed to maintain sanitary conditions for ice machines. | F |
Report Facts
Residents present: 81
Sample size: 40
Unlabeled meat products: 48
Expired snack cookies: 22
Expired water bottles: 140
Expired water cases: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nursing Assistant | Named in privacy during incontinent care deficiency |
| MD | Maintenance Director | Interviewed regarding HVAC filter maintenance |
| MDS Coordinator | Confirmed PICC line care plan omissions and additions | |
| LPN II | Licensed Practical Nurse | Observed medication storage room and medication security |
| MM | Regional Manager | Identified unlabeled frozen items and directed discarding expired supplies |
| AA | Vice President of Clinical Services | Observed expired snack cookies and dirty ice machine |
| HH | Housekeeping Supervisor | Confirmed ice machine condition and directed discarding expired water |
| DON | Director of Nursing | Confirmed medication storage requirements |
Inspection Report
Life Safety
Census: 82
Capacity: 87
Deficiencies: 5
Aug 14, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with the kitchen hood system being out of service, sprinkler system maintenance deficiencies, a resident room door that would not close and latch, and improper use of power strips and multi-plugs in several areas.
Severity Breakdown
F: 2
D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility kitchen hood system was out of service and red tagged, with one fryer not located under the hood and a plastic trash can positioned between fryers. | F |
| Sprinkler system had materials on piping and was missing spare sprinkler heads. | F |
| Resident room number 406 door would not close and latch. | D |
| Power strips were used on the floor in office and lobby areas. | D |
| Multi-plugs were used at employee clock in and nurse's station. | D |
Report Facts
Census: 82
Total Capacity: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 20, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Cumming Health & Rehab following a survey completed on 12/20/2022.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey. Specific deficiencies and severity levels are not detailed in the provided page.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 0
Dec 20, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/27/22 Recertification Survey.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit survey.
Report Facts
Census: 67
Inspection Report
Follow-Up
Deficiencies: 0
Dec 13, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Renewal
Deficiencies: 0
Oct 27, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 10/25/2022 through 10/27/2022 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the licensure survey conducted from 10/25/2022 through 10/27/2022.
Inspection Report
Life Safety
Census: 62
Capacity: 87
Deficiencies: 7
Oct 26, 2022
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements including missing fire alarm sensitivity test documents, improper smoke detector placement, fire sprinkler heads obstructed by debris, corridor door issues, presence of louvers/grills in corridor doors, unsafe staff smoking area, and lack of proper signage for oxygen tank storage.
Severity Breakdown
D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to have fire alarm sensitivity test/inspection documents on site when requested. | D |
| Ceiling mounted smoke detector located too close to HVAC vent in 400 hall central bath. | D |
| Fire sprinkler heads covered with grease and debris; fire sprinkler riser room egress blocked by storage. | D |
| Room 202 door obstructed from closing by occupant's bed; room 302 door latch malfunctioning; room 101 door damaged by nail. | D |
| Louvers/grills present in doors of central bath (300 hall), oxygen storage/clean linen closet, pantry, and 400 hall pantry. | D |
| Facility failed to have a safe designated staff smoking area; improper cigarette disposal observed near propane tanks. | D |
| Oxygen storage/clean linen closet lacks proper signage indicating storage of full oxygen tanks. | D |
Report Facts
Census: 62
Total Capacity: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Routine
Census: 62
Deficiencies: 2
Oct 25, 2022
Visit Reason
A standard survey was conducted at Cumming Health And Rehab from October 25, 2022, through October 27, 2022, to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance due to failure to ensure medication carts were locked when unattended and failure to maintain sanitary conditions of the kitchen ice machine, including buildup of black substance and inadequate cleaning logs.
Severity Breakdown
SS= D: 1
SS= F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that one of three medication carts was locked and secured when unattended. | SS= D |
| Failed to maintain sanitary conditions of the kitchen ice machine, with buildup of black substance and inadequate cleaning. | SS= F |
Report Facts
Resident census: 62
Sanitation score: 64.71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Verified leaving medication cart unlocked and unattended |
| Director of Nursing | Stated expectations for medication carts to be locked when unattended | |
| Dietary Manager | Responsible for cleaning the ice machine and provided sanitation score |
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Feb 24, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and in substantial compliance with 42 CFR §483.80 infection control regulations, implementing recommended practices to prepare for COVID-19.
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