Inspection Reports for East Cobb Center for Nursing and Healing
4360 Johnson Ferry Pl, Marietta, GA 30068, GA, 30068
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 8, 2024, found no deficiencies after a revisit survey verified correction of prior issues. Earlier inspections showed a pattern of deficiencies related mainly to medication management, respiratory equipment maintenance, and life safety code compliance, including expired biologicals not discarded on time and corridor doors failing to resist smoke passage. Complaint investigations were mostly unsubstantiated, though a prior substantiated complaint involved failure to provide individualized, person-centered activities for one resident requiring extensive assistance. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed previous deficiencies effectively, as recent follow-up surveys confirmed corrections.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
84% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
109 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 109
Deficiencies: 5
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a standard regulatory survey of East Cobb Center for Nursing and Healing LLC to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including inadequate assessment for resident self-administration of medication, failure to provide oxygen tubing extensions, unsafe medication administration practices, improper food storage and handling, and failure to implement proper infection prevention and control measures related to respiratory equipment.
Deficiencies (5)
Failed to adequately assess two residents for self-administration of medication, allowing potential access to medications not prescribed.
Failed to provide oxygen tubing extensions for one resident, impacting mobility and independence.
Failed to ensure safe medication administration for one resident receiving insulin; administered insulin from a vial not intended for that resident.
Failed to procure, store, prepare, distribute, and serve food according to professional standards, including expired food items, unlabeled frozen food, unclean ice machine, and improper food temperatures.
Failed to ensure respiratory equipment (incentive spirometer) was properly stored to prevent contamination.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 107
Residents affected: 14
Facility census: 109
Expiration dates: 7
Food temperatures: 43
Food temperatures: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN HH | Registered Nurse | Administered insulin from vial not intended for resident R3 |
| LPN OO | Licensed Practical Nurse | Confirmed residents R60 and R75 were not assessed for self-administration of medication |
| DON | Director of Nursing | Provided statements regarding medication administration expectations and rounds to prevent unauthorized medications |
| ADON | Assistant Director of Nursing | Unaware of resident R68's request for extended oxygen tubing |
| FSD | Food Service Director | Confirmed expired food items, unclean ice machine, and improper food temperatures |
| UM GG | Unit Manager | Initially unaware incentive spirometer needed to be bagged; later confirmed after consulting Respiratory Therapist |
| Dietary Aide MM | Dietary Aide | Stated she did not check resident refrigerators for expired food |
| CNA NN | Certified Nursing Assistant | Responsible for checking expiration dates and cleaning resident refrigerators |
| Housekeeping Supervisor | Stated responsibility for cleaning resident refrigerators shared between housekeeping and CNAs |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for East Cobb Center for Nursing and Healing LLC following a survey completed on May 8, 2024.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: May 8, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/14/2024 recertification survey.
Findings
All deficiencies cited as a result of the 3/14/2024 recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
A State Licensure survey was conducted at East Cobb Center for Nursing and Healing from March 12, 2024, through March 14, 2024, to assess compliance with State Health regulations.
Findings
The facility failed to discard expired biologicals prior to the expiration date printed on the medication in one of two medication storage rooms and one of seven medication carts, including a vial of Tuberculin Purified Protein Derivative and a vial of Lantus insulin that were not discarded within the required timeframe.
Deficiencies (1)
Failure to discard expired biologicals prior to the expiration date printed on the medication in medication storage rooms and medication carts.
Report Facts
Medication carts inspected: 7
Medication storage rooms inspected: 2
Discard timeframe for Tuberculin Purified Protein Derivative: 30
Discard timeframe for Lantus insulin: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Verified vial of Tuberculin Purified Protein Derivative was not labeled with an open date and should be discarded after 30 days. |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Verified vial of Lantus insulin should be discarded 28 days after opening. |
| Director of Nursing | Director of Nursing | Reported medication rooms and carts are checked twice weekly and as needed; expired medicines are to be removed immediately. |
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 4
Date: Mar 14, 2024
Visit Reason
A standard annual survey was conducted at East Cobb Center for Nursing and Healing from March 12 through March 14, 2024, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to complete a significant change Minimum Data Set (MDS), failure to include anticoagulant use in baseline care plans, failure to maintain respiratory equipment properly, and failure to discard expired biologicals in medication storage.
Deficiencies (4)
Failed to complete a significant change Minimum Data Set (MDS) after a significant change occurred for one resident (R44).
Failed to add anticoagulant use to the baseline care plan for one resident (R267), risking lack of monitoring interventions.
Failed to maintain respiratory equipment consistent with professional standards for three residents (R91, R74, R271), including failure to bag CPAP mask and failure to clean/change oxygen concentrator filters.
Failed to discard expired biologicals prior to expiration date in medication storage rooms and medication carts.
Report Facts
Resident census: 107
Sampled residents: 50
Medication carts inspected: 7
Medication storage rooms inspected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator CC | MDS Coordinator | Confirmed missing significant change MDS and care plan deficiencies |
| John Smith | Director of Nursing | Confirmed missing significant change MDS and care plan deficiencies, provided education and policy details |
| LPN HH | Licensed Practical Nurse | Provided information on anticoagulant monitoring and care plan updates |
| LPN DD | Licensed Practical Nurse | Confirmed CPAP mask should be cleaned and bagged after use |
| Assistant Director of Nursing | Assistant Director of Nursing | Confirmed oxygen concentrator filter responsibilities and audit process |
| LPN AA | Licensed Practical Nurse | Verified expired Tuberculin Purified Protein Derivative vial not labeled with open date |
| LPN BB | Licensed Practical Nurse | Verified expired Lantus insulin vial on medication cart |
Inspection Report
Routine
Census: 107
Deficiencies: 4
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including assessment of significant changes in condition, baseline care planning, respiratory care, and medication storage.
Findings
The facility was found deficient in completing significant change Minimum Data Set assessments, creating baseline care plans addressing anticoagulant use, maintaining respiratory equipment including oxygen concentrator filters and CPAP mask storage, and properly discarding expired biological medications. These deficiencies had potential for minimal harm or actual harm to residents.
Deficiencies (4)
Failed to complete a significant change Minimum Data Set (MDS) after a significant change occurred for one resident (R44).
Failed to add anticoagulant use to the baseline care plan for one resident (R267), risking lack of monitoring interventions.
Failed to maintain respiratory equipment properly for three residents (R91, R74, R271), including failure to bag CPAP mask and clean/change/install filters on oxygen concentrators.
Failed to discard expired biologicals prior to expiration date in medication storage rooms and medication carts.
Report Facts
Residents sampled: 50
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Facility census: 107
Medication order dose: 40
Medication order duration: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | MDS Coordinator | Confirmed missed significant change MDS assessment for resident R44 and baseline care plan responsibilities |
| DON | Director of Nursing | Confirmed deficiencies related to significant change MDS, baseline care plan, respiratory equipment maintenance, and medication storage |
| HH | LPN | Provided information on monitoring anticoagulant use and care plan updates |
| ADON | Assistant Director of Nursing | Discussed in-service training and respiratory equipment maintenance responsibilities |
| DD | LPN | Confirmed CPAP mask should be cleaned and bagged after every use |
| AA | Licensed Practical Nurse | Verified medication vial labeling and discard requirements |
| BB | Licensed Practical Nurse | Verified medication vial labeling and discard requirements |
Inspection Report
Life Safety
Census: 107
Capacity: 117
Deficiencies: 2
Date: Mar 12, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with life safety requirements, specifically regarding corridor doors that failed to resist the passage of smoke and failure to maintain emergency electrical systems, including a missed 4-hour load bank test for the generator.
Deficiencies (2)
Corridor doors failed to assure against the passage of smoke, with a door in resident room 343 not sealing properly.
Facility failed to assure up-to-date maintenance of emergency electrical equipment; generator missed the required 4-hour load bank test due every 36 months.
Report Facts
Census: 107
Total Capacity: 117
Load Bank Test Interval: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to door sealing and generator maintenance during facility tour |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 12, 2023
Visit Reason
The inspection report documents the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 06/05/2023 and 06/11/2023 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
A revisit survey was conducted on 3/23/2023 to verify correction of deficiencies cited in the 1/26/2023 Recertification Survey and to investigate Complaint Intake Number GA00231863.
Complaint Details
Complaint Intake Number GA00231863 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the 1/26/2023 Recertification Survey were found to be corrected. The complaint investigation for GA00231863 was found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 26, 2023
Visit Reason
A State Licensure survey was conducted at East Cobb Center for Nursing and Healing, LLC from January 24, 2023 through January 26, 2023 to assess compliance with state health regulations.
Findings
The facility failed to follow the comprehensive, person-centered care plan for one resident (R#58) related to activities. The resident did not receive individualized, person-centered activities as required, and the facility lacked documentation of one-on-one activities provided. The resident was cognitively intact but confined to bed and did not participate in activities outside her room except bingo via intercom.
Deficiencies (2)
Failure to follow the comprehensive, person-centered care plan for one resident related to activities.
Failure to provide an individualized, person-centered activities program to meet the needs of one resident requiring extensive assistance.
Report Facts
Sample size: 34
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Charge Nurse Licensed Practical Nurse (LPN) | Familiar with resident R#58 care and activities participation |
| Director of Nursing | Director of Nursing (DON) | Provided information on interdisciplinary team meetings and activities offered to resident R#58 |
| Activities Director | Activities Director (AD) | Interviewed regarding activities provided to resident R#58 and documentation of one-on-one activities |
| Rehab Manager | Rehab Manager (RM) | Provided information on resident R#58 therapy status and wheelchair use |
| MDS Coordinator | MDS Coordinator | Responsible for updating care plans and provided information on care plan creation |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 2
Date: Jan 26, 2023
Visit Reason
A standard survey was conducted from January 24, 2023 through January 26, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
The investigation included multiple complaint intake numbers (GA00224784, GA00231475, GA00225265, GA00225706, GA00228161) and found that the resident R#58 was not provided one-on-one activities as required. The resident expressed desire for more socialization and activities in her room due to inability to participate in group activities outside her room. Staff interviews confirmed lack of documentation and provision of one-on-one activities.
Findings
The facility was found not in substantial compliance with regulations, specifically failing to provide a comprehensive, person-centered activities program for one resident (R#58) who required extensive assistance. The resident did not receive one-on-one activities as outlined in the care plan, and the facility lacked documentation of such activities being offered or refused.
Deficiencies (2)
Failed to follow the comprehensive, person-centered care plan for one resident related to activities.
Failed to provide an individualized, person-centered activities program to meet the needs of one resident who needed extensive assistance.
Report Facts
Resident census: 108
Sample size: 34
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director | Interviewed regarding activities provided to resident #58; could not provide documentation of one-on-one activities. | |
| MDS Coordinator | Interviewed about care plan updates and activities; stated care plans should reflect current needs but resident #58 was never seen outside for activities. | |
| AA | Charge Nurse Licensed Practical Nurse (LPN) | Interviewed and stated resident #58 does not get out of bed and has not witnessed one-on-one activities. |
| Rehab Manager | Interviewed and stated resident #58 was previously able to sit in wheelchair but currently not receiving therapy. | |
| Director of Nursing (DON) | Interviewed and stated resident #58's name comes up frequently in interdisciplinary team meetings; noted current AD is new and former AD offered one-on-one activities which resident refused but no documentation was provided. |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and activities provision requirements, specifically focusing on the care and activities provided to resident #58.
Findings
The facility failed to follow the comprehensive, person-centered care plan for resident #58 related to activities. The resident did not receive individualized, one-on-one activities as outlined in the care plan, and the facility lacked documentation of such activities. The resident was mostly confined to bed and did not participate in group activities outside her room.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions.
Failed to provide an individualized, person-centered activities program to meet the needs of resident #58.
Report Facts
Sample size: 34
Brief Interview of Mental Status (BIMS) score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director (AD) | Interviewed regarding resident #58's activities and care plan; stated resident does independent activities but no one-on-one visits documented. | |
| MDS Coordinator | Interviewed about care plan updates and resident #58's activity participation; stated care plans should reflect current needs and that resident was never seen outside for activities. | |
| AA | Charge Nurse Licensed Practical Nurse (LPN) | Interviewed about resident #58's care; stated resident does not get out of bed and only participates in bingo. |
| Rehab Manager (RM) | Interviewed about resident #58's therapy status; stated resident was capable of sitting in wheelchair in 2020 but did not like to. | |
| Director of Nursing (DON) | Interviewed about resident #58's care and activities; stated former AD offered one-on-one activities which resident refused but no documentation was provided. |
Inspection Report
Life Safety
Census: 111
Capacity: 117
Deficiencies: 4
Date: Jan 25, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety code requirements, including issues with delayed egress doors lacking proper panic hardware and signage, outdated fire suppression hood system inspection, blocked electrical panels, resident room door failing to latch, and smoke barriers with unsealed penetrations.
Deficiencies (4)
Delayed Egress doors were not equipped with Panic hardware and lacked proper exit instructions signage.
Fire suppression hood system was not kept up to date and electrical panels were obstructed in the cooking area.
Resident room door (#312) would not latch to stay closed after multiple attempts.
Smoke barriers had penetrations that needed to be sealed to resist passage of smoke.
Report Facts
Smoke Compartments affected: 6
Smoke Compartments affected: 1
Smoke Compartments affected: 1
Smoke Compartments affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
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