Inspection Reports for
Rockdale Healthcare Center
1510 RENIASSANCE DRIVE, CONYERS, GA, 30012
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
98% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 29, 2026
Visit Reason
The inspection was conducted to investigate a complaint regarding inconsistent documentation of a resident's Advance Directive status in the clinical record.
Complaint Details
The complaint investigation found that the Advance Directive status for resident R71 was not updated in the EMR after a Full Code directive was signed, leaving a DNR order visible. This discrepancy was confirmed by staff interviews and was identified as a human error with potential negative outcomes.
Findings
The facility failed to ensure the Advance Directive status was consistently documented for one resident, resulting in conflicting Do Not Resuscitate (DNR) and Full Code orders in the electronic medical record (EMR). This discrepancy could lead to staff not following the resident's current wishes during an emergency.
Deficiencies (1)
F 0578: The facility failed to consistently document the Advance Directive status for resident R71, resulting in conflicting DNR and Full Code orders in the EMR. This error could cause staff to not resuscitate the resident according to their current wishes during an emergency.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SSA AA | Social Services Assistant | Confirmed the DNR order in the EMR and explained the failure to update the Advance Directive status. |
| Interim Director of Nursing | Confirmed the DNR order was placed in the EMR by human error and explained the potential negative outcome. | |
| Unit Manager | Explained staff reliance on EMR banner for Advance Directive status and potential negative outcome if incorrect. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jul 3, 2025
Visit Reason
The inspection was conducted to investigate multiple complaints regarding resident rights violations, improper discharge/transfer practices, failure to report and investigate abuse allegations, and failure to ensure resident privacy and appropriate communication.
Complaint Details
The complaint investigation was substantiated with findings that the facility violated residents' rights related to privacy, discharge/transfer procedures, abuse prevention and reporting, and proper documentation and notification of discharges/transfers.
Findings
The facility failed to ensure residents' privacy in communication, failed to notify responsible parties timely about discharges/transfers, failed to prevent verbal abuse and properly investigate abuse allegations, and failed to document and notify appropriate parties regarding resident discharges/transfers. Two residents were inappropriately transferred without proper notice or documentation, and abuse allegations were not reported to the State Survey Agency as required.
Deficiencies (7)
F 0576: The facility failed to ensure residents could receive mail/packages unopened and maintain privacy, as staff copied private documents without resident permission.
F 0580: The facility failed to notify the resident's responsible party on the day of discharge/transfer for one resident.
F 0600: The facility failed to protect a resident from verbal/mental abuse by a social worker who told the resident she had to move, causing distress.
F 0609: The facility failed to report an allegation of verbal/mental abuse to the State Survey Agency within two hours as required.
F 0610: The facility failed to thoroughly investigate allegations of abuse for two residents, lacking witness statements and resident interviews.
F 0627: The facility failed to ensure residents were not inappropriately transferred or discharged against their or their representatives' wishes for two residents.
F 0628: The facility failed to notify residents and representatives of reasons for discharge/transfer, failed to notify the Ombudsman, and failed to document reasons or provide discharge notices for two residents.
Report Facts
Residents reviewed for discharge: 3
Residents reviewed for abuse: 8
Residents affected by deficiencies: 14
Residents affected by verbal abuse: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Named in findings related to copying resident mail without permission, verbal abuse, and improper discharge communication. | |
| RN1 | Registered Nurse Supervisor | Provided statements regarding resident verbal abuse and investigation. |
| Administrator | Provided statements regarding incidents, social worker termination, and discharge procedures. | |
| DON | Director of Nursing | Provided statements regarding abuse incident and reporting. |
| LPN11 | Licensed Practical Nurse | Interviewed about notification of resident transfer. |
Inspection Report
Abbreviated Survey
Census: 100
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00254526 and GA00255548.
Complaint Details
Complaints GA00254526 and GA00255548 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Report Facts
Complaints investigated: 2
Census: 100
Inspection Report
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Rockdale Healthcare Center following a survey completed on December 19, 2024.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
A health revisit survey was conducted from December 17, 2024 through December 19, 2024 to verify correction of deficiencies cited in the October 31, 2024 Recertification Survey conducted in conjunction with a Complaint Investigation.
Findings
All deficiencies cited as a result of the October 31, 2024 Recertification Survey and Complaint Investigation were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The Life Safety Code revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Routine
Census: 103
Deficiencies: 10
Date: Oct 31, 2024
Visit Reason
Routine inspection of Rockdale Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to assess residents for self-administration of medication, untimely Medicaid/Medicare notifications, unclean air conditioner filters, incomplete resident assessments and care plans, inadequate activities of daily living assistance, failure to administer ordered medications, improper respiratory care, lack of 14-day stop dates on psychotropic PRN medications, and unsanitary food handling practices in the kitchen.
Deficiencies (10)
F 0554: The facility failed to adequately assess one resident for self-administration of medication, placing the resident at risk for unsafe medication use.
F 0582: The facility failed to ensure timely notification of Medicaid/Medicare coverage discontinuation for three residents, risking lack of understanding of appeal rights.
F 0584: The facility failed to maintain a clean environment by not ensuring air conditioner filters were free of debris in 2 of 42 resident rooms.
F 0641: The facility failed to accurately code all high-risk medications on the admission assessment for one resident.
F 0656: The facility failed to develop comprehensive care plans addressing all high-risk medications for two residents.
F 0677: The facility failed to provide adequate nail care and assistance with activities of daily living for two residents.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for one resident, including failure to implement podiatrist recommendations.
F 0695: The facility failed to administer oxygen as ordered and failed to secure the oxygen canister for one resident.
F 0758: The facility failed to add a 14-day stop date for PRN psychotropic medication for one resident, risking excessive sedation.
F 0812: The facility failed to maintain sanitary food handling practices in the kitchen, including lack of beard nets and improper storage of food items.
Report Facts
Residents affected: 1
Residents affected: 3
Resident rooms: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 101
Facility census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse/Unit Manager | Named in medication self-administration deficiency interview |
| UU | Housekeeper | Named in PTAC filter cleanliness deficiency |
| MD | Maintenance Director | Named in PTAC filter cleanliness deficiency |
| BBB | MDS Director | Named in resident assessment and care plan deficiencies |
| DON | Director of Nursing | Named in multiple deficiencies including medication administration and psychotropic medication oversight |
| Administrator | Named in multiple interviews regarding facility expectations and deficiencies | |
| RN RR | Registered Nurse | Named in medication administration deficiency |
| RN Area Director | Hospice RN Area Director | Named in psychotropic medication PRN stop date deficiency |
| DM | Dietary Manager | Named in kitchen sanitation deficiency |
Inspection Report
Routine
Census: 103
Deficiencies: 6
Date: Oct 31, 2024
Visit Reason
The inspection was a State Licensure survey conducted at Rockdale Healthcare Center from October 29, 2024, through October 31, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to timely notify residents of Medicare Part A benefit discontinuation, failure to add a 14-day stop date for PRN psychotropic medication, inadequate assessment for self-administration of medication, failure to develop comprehensive care plans addressing high-risk medications and ADL needs, failure to maintain a clean environment including dirty PTAC filters, and unsanitary food handling practices in the kitchen.
Deficiencies (6)
Failure to ensure timely notifications of discontinuation of Medicare Part A benefits for three residents.
Failure to add a 14-day stop for as-needed psychotropic medication for one resident.
Failure to adequately assess one resident for self-administration of medication.
Failure to develop comprehensive person-centered care plans addressing high-risk medications for two residents and failure to ensure ADL care for two residents.
Failure to maintain clean PTAC filters in 2 resident rooms.
Failure to maintain sanitary practices in the kitchen regarding food handling and hair coverings.
Report Facts
Facility census: 103
Residents reviewed for Medicare Part A notification: 3
Residents reviewed for unnecessary psychotropic medication: 5
Residents sampled for self-administration assessment: 50
Residents sampled for care plan review: 50
Residents reviewed for ADL care: 3
Resident rooms inspected for PTAC filter cleanliness: 42
Residents affected by kitchen sanitation deficiency: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse/Unit Manager | Interviewed regarding psychotropic medication stop dates and medication at bedside |
| TT | Infection Preventionist | Interviewed regarding care plan updates |
| BBB | Minimum Data Set Director | Interviewed regarding care plan updates and reviews |
| GG | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| HH | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| BB | Licensed Practical Nurse | Interviewed regarding nail care expectations |
| NN | Cook | Observed without beard net in kitchen food preparation area |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation and hair covering practices |
| SSD | Social Services Director | Interviewed regarding Medicare Part A discharge notifications |
| BOM | Business Office Manager | Interviewed regarding Medicare Part A discharge notifications |
| DON | Director of Nursing | Interviewed regarding psychotropic medication stop dates, medication at bedside, care plans, and nail care |
| MD | Facility Medical Doctor | Interviewed regarding psychotropic medication orders |
| Administrator | Facility Administrator | Interviewed regarding facility expectations for notifications, medication orders, and environmental maintenance |
| MD | Maintenance Director | Interviewed regarding PTAC filter maintenance |
| RN Area Director | RN Area Director from Hospice | Interviewed regarding hospice medication orders |
Inspection Report
Routine
Census: 103
Deficiencies: 10
Date: Oct 31, 2024
Visit Reason
A standard survey was conducted at Rockdale Healthcare Center from October 29, 2024, through October 31, 2024, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00246329, GA00247316, GA00248676, GA00249019, and GA00252114 were investigated. Four were unsubstantiated; one (GA00252114) was substantiated with deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with deficiencies including failure to assess self-administration of medication, untimely Medicare Part A discharge notifications, unclean PTAC filters, incomplete resident assessments and care plans, inadequate ADL care, medication administration errors, failure to secure oxygen, lack of 14-day stop dates on PRN psychotropic medications, and unsanitary food handling practices in the kitchen.
Deficiencies (10)
Failure to adequately assess one resident for self-administration of medication, placing resident at risk for unsafe medication use.
Failure to ensure timely notifications of discontinuation of Medicare Part A benefits for three residents.
Failure to maintain clean PTAC filters in resident rooms, risking infection and poor air quality.
Failure to ensure all high-risk medications were coded on admission assessment for one resident.
Failure to develop comprehensive person-centered care plans addressing high-risk medications for two residents.
Failure to provide Activities of Daily Living (ADL) care including nail care for two residents.
Failure to administer ordered medications and implement resident-directed care consistent with podiatrist orders for two residents.
Failure to administer oxygen as ordered and failure to secure oxygen canister for one resident.
Failure to add a 14-day stop date for PRN psychotropic medication for one resident on hospice.
Failure to maintain sanitary food handling practices including lack of hair coverings and unclean environment in kitchen.
Report Facts
Residents sampled: 50
Residents reviewed for Medicare notification: 3
Resident rooms inspected for PTAC filters: 42
Residents reviewed for ADL care: 3
Residents reviewed for oxygen administration: 5
Facility census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse/Unit Manager | Named in medication self-administration deficiency and medication administration interview. |
| UU | Housekeeper | Named in PTAC filter cleanliness deficiency. |
| BBB | Minimum Data Set Director | Named in resident assessment and care plan deficiencies. |
| TT | Infection Preventionist | Named in resident assessment deficiency. |
| GG | Certified Nursing Assistant | Named in ADL care deficiency. |
| HH | Certified Nursing Assistant | Named in ADL care deficiency. |
| BB | Licensed Practical Nurse | Named in ADL care deficiency. |
| RR | Registered Nurse | Named in medication administration deficiency. |
| KK | Licensed Practical Nurse | Named in podiatry care deficiency. |
| JJ | Certified Nursing Assistant | Named in podiatry care deficiency. |
| DM | Dietary Manager | Named in food service sanitary practice deficiency. |
| NN | Cook | Named in food service sanitary practice deficiency. |
| DON | Director of Nursing | Named in multiple deficiencies including medication administration, care plans, oxygen administration, and psychotropic medication oversight. |
| Administrator | Named in multiple deficiencies including medication administration and psychotropic medication oversight. |
Inspection Report
Routine
Census: 103
Deficiencies: 11
Date: Oct 31, 2024
Visit Reason
Routine inspection of Rockdale Healthcare Center to assess compliance with regulatory requirements including medication self-administration, resident notifications, environmental services, resident assessments, care planning, activities of daily living, medication administration, respiratory care, psychotropic medication use, and food service sanitation.
Findings
The facility had multiple deficiencies including failure to assess resident for self-administration of medication, untimely notification of Medicare Part A discharge, unclean air conditioner filters in resident rooms, inaccurate resident assessments, incomplete care plans, inadequate assistance with activities of daily living, failure to administer ordered medications, improper oxygen administration, lack of 14-day stop dates on PRN psychotropic medications, and unsanitary food handling practices in the kitchen.
Deficiencies (11)
F 0554: The facility failed to adequately assess one resident for self-administration of medication, placing the resident at risk for unsafe medication use.
F 0582: The facility failed to issue timely notifications of Medicare Part A benefit discontinuation for three residents, risking lack of understanding of appeal rights.
F 0584: The facility failed to maintain clean air conditioner filters in 2 of 42 resident rooms, risking infection and poor air quality.
F 0641: The facility failed to code all high-risk medications on the admission assessment for one resident, risking inadequate person-centered care.
F 0656: The facility failed to develop comprehensive care plans addressing all high-risk medications for two residents, risking inadequate treatment.
F 0677: The facility failed to provide adequate nail care and assistance with activities of daily living for two residents.
F 0684: The facility failed to provide ordered skin care and medications, and failed to implement podiatrist recommendations for one resident, risking pain and infection.
F 0684: The facility failed to administer ordered medications to one resident, risking medical complications.
F 0695: The facility failed to administer oxygen as ordered and failed to secure the oxygen canister for one resident, risking respiratory complications.
F 0758: The facility failed to include a 14-day stop date on PRN psychotropic medication orders for one resident, risking excessive sedation and lack of oversight.
F 0812: The facility failed to maintain sanitary food handling practices including hair coverings and proper storage, risking foodborne illness for residents.
Report Facts
Residents affected: 1
Residents affected: 3
Resident rooms: 2
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 101
Facility census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| VV | Registered Nurse/Unit Manager | Named in medication self-administration finding |
| DON | Director of Nursing | Named in multiple findings including medication administration and psychotropic medication oversight |
| Administrator | Facility Administrator | Named in multiple findings including medication self-administration and psychotropic medication oversight |
| BOM | Business Office Manager | Named in Medicare Part A notification deficiency |
| SSD | Social Services Director | Named in Medicare Part A notification deficiency and podiatry coordination |
| MD | Maintenance Director | Named in PTAC filter cleanliness finding |
| BBB | MDS Director | Named in resident assessment and care plan findings |
| TT | Infection Preventionist | Named in care plan update process |
| RN RR | Registered Nurse | Named in medication administration deficiency |
| RN Area Director | RN Area Director from Hospice | Named in psychotropic medication PRN stop date finding |
| DM | Dietary Manager | Named in food service sanitation deficiency |
Inspection Report
Life Safety
Census: 103
Capacity: 102
Deficiencies: 2
Date: Oct 30, 2024
Visit Reason
The inspection was conducted to review the Emergency Preparedness Program and to perform a Life Safety Code Survey to assess compliance with federal regulations and fire safety standards.
Findings
The facility failed to properly update the Emergency Preparedness Plan annually, affecting all six smoke compartments. Additionally, the facility failed to repair holes/penetrations in oxygen rooms and dirty linen room doors, affecting two of six smoke compartments.
Deficiencies (2)
Facility failed to properly update the Emergency Preparedness Plan annually.
Facility failed to repair holes/penetrations in oxygen rooms and dirty linen room doors.
Report Facts
Census: 103
Total Capacity: 102
Smoke Compartments Affected: 6
Smoke Compartments Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 10/30/2024 |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating Complaint Number GA00243864.
Complaint Details
Complaint Number GA00243864 was unsubstantiated.
Findings
The complaint was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with 42 CFR 483.80 infection control regulations and CMS/CDC recommended COVID-19 practices.
Inspection Report
Deficiencies: 0
Date: Feb 19, 2024
Visit Reason
The inspection was conducted as a regulatory survey of Rockdale Healthcare Center to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Census: 100
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaint numbers GA00237982, GA00240702, GA00242290, GA00243026, and GA00241108.
Complaint Details
The survey investigated complaints GA00237982, GA00240702, GA00242290, GA00243026, and GA00241108. No deficiencies were cited related to these complaints.
Findings
No deficiencies were cited related to the investigated complaints during the survey.
Inspection Report
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Rockdale Healthcare Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Oct 16, 2023
Visit Reason
A revisit survey was conducted on 10/19/2023 to verify correction of deficiencies cited during the 6/25/2023 Recertification Survey.
Findings
All deficiencies cited as a result of the 6/25/2023 Recertification Survey were found to be corrected.
Report Facts
Census: 97
Inspection Report
Routine
Census: 98
Capacity: 99
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
The inspection was conducted to assess sanitary conditions related to dishware drying and storage practices in the facility's kitchen.
Findings
The facility failed to maintain sanitary conditions during the drying process for dishware by stacking and storing wet cups, glasses, and plate covers, which had the potential to cause food borne illness affecting 98 residents. Audits and interviews confirmed improper wet stacking practices despite staff training.
Deficiencies (1)
Failure to maintain sanitary conditions during dishware drying by stacking and storing wet cups, glasses, and plate covers.
Report Facts
Residents affected: 98
Residents census: 98
Total facility capacity: 99
Staff trained: 12
Wet dishware items stacked: 4
Wet dishware items stacked: 8
Wet dishware items stacked: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Monitored kitchen sanitation, stopped improper stacking, confirmed wet dishware, and conducted audits | |
| Dietary Aide CC | Observed stacking wet dishware and confirmed recent training on wet nesting | |
| Dietary Aide AA | Interviewed about dish drying process and stacking practices | |
| Dietary Aide BB | Interviewed about dish drying process and stacking practices | |
| Administrator | Presented training on kitchen sanitation and wet nesting, aware of audit documentation |
Inspection Report
Re-Inspection
Census: 99
Deficiencies: 1
Date: Aug 23, 2023
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a prior survey.
Findings
The facility failed to maintain sanitary conditions during the drying process for dishware by stacking and storing wet cups, glasses, and plate covers, which could potentially cause foodborne illness affecting 98 of 99 residents receiving an oral diet. The Dietary Manager and staff acknowledged the issue and had recently conducted training on proper sanitation and wet nesting procedures.
Deficiencies (1)
Failed to maintain sanitary conditions during drying process for dishware by stacking and storing wet cups, glasses, and plate covers.
Report Facts
Census: 99
Staff trained: 12
Wet dishware items stacked: 4
Wet dishware items stacked: 8
Wet dishware items stacked: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Monitored kitchen sanitation, verified stacked wet dishware, and conducted staff training |
| Dietary Aide CC | Dietary Aide | Observed stacking wet dishware and interviewed regarding sanitation practices |
| Dietary Aide AA | Dietary Aide | Interviewed about dish drying process and stacking practices |
| Dietary Aide BB | Dietary Aide | Interviewed about dish drying process and stacking practices |
| Administrator | Administrator | Provided information about audit documentation and staff training |
Inspection Report
Life Safety
Census: 92
Capacity: 102
Deficiencies: 0
Date: Jun 30, 2023
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Routine
Deficiencies: 7
Date: Jun 25, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory standards related to resident dignity, safety, care planning, fall management, pain management, radiology services, and food safety in the nursing home.
Findings
The facility was found deficient in maintaining resident dignity related to urinary catheter privacy, cleanliness and maintenance of resident rooms, updating care plans after falls, conducting proper fall assessments and neuro checks, managing pain adequately, timely provision of radiology services, and proper food storage and sanitation practices.
Deficiencies (7)
F 0550: The facility failed to maintain dignity by ensuring urinary catheter drainage bags were covered with a privacy bag for one resident, visible to staff and visitors.
F 0584: The facility failed to maintain a clean and comfortable environment in eight resident rooms, including black scuff marks on walls and dusty bathroom vents.
F 0657: The facility failed to update and revise the comprehensive care plan related to unwitnessed falls for one resident.
F 0689: The facility failed to ensure proper assessment and follow-up after an unwitnessed fall, including incomplete neuro checks and delayed radiology services for one resident.
F 0697: The facility failed to manage pain adequately for one resident after a fall, with inconsistent pain documentation and delayed treatment.
F 0776: The facility failed to provide timely radiology services for one resident, with no documentation of completed x-rays and poor follow-up on delays.
F 0812: The facility failed to label and date opened food items in storage areas, failed to discard food by discard dates, and failed to maintain sanitary conditions by stacking wet drinking cups.
Report Facts
Residents affected: 7
Residents affected: 8
Residents affected: 35
Residents affected: 89
Medication dose: 1000
Medication dose: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse / Unit Manager | Responsible for follow-up on mobile x-ray delays; unavailable for interview |
| Director of Nursing | Director of Nursing | Provided expectations on catheter care, fall assessments, and radiology follow-up |
| LPN EE | Licensed Practical Nurse | Described neuro check procedures and fall assessment protocols |
| Dietary Aide FF | Dietary Aide | Verified food storage and labeling deficiencies |
| Dietary Manager | Dietary Manager | Confirmed food storage and sanitation issues |
| Registered Dietician | Registered Dietician | Provided expectations on food labeling and discard practices |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 25, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Rockdale Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity related to urinary catheter privacy, inadequate environmental cleanliness in resident rooms, failure to update and revise care plans after falls, inadequate fall assessment and follow-up, failure to manage pain appropriately after a fall, delayed radiology services, and improper food storage and sanitation practices.
Deficiencies (7)
F 0550: The facility failed to maintain dignity by not providing a privacy bag for a resident's urinary catheter drainage bag, visible to staff and visitors.
F 0584: The facility failed to maintain a clean and comfortable environment in eight resident rooms, including black scuff marks on walls and dusty bathroom vents.
F 0657: The facility failed to update and revise the comprehensive care plan related to unwitnessed falls for one resident.
F 0689: The facility failed to ensure proper fall assessment, neuro-checks, and timely radiology services after an unwitnessed fall, resulting in actual harm to a resident.
F 0697: The facility failed to provide safe and appropriate pain management for a resident after a fall, resulting in actual harm.
F 0776: The facility failed to provide timely radiology services for a resident after a fall, with no documentation of follow-up on delayed mobile x-ray services.
F 0812: The facility failed to label and date opened food items in storage areas, failed to discard food by discard dates, and failed to maintain sanitary conditions by stacking wet drinking cups.
Report Facts
Residents in sample size: 35
Residents affected: 7
Resident rooms with environmental issues: 8
Residents affected: 1
Residents affected: 1
Residents affected: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse / Unit Manager | Responsible for follow-up on mobile x-ray delays; not available for interview |
| Director of Nursing | Director of Nursing | Provided expectations on urinary catheter privacy, fall care plans, and mobile x-ray follow-up |
| Dietary Aide FF | Dietary Aide | Verified food storage and labeling deficiencies |
| Dietary Manager | Dietary Manager | Confirmed food storage and sanitation deficiencies |
| Registered Dietician | Registered Dietician | Provided expectations on food labeling and storage |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jun 25, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from June 23, 2023 through June 25, 2023 to assess compliance with state regulations for Rockdale Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not providing privacy bags for urinary catheter drainage bags, failure to manage pain adequately for a resident after a fall resulting in actual harm, failure to maintain a clean and homelike environment in resident rooms, and failure to properly label, date, and store food items in the dietary department.
Deficiencies (4)
Failure to maintain dignity by ensuring a dignity bag was provided for a resident with an indwelling urinary catheter.
Failure to manage pain for a resident after a fall, resulting in actual harm including a chronic subdural hematoma.
Failure to maintain a clean and comfortable homelike environment in eight resident rooms, including black scuff marks on walls and dirty, dusty air vents in bathrooms.
Failure to label and date opened food items in the walk-in cooler, freezer, and dry storage pantry; failure to discard food items by discard date; and failure to maintain sanitary conditions by stacking wet drinking cups.
Report Facts
Residents in sample size: 35
Residents receiving oral diet: 89
Date of inspection completion: Jun 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nurse's Aide (CNA) | Provided information about catheter care and privacy bag availability |
| BB | Licensed Practical Nurse (LPN) | Confirmed catheter care responsibilities and privacy bag expectations |
| CC | Licensed Practical Nurse (LPN) | Confirmed nursing staff responsibility for catheter privacy bags |
| DD | LPN Unit Manager | Discussed privacy cover use and planned staff education |
| EE | Licensed Practical Nurse (LPN) | Provided information about incident packet and fall protocol |
| FF | Dietary Aide | Verified food storage and labeling deficiencies |
| GG | Dietary Aide | Discussed food labeling and discard date requirements |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 7
Date: Jun 25, 2023
Visit Reason
A standard survey was conducted in conjunction with complaint investigations of two complaint intake numbers, one found unsubstantiated and the other substantiated with deficiencies.
Complaint Details
Complaint Intake Numbers GA00231401 and GA00231835 were investigated. GA00231401 was unsubstantiated. GA00231835 was substantiated with deficiencies including actual harm from an unwitnessed fall resulting in a subdural hematoma and pain.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain dignity for a resident with a urinary catheter, failure to maintain a clean environment in resident rooms, failure to update care plans related to falls, failure to properly assess and follow up after a resident's fall including neuro checks and timely radiology services, failure to manage pain after a fall, and failure to properly label and date food items and maintain sanitary conditions in dietary areas.
Deficiencies (7)
Failure to maintain dignity by ensuring a dignity bag was provided for a resident with an indwelling urinary catheter.
Failure to maintain a clean and comfortable homelike environment in eight resident rooms including black scuff marks on walls and dirty and dusty air vents in bathrooms.
Failure to update and revise the comprehensive person-centered care plan related to unwitnessed falls for one resident.
Failure to ensure proper assessment and followup for one resident post fall including incomplete neuro-checks and delayed radiology services.
Failure to manage pain for one resident after a fall, with continued pain and delayed treatment.
Failure to provide radiology services in a timely manner for one resident.
Failure to label and date opened food items in walk-in cooler, freezer, and dry storage; failure to discard food by discard date; and failure to maintain sanitary conditions by stacking wet drinking cups.
Report Facts
Resident census: 90
Deficiencies cited: 7
Pain medication dose: 1000
Neuro check frequency: 15
Neuro check frequency: 30
Neuro check frequency: 60
Neuro check frequency: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Interviewed regarding urinary catheter drainage bag privacy bag policy and observations |
| LPN CC | Licensed Practical Nurse | Interviewed regarding urinary catheter drainage bag privacy bag policy |
| LPN Unit Manager DD | Licensed Practical Nurse Unit Manager | Interviewed regarding urinary catheter drainage bag privacy bag policy and corrective actions |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding urinary catheter drainage bag privacy bag policy, fall care plan updates, neuro checks, and pain management |
| Maintenance Director | Interviewed regarding maintenance concerns and cleaning responsibilities | |
| Housekeeping Supervisor | Interviewed regarding cleaning protocols and responsibilities | |
| LPN II | Licensed Practical Nurse II | Interviewed regarding fall assessment and neuro checks |
| Medical Doctor | Resident's Medical Doctor | Interviewed regarding expectations for fall assessment and pain management |
| Dietary Aide FF | Dietary Aide | Interviewed regarding food labeling and storage practices |
| Dietary Aide GG | Dietary Aide | Interviewed regarding food labeling and discard dates |
| Dietary Manager | Dietary Manager (DM) | Interviewed regarding food storage, labeling, and discard practices |
| Registered Dietician | Registered Dietician (RD) | Interviewed regarding expectations for food labeling and drying procedures |
| Administrator | Interviewed regarding expectations for maintenance and dietary compliance |
Inspection Report
Abbreviated Survey
Census: 88
Deficiencies: 0
Date: Oct 6, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00223025 and #GA00227846.
Complaint Details
Complaint #GA00223025 was substantiated with no deficiencies. Complaint #GA00227846 was unsubstantiated with no deficiencies.
Findings
Complaint #GA00223025 was substantiated with no deficiencies found, and complaint #GA00227846 was unsubstantiated with no deficiencies identified.
Report Facts
Resident Census: 88
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 0
Date: Feb 21, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Rockdale Healthcare Center following a state inspection.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
A revisit survey was conducted on 1/24/2022 through 1/25/2022 to verify correction of deficiencies cited in the 11/19/2021 Standard Survey.
Findings
All deficiencies cited as a result of the 11/19/2021 Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00219419.
Complaint Details
Complaint #GA00219419 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
The inspection was conducted as a licensure survey for Rockdale Healthcare Center.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Nov 19, 2021
Visit Reason
A standard survey was conducted from 11/16/21 to 11/19/21, including investigation of Complaint Intake Numbers GA00214707 and GA00212256, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA00214707 and GA00212256 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations due to failure to follow physician orders for two residents. Specifically, the facility administered Eliquis without consulting the GI physician for Resident #145 and administered oxygen at a higher flow rate than ordered for Resident #198.
Deficiencies (2)
Failure to consult the Gastrointestinal physician before administering Eliquis to Resident #145.
Failure to administer the correct amount of oxygen to Resident #198, administering 5L/NC instead of the ordered 2L/NC.
Report Facts
Resident census: 98
Medication dosage: 2.5
Oxygen flow rate ordered: 2
Oxygen flow rate administered: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding lack of evidence of GI physician consultation and confirmation of oxygen order. | |
| Licensed Practical Nurse GG | Confirmed resident had physician's order for oxygen at 2L/NC. |
Inspection Report
Deficiencies: 2
Date: Nov 19, 2021
Visit Reason
The inspection was conducted to evaluate compliance with physician orders and proper administration of treatments for residents, specifically regarding medication and oxygen therapy.
Findings
The facility failed to consult the Gastrointestinal physician before administering Eliquis to Resident #145 and did not administer the correct oxygen flow rate to Resident #198, who received oxygen at 5L/NC instead of the ordered 2L/NC.
Deficiencies (2)
F 0684: The facility did not consult the Gastrointestinal physician before administering Eliquis anticoagulant medication to Resident #145, contrary to discharge instructions.
F 0684: Resident #198 received oxygen at 5 liters per minute via nasal cannula instead of the physician-ordered 2 liters per minute.
Report Facts
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 5
Medication dose: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding lack of consultation with GI physician and oxygen order confirmation | |
| Licensed Practical Nurse (LPN) GG | Confirmed physician's order for oxygen at 2L/NC for Resident #198 |
Inspection Report
Life Safety
Census: 98
Capacity: 102
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
A Life Safety code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in compliance with the Life Safety code requirements and the Emergency Preparedness Program met the regulatory standards.
Report Facts
Census: 98
Total Capacity: 102
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 23, 2021
Visit Reason
A revisit to the Focused Infection Control survey of 1/19/2021 was conducted to verify correction of previously identified deficiencies.
Findings
The revisit revealed that the deficiency identified in the prior survey had been corrected as of 3/5/2021.
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Date: Feb 8, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a COVID-19 Focused Infection Control Survey to investigate Complaint GA00211637.
Complaint Details
Complaint GA00211637 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
Complaint GA00211637 was found to be unsubstantiated with no deficiencies cited. No additional deficient practice was identified during the Focused Infection Control Survey.
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 1
Date: Jan 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to provide education and/or offer the PCV13 pneumococcal vaccine to four of five residents reviewed, increasing the risk of pneumonia among residents.
Deficiencies (1)
Failure to provide education and/or offer the PCV13 pneumococcal vaccine to four of five residents reviewed for flu/pneumonia vaccinations.
Report Facts
Residents reviewed for flu/pneumonia vaccinations: 5
Residents not offered PCV13 vaccine: 4
Total census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Stated that PCV13 vaccine was not offered and was new to them | |
| Consultant Pharmacist | Stated that PCV13 immunization was not normally provided and was at discretion of physician and resident | |
| Facility Physician | Voicemail stating the facility had not been giving the 13 valent vaccine or providing educational pieces |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 10, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints (#GA00198380, #GA00198367, #GA00199945, #GA00201644, and #GA00206293) at the facility.
Complaint Details
Complaints #GA00198367 and #GA00201644 were substantiated without regulatory violations. Complaints #GA00206923, #GA00199945, and #GA00198380 were unsubstantiated with no regulatory violations.
Findings
Complaints #GA00198367 and #GA00201644 were substantiated without regulatory violations. Complaints #GA00206923, #GA00199945, and #GA00198380 were unsubstantiated with no regulatory violations.
Inspection Report
Routine
Census: 84
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 93
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on July 30-31, 2020.
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, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/18/18 recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 94
Capacity: 105
Deficiencies: 0
Date: Oct 29, 2018
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
Rockdale Healthcare Center was found to be in substantial compliance with the Life Safety Code requirements, including the Emergency Preparedness plan and NFPA 101 Life Safety Code 2012 edition standards.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Oct 18, 2018
Visit Reason
A standard survey was conducted from 10/15/18 through 10/18/18, including investigation of two complaint intake numbers GA00189040 and GA00191296. The visit was triggered by complaints and the standard survey to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Number GA00189040 was substantiated with deficiencies cited related to failure to follow care plans and prevent accidents. Complaint Intake Number GA00191296 was substantiated without deficiencies cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to follow care plans for activities of daily living (ADL) for two residents, including inadequate assistance with bed mobility leading to a fall and failure to provide proper nail care. The facility also failed to provide adequate supervision and assistance devices to prevent accidents, resulting in a resident fall due to staff not following the care plan.
Deficiencies (3)
Failure to follow the plan of care related to activities of daily living (ADL) for two residents, including assistance with bed mobility and nail care.
Failure to provide necessary services to maintain good nutrition, grooming, and personal hygiene for one dependent resident related to nail care.
Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents, resulting in a fall.
Report Facts
Resident census: 88
Sample size: 25
Date of incident: May 11, 2018
Number of staff trained: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in fall incident involving Resident #20 and found to have left resident unattended; received education on care plan and Kardex system after incident; no longer employed at facility. |
| CNA GG | Certified Nursing Assistant | Interviewed regarding ADL care and nail care practices for Resident #6. |
| LPN HH | Licensed Practical Nurse Unit Manager | Interviewed regarding expectations for staff to provide care per orders and care plan including nail care. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for staff to follow care plans and facility policies; confirmed no nail care policy. |
| LPN BB | Licensed Practical Nurse | Provided report on resident fall incident and care requirements for Resident #20. |
| CNA AA | Certified Nursing Assistant | Interviewed about care needs of Resident #20 and staff awareness of care requirements. |
| LPN AA | Licensed Practical Nurse | Interviewed about staff communication and resident care needs for Resident #20. |
| Staff Educator | Staff Educator | Interviewed about CNA orientation and training process including use of electronic care plan and Kardex system. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 18, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care plans and overall facility adherence to regulatory requirements related to patient care, including activities of daily living (ADL) and safety measures.
Findings
The facility failed to follow the plan of care related to activities of daily living for two residents, including inadequate assistance with bed mobility and unkept nails. A resident fall occurred due to staff not following the plan of care, and staff education was recommended. The facility lacked a policy for nail care.
Deficiencies (1)
Failure to follow the plan of care related to activities of daily living for two residents, including assistance with bed mobility and nail care.
Report Facts
Residents sampled: 25
Incident date: May 11, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA EE | Certified Nursing Assistant | Named in fall incident and related care plan deficiency |
| Director of Nursing | Interviewed regarding incident and care plan expectations | |
| Assistant Director of Nursing | Interviewed regarding incident and care plan expectations | |
| Licensed Practical Nurse HH | Unit Manager | Interviewed regarding nail care expectations |
| Certified Nursing Assistant GG | Certified Nursing Assistant | Interviewed regarding ADL care and nail care |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 17, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00187233 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00187233 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 1, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00185311.
Complaint Details
Complaint #GA00185311 was investigated and found to be unsubstantiated.
Findings
The complaint investigation was concluded as unsubstantiated with no deficiencies detailed in the report.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 27, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 97
Deficiencies: 0
Date: Nov 9, 2017
Visit Reason
A standard survey was conducted at Rockdale Healthcare from November 6th, 2017 through November 9th, 2017 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 98
Capacity: 102
Deficiencies: 2
Date: Nov 6, 2017
Visit Reason
The 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 failure to maintain the sprinkler system, evidenced by a yellow tag with repair notes on the sprinkler riser, and failure to maintain the laundry room door which was damaged and needed replacement to ensure it remains self-closed and latched or magnetically held open by the fire alarm system.
Deficiencies (2)
Failure to maintain the sprinkler system; a yellow tag with repair notes was found on the sprinkler system riser.
Failure to maintain corridor door to laundry room; door was damaged and needed replacement to ensure proper self-closing and latching.
Report Facts
Census: 98
Total Capacity: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system and laundry room door during facility tour |
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