Inspection Reports for Pruitthealth – Rome
2 THREE MILE ROAD NE, ROME, GA, 30165
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, found no deficiencies, confirming that previously cited issues were corrected. Earlier inspections showed a pattern of deficiencies related mainly to infection control, medication administration, psychotropic medication risk communication, resident wandering interventions, side rail use, and kitchen sanitation, along with life safety code concerns such as hazardous area enclosures and sprinkler maintenance. Complaint investigations throughout the years were consistently unsubstantiated, with no enforcement actions, fines, or license suspensions listed in the available reports. Prior reports noted improvements following follow-up surveys that verified correction of deficiencies. The trend suggests the facility has addressed past issues and demonstrated compliance in its most recent inspections.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
94 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - ROME, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
A revisit survey was conducted from 3/5/2025 to 3/6/2025 to verify correction of deficiencies cited in the 1/9/2025 recertification survey.
Findings
All deficiencies cited as a result of the 1/9/2025 recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Deficiencies: 6
Date: Jan 9, 2025
Visit Reason
The inspection was a State Licensure survey conducted from 1/6/2025 through 1/9/2025 to determine compliance with State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to inform residents or their representatives of risks of psychotropic medications, failure to follow COVID-19 infection control policies including PPE use and dish sanitization, improper medication administration practices by staff, inadequate interventions for a wandering resident, inappropriate use of bed rails for a resident, and failure to maintain kitchen sanitation and dish machine temperatures per manufacturer guidelines.
Deficiencies (6)
Failure to ensure residents and/or their representatives were informed of the risks of psychotropic medications for five residents.
Failure to follow COVID policies regarding containment and PPE use for COVID-positive residents, including failure to keep doors closed, improper PPE use, and improper handling of dishes.
Infection control procedures not followed during medication administration for one resident, including staff wearing long false nails, not sanitizing hands, and improper handling of medications and equipment.
Failure to provide resident-specific activities as interventions for wandering into other resident rooms for one resident.
Failure to ensure appropriate use of side rails on bed for one resident, resulting in potentially unnecessary use.
Failure to ensure dish machine operated at correct temperature and maintain kitchen equipment and surfaces in clean and good repair.
Report Facts
Residents reviewed for psychotropic medication risk discussion: 5
Residents positive for COVID-19 with doors open: 14
Dish machine wash cycle temperature observed: 104
Dish machine rinse cycle temperature observed: 110
Dish machine wash cycle temperature observed: 105
Dish machine rinse cycle temperature observed: 118
Dish machine wash cycle temperature observed: 118
Dish machine rinse cycle temperature observed: 122
Resident R52 BIMS score: 15
Resident R77 BIMS score: 99
Resident R3 BIMS score: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in medication administration infection control deficiency for wearing long false nails and improper medication handling |
| LPN 1 | Licensed Practical Nurse | Commented on resident wandering and missing personal items |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration expectations, wandering resident interventions, and bed rail use |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding COVID-19 kitchen procedures and dish machine temperatures |
| Certified Nurse Assistant 3 | Certified Nursing Assistant (CNA) | Observed not wearing full PPE during care of COVID-positive resident |
| Housekeeper 1 | Housekeeper | Observed not wearing full PPE and redirecting wandering resident |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Observed with resident R3 regarding bed rail use |
| Dietary Aide 2 | Dietary Aide | Observed and interviewed regarding dish machine temperatures and hand hygiene |
| Dietary Aide 1 | Dietary Aide | Observed loading soiled trays and handling clean dishes without washing hands |
Inspection Report
Routine
Census: 82
Deficiencies: 11
Date: Jan 9, 2025
Visit Reason
A standard survey was conducted from 1/6/2025 through 1/9/2025 to assess compliance with Medicare/Medicaid regulations and infection control requirements, including COVID-19 containment.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including infection control related to COVID-19, care planning participation, medication self-administration, abuse prevention, side rail use, PPE use for COVID-positive residents, resident wandering interventions, psychotropic medication risk communication, and kitchen sanitation and dishwashing procedures.
Deficiencies (11)
Failure to follow CDC guidance and facility COVID-19 policies including keeping doors closed to COVID-positive residents' rooms, proper PPE use, and sanitizing dishes at required temperatures.
Failure to ensure residents and/or their representatives participated in care planning conferences for four of five residents reviewed.
Failure to ensure one resident was capable of safely self-administering medication, including lack of assessment and improper medication handling.
Failure to prevent misappropriation of resident funds by a staff member.
Failure to ensure appropriate use of side rails for one resident, resulting in unnecessary use.
Failure to ensure staff used appropriate PPE when providing care to COVID-positive residents, increasing risk of virus spread.
Failure to provide resident-specific activities as interventions for wandering into other resident rooms for one resident.
Failure to inform residents and/or their representatives of the risks versus benefits of psychotropic medications for five residents.
Failure to ensure proper dishwashing temperatures, cleanliness of kitchen equipment and surfaces, and hand hygiene during dish handling.
Failure to follow infection control policies regarding COVID-19 containment, PPE use, and medication pass procedures.
Failure to follow infection control procedures during medication administration including use of gloves, hand hygiene, and clean barriers; staff observed with long false nails.
Report Facts
Facility census: 82
COVID-19 positive residents: 16
Dish machine wash temperature: 104
Dish machine rinse temperature: 110
Dish machine wash temperature: 118
Dish machine rinse temperature: 122
Resident BIMS scores: 5
Resident BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Observed administering medication with long false nails, improper hand hygiene, and improper medication handling |
| CNA3 | Certified Nursing Assistant | Observed not wearing proper PPE when caring for COVID-positive residents |
| DA1 | Dietary Aide | Observed handling clean dishes without washing hands |
| DM | Dietary Manager | Observed dish machine temperatures below manufacturer requirements and acknowledged issues |
| LPN1 | Licensed Practical Nurse | Acknowledged inability to prevent resident wandering into other rooms |
| DON | Director of Nursing | Informed of Immediate Jeopardy and confirmed expectations for infection control and medication administration |
| SSD | Social Service Director | Unaware of requirement to discuss psychotropic medication risks vs benefits |
| F4 | Family Member | Reported lack of invitation to care planning conferences |
Inspection Report
Life Safety
Census: 81
Capacity: 100
Deficiencies: 3
Date: Jan 7, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to deficiencies in maintaining vertical openings, hazardous area enclosures, and sprinkler system maintenance. Specific issues included missing ceiling tiles, use of unapproved materials for fire-stopping, and a non-functional sprinkler head in the north wing.
Deficiencies (3)
Failed to maintain vertical openings; missing ceiling tiles in janitor closet and penetrations in IT room ceilings.
Failed to maintain hazardous area enclosures; use of unapproved materials (fire foam) to seal penetrations in mechanical room.
Failed to maintain sprinkler system; single sprinkler head in north wing storage room not in working order with factory protective device still in place and no escutcheon ring installed.
Report Facts
Census: 81
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 21, 2023
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.
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from May 30, 2023 through June 1, 2023 to assess compliance for facility licensure.
Findings
No deficiencies were identified during the Licensure Survey conducted May 30, 2023 through June 1, 2023.
Inspection Report
Routine
Census: 91
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
A standard survey was conducted at Pruitthealth-Rome from May 30, 2023 through June 1, 2023 by the Georgia Department of Community Health. The survey also included investigation of complaint intake numbers GA00234864, GA00234132, and GA00232616.
Complaint Details
Complaint Intake Numbers GA00234864, GA00234132, and GA00232616 were investigated and found to be unsubstantiated.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities. The complaints investigated were found to be unsubstantiated.
Inspection Report
Life Safety
Census: 92
Capacity: 100
Deficiencies: 5
Date: May 31, 2023
Visit Reason
A Life Safety Code Survey was 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 life safety requirements, including failure to maintain smoke tight enclosures, out-of-date sprinkler riser gauge, open electrical junction boxes, improper combustible storage near electrical panels, and missing approved signage in the oxygen storage area.
Deficiencies (5)
Failed to maintain smoke tight enclosure of the electrical/sprinkler riser room with holes in smoke barrier.
Sprinkler riser gauge was out-of-date; gauge dated 2016 exceeding 5-year lifespan.
Two open electrical junction boxes found in mechanical and electrical/riser rooms.
Combustible storage found too close to electrical panels in the TCU Hall electrical room.
Oxygen storage area lacked approved signage as required.
Report Facts
Census: 92
Total Capacity: 100
Sprinkler riser gauge date: 2016
Inspection date: May 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
A Focused Infection Control Survey in conjunction with an Abbreviated Survey was conducted to investigate complaints #GA00220234 and #GA00230168 at Pruitt Health - Rome.
Complaint Details
Complaints #GA00220234 and #GA00230168 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and COVID-19 preparedness requirements.
Report Facts
Total census: 91
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 28, 2021
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 visit.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 3, 2021
Visit Reason
A Follow-Up Survey was conducted to determine if previously cited survey tags had been corrected.
Findings
The facility failed to ensure that all hazardous rooms were properly compartmentalized to resist the passage of smoke, specifically the laundry room doors failed to self-close and latch in the closed position. Replacement doors have been ordered but are back-ordered and currently unavailable.
Deficiencies (1)
Laundry room doors failed to self-close and latch in the closed position, compromising hazardous area enclosure.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the deficiency and stated replacement doors have been ordered but are back-ordered. |
Inspection Report
Routine
Census: 82
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
A standard survey was conducted at Pruitt Health - Rome from October 12, 2021 through October 14, 2021. In addition, Complaint Intake Number GA#00212157 was investigated in conjunction with the standard survey.
Complaint Details
Complaint GA00212157 was investigated and found to be unsubstantiated.
Findings
The complaint GA00212157 was unsubstantiated. The standard survey revealed that the facility was in compliance with Medicare/Medicaid regulation 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 14, 2021
Visit Reason
The inspection was conducted as a Licensure Survey from October 12, 2021 through October 14, 2021.
Findings
No deficiencies were identified during the Licensure Survey conducted at the facility.
Inspection Report
Life Safety
Census: 75
Capacity: 100
Deficiencies: 1
Date: Oct 12, 2021
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to properly compartmentalize hazardous areas to resist smoke passage, specifically in the kitchen and cafeteria portions of the building. Observations included cracks and gaps in the laundry room ceiling and a laundry room door that was not self-closing.
Deficiencies (1)
Hazardous areas were not properly compartmentalized to resist the passage of smoke, affecting the kitchen and cafeteria portion of the building. Laundry room ceiling had cracks and gaps, and the laundry room door was not self-closing.
Report Facts
Census: 75
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding laundry room ceiling and door during tour |
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 8, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 74
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant federal regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, having implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 74
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 15, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00207371, #GA00208810, and #GA00209619.
Complaint Details
Complaints #GA00207371, #GA00208810, and #GA00209619 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaints investigated were unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Abbreviated Survey
Census: 80
Deficiencies: 2
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on December 7 and 8, 2020, to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to ensure proper sanitization of blood glucose monitors and consistent use of Personal Protective Equipment (PPE) in the COVID-19 Isolation Unit.
Deficiencies (2)
Failure to adequately sanitize facility glucose monitors, as Licensed Practical Nurse (LPN BB) used only alcohol wipes instead of the required disinfectant wipes and did not allow proper drying time.
Failure to consistently follow PPE guidelines in the COVID-19 Isolation Unit, including not wearing a face shield continuously as required.
Report Facts
Census: 80
Blood sugar tests administered by LPN BB: 9
Blood sugar tests administered by LPN BB: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in findings related to failure to sanitize glucose monitors and inconsistent PPE use |
| DON | Director of Nursing | Provided statements regarding expectations for infection control and PPE use |
| Administrator | Participated in interview confirming PPE policies |
Inspection Report
Routine
Census: 81
Deficiencies: 0
Date: Aug 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at PruittHealth Rome on July 9, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 7, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00194926 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00194926 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 15, 2018
Visit Reason
A revisit survey was conducted on 11/15/2018 to verify correction of deficiencies cited in the 9/27/2018 recertification survey. Additionally, Complaint Intake Number GA00192514 was investigated in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00192514 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 9/27/2018 recertification survey were found to be corrected. The complaint investigation was unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 15, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00192514, initiated on 2018-10-30 and concluded on 2018-11-15.
Complaint Details
Complaint GA00192514 was investigated and found to be unsubstantiated.
Findings
The investigation of the complaint was unsubstantiated, with no deficiencies cited in the report.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 13, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 93
Capacity: 100
Deficiencies: 2
Date: Sep 25, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically failing to maintain smoke resistant partitions in hazardous areas and failing to provide proper ashtrays and metal containers in the designated resident smoking area, which could place residents at risk in the event of fire.
Deficiencies (2)
Failed to maintain smoke resistant partitions in hazardous areas, including unsealed penetrations in the janitors' room near DHS and across from Therapy.
Failed to provide ashtrays of noncombustible material and metal containers with self-closing cover devices in the designated resident smoking area.
Report Facts
Census: 93
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the tour and observation of the facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 16, 2018
Visit Reason
A complaint survey was conducted on 7/16/2018 to investigate complaints #GA00189515 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00189515 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 1, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 0
Date: Oct 26, 2017
Visit Reason
A standard survey was conducted at Pruitt Health of Rome from October 23, 2017 through October 26, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 91
Capacity: 100
Deficiencies: 2
Date: Oct 23, 2017
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 due to deficiencies in cooking equipment installation and electrical equipment usage, which could place residents and staff at risk in the event of fire or emergency.
Deficiencies (2)
Cooking equipment was not properly installed; specifically, a deep fry setting was within 16 inches of an open flame cooktop without any separation device.
Unapproved multi-tab plugs were used in patient treatment and non-treatment areas, including rooms 223, 213, 118, and others, posing risk in emergency situations.
Report Facts
Residents at risk: 25
Staff at risk: 5
Census: 91
Total capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 14, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA 00167785 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00167785 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey conducted by a Registered Nurse at PH-Rome.
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