Inspection Reports for Rome Health and Rehabilitation Center
1345 REDMOND ROAD, ROME, GA, 30165
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 23, 2021, found no deficiencies and confirmed compliance with infection control regulations, with complaints investigated and unsubstantiated. Earlier inspections similarly showed compliance with infection control and emergency preparedness requirements related to COVID-19, with no cited deficiencies. Prior to 2020, the facility had some deficiencies mainly related to care planning for antipsychotic medication use and fire safety issues such as sprinkler system monitoring and smoke barrier maintenance. Complaint investigations were mostly unsubstantiated or substantiated without deficiencies, and no fines or enforcement actions were listed in the available reports. The overall trend suggests improvement in regulatory compliance, particularly in infection control and care planning areas.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
63% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
73 residents
Based on a September 2021 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00213776 and #GA00214207.
Complaint Details
Complaints #GA00213776 and #GA00214207 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaints were unsubstantiated with no regulatory violations cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Report Facts
Complaints investigated: 2
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 17, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00205288, #GA00203794, and #GA00201742.
Complaint Details
Complaints #GA00205288, #GA00203794, and #GA00201742 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 51
Deficiencies: 0
Date: Nov 25, 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.
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 recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's infection control practices and processes related to COVID-19.
Findings
No deficiencies were cited during the desk review conducted in April 2020 or the COVID-19 focused infection control survey conducted on June 16, 2020.
Report Facts
Total census: 68
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jun 16, 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 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 14, 2020
Visit Reason
A desk review for a Focused Schizophrenia Revisit Survey was conducted to verify correction of deficiencies cited in the prior 2/27/2020 Focused Schizophrenia Survey.
Findings
All deficiencies cited in the previous Focused Schizophrenia Survey were found to be corrected and in compliance with 42 CFR 483 Subpart B.
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Date: Feb 27, 2020
Visit Reason
A focused schizophrenia survey was conducted by Healthcare Management Solutions, LLC on behalf of CMS to assess compliance with 42 CFR 483 subpart B, specifically related to schizophrenia diagnoses and antipsychotic medication use.
Complaint Details
The survey was complaint-related, focusing on schizophrenia diagnoses and antipsychotic medication use. The facility was found not in substantial compliance with 42 CFR 483 subpart B.
Findings
The facility failed to develop comprehensive care plans related to antipsychotic medication use, and five of six sampled residents were given a diagnosis of schizoaffective disorder without meeting DSM-5 diagnostic criteria or psychiatric consultation. Additionally, one resident received antipsychotic medication without adequate clinical indication or documented behaviors warranting its use.
Deficiencies (3)
Failure to develop a comprehensive care plan related to antipsychotic medication use for one resident, lacking resident-specific target behaviors and gradual dose reduction parameters.
Failure to ensure diagnoses of schizoaffective disorder met accepted DSM-5 criteria and were supported by psychiatric evaluation for five residents.
Failure to ensure antipsychotic medications were only used when clinically indicated and to document behaviors justifying their use for one resident.
Report Facts
Survey Census: 87
Sample Size: 6
Residents receiving antipsychotic medications: 21
Residents with schizophrenia or schizoaffective diagnosis: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Family Nurse Practitioner 2 | Family Nurse Practitioner | Diagnosed residents with schizoaffective disorder without following DSM-5 criteria or psychiatric consultation; wrote orders for antipsychotic medications |
| Director of Nursing | Director of Nursing | Verified lack of resident-specific target behaviors in care plans and absence of psychiatric consultation for diagnoses |
| Consultant Psychologist | Consultant Psychologist | Stated nurse practitioners should follow DSM-5 criteria and had not been asked to validate mental health diagnoses |
| Family Nurse Practitioner 1 | Family Nurse Practitioner | Added schizoaffective diagnosis for a resident without clinical evidence or psychiatric referral |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Reported no behaviors, hallucinations, or delusions observed in resident receiving antipsychotic medication |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 12, 2019
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 survey tags have been corrected during the follow-up survey.
Inspection Report
Routine
Census: 81
Deficiencies: 0
Date: Sep 26, 2019
Visit Reason
A standard survey was conducted at Rome Health & Rehabilitation from September 23, 2019 through September 26, 2019 to assess compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The standard survey revealed the facility was in compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 80
Capacity: 100
Deficiencies: 1
Date: Sep 24, 2019
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 failure to ensure automatic sprinkler system supervisory attachments are installed and monitored for integrity as required by NFPA 72. Specifically, the control valves for the sprinkler system in the backflow pit were not supervised, which could place residents at risk if the sprinkler system is impaired.
Deficiencies (1)
Automatic sprinkler system supervisory attachments are not installed and monitored for integrity; control valves for the sprinkler system in the backflow pit are not supervised.
Report Facts
Census: 80
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system supervisory attachments during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 1, 2018
Visit Reason
The inspection was conducted as a complaint survey on July 31, 2018, to investigate complaint # GA 00189368 and determine compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint # GA 00189368 was substantiated with no deficiencies.
Findings
The complaint was substantiated but no deficiencies were found during the investigation.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Aug 1, 2018
Visit Reason
This was a follow-up visit to the Recertification survey of June 14, 2018, conducted on July 31, to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies identified in the prior Recertification survey were corrected, and the facility was in substantial compliance as of July 31, 2018.
Deficiencies (1)
483.25(e)(1)-(3) Bowel/Bladder Incontinence, Catheter, UTI - The facility must ensure residents maintain continence or receive appropriate treatment and services for urinary and fecal incontinence.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 30, 2018
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 survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 89
Capacity: 100
Deficiencies: 2
Date: Jun 12, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain hazardous areas to resist smoke passage and improper maintenance of the fire alarm and smoke detection system. Specific issues included a cracked sheet rock ceiling in the mechanical room and smoke detectors placed directly in the airflow of HVAC supply vents.
Deficiencies (2)
Hazardous areas are not maintained to resist the passage of smoke, including a cracked sheet rock ceiling in the mechanical room.
Fire alarm and smoke detection system is not properly maintained; several smoke detectors were placed directly in the airflow of HVAC supply vents.
Report Facts
Census: 89
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to hazardous areas and fire alarm system during facility tour |
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Date: Dec 14, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/31/17 Complaint Survey.
Complaint Details
This visit was a follow-up to a complaint survey conducted on 10/31/17; all prior deficiencies were corrected.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 28, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags had been corrected during this follow-up visit.
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Jul 13, 2017
Visit Reason
A standard survey was conducted from July 10, 2017 through July 13, 2017, and Complaint Intake Number GA00177107 was investigated in conjunction with this standard survey.
Complaint Details
Complaint Intake Number GA00177107 was investigated in conjunction with the standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 93
Capacity: 100
Deficiencies: 2
Date: Jul 11, 2017
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 NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failures in maintaining fire/smoke separation walls with properly sealed penetrations and the use of electrical power strips/multi-taps that did not meet required UL ratings in patient care and non-care areas.
Deficiencies (2)
Failed to ensure all Fire/Smoke walls were properly maintained and all penetrations sealed, risking smoke/fire passage.
Electrical equipment power strips/multi-taps used in patient care areas and non-care areas did not meet required UL ratings.
Report Facts
Census: 93
Certified beds: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire/smoke wall penetrations and electrical equipment issues during the inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 22, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate multiple complaint numbers to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey investigated complaint numbers GA00178234, GA00171265, GA00167726, GA00167638, and GA00166582 and found no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from April 21 to April 22, 2017.
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