Inspection Reports for Roselane Health Center by Harborview
613 ROSELANE STREET, MARIETTA, GA, 30060
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 6, 2025, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to fire safety issues, such as sprinkler system maintenance and corridor door compliance, as well as resident care concerns including pain management, care planning, medication administration, and food labeling. Several complaint investigations were substantiated with federal deficiencies, particularly involving care planning and medication management, while most other complaints were unsubstantiated. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility’s record shows improvement over time, with follow-up surveys consistently confirming correction of prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
123 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected. This was a desk review.
Inspection Report
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Roselane Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the text or image.
Inspection Report
Re-Inspection
Census: 123
Deficiencies: 0
Date: Jan 30, 2025
Visit Reason
A revisit was conducted at Roselane by Harborview beginning 1/28/2025 through 1/30/2025 to verify correction of previously cited deficiencies from the recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found corrected as of 1/19/2025.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jan 27, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags were corrected except for deficiency K353 related to sprinkler system maintenance. The facility failed to have a green tag on the automatic sprinkler riser, which remained yellow-tagged at the time of inspection.
Deficiencies (1)
Failed to have a green tag on the automatic sprinkler riser; system still yellow-tagged.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed the findings regarding the sprinkler system tag. |
Inspection Report
Abbreviated Survey
Census: 124
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00253374.
Complaint Details
Complaint GA00253374 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated, and no regulatory violations were cited during the survey.
Inspection Report
Life Safety
Census: 111
Capacity: 137
Deficiencies: 6
Date: Dec 17, 2024
Visit Reason
The inspection 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 standards.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements, including obstruction of an exit in the east wing, lack of approved lock out device and red breaker for the fire alarm control panel, missing escutcheon ring around a sprinkler head, yellow tagged sprinkler risers, missing covers on light fixtures and electrical junction boxes, lack of approved oxygen storage signage, and unsecured compressed gas cylinders in the outside storage room.
Deficiencies (6)
Obstruction in the east wing exit corridor with boxes partially blocking the exit door.
Fire alarm control panel breaker not red and missing approved lock out device.
Missing escutcheon ring around sprinkler head in main hall CPU room; dry automatic sprinkler risers yellow tagged due to air compressor issues.
Missing covers on multiple light fixtures throughout the building, missing covers on electrical junction boxes behind clothes dryers, and open electrical breaker slots in main hall electrical room.
No approved signage on the door of the oxygen storage room in the east wing.
Compressed gas cylinders in outside storage room not properly secured; four cylinders found unsecured.
Report Facts
Census: 111
Total Capacity: 137
Compressed gas cylinders unsecured: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 5, 2024
Visit Reason
A State Licensure survey was conducted at Roselane Health by Harborview from December 2, 2024, through December 5, 2024, to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey identified multiple deficiencies including failure to properly sign out narcotic medications, improper cleaning of glucometers, incomplete care plans for residents, and inadequate labeling and dating of food items in the kitchen.
Deficiencies (4)
Failure to ensure narcotics were signed out for one of 36 sampled residents, risking drug diversion.
Failure to properly clean glucometer after blood glucose testing for one of three residents observed, risking cross contamination.
Failure to develop comprehensive care plans for two of 36 sampled residents, potentially leading to unmet care needs.
Failure to ensure all food in freezer, refrigerator, and dry storage was labeled, dated, and not expired, potentially affecting all 116 residents.
Report Facts
Sampled residents for narcotic sign-out: 36
Sampled residents for glucometer use: 36
Residents reviewed for care plans: 36
Total residents potentially affected by food labeling issues: 116
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Observed not signing out narcotic medication prior to administration. |
| LPN2 | Licensed Practical Nurse | Observed not signing out narcotic medications prior to administration. |
| LPN4 | Licensed Practical Nurse | Observed using alcohol wipes instead of germicidal wipes to clean glucometer. |
| DON | Director of Nursing | Provided expectations regarding narcotic sign-out and care plan specificity. |
| Unit Manager 1 | Unit Manager | Interviewed about glucometer cleaning procedures. |
| MDS Coordinator | MDS Coordinator | Interviewed about care plan development for resident R97. |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed about physician notification for missed medications. |
| Dietary Manager | Dietary Manager | Verified food labeling and dating deficiencies in kitchen. |
| Administrator | Administrator | Provided expectations for kitchen food labeling and expiration. |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 9
Date: Dec 5, 2024
Visit Reason
A recertification survey was conducted from December 2, 2024 through December 5, 2024, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00252088 and GA00249391 were substantiated with federal deficiencies. Several other complaint intake numbers were substantiated without federal deficiencies or unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate Minimum Data Set assessments, failure to update PASARR for a resident with major depression, incomplete care plans, failure to identify need for hospital transfer for a resident with altered mental status, failure to sign out narcotics properly, failure to administer ordered insulin, improper food labeling and dating, improper garbage disposal, and inadequate cleaning of glucometers.
Deficiencies (9)
Failed to ensure accurate Minimum Data Set (MDS) assessments for three residents with incorrect coding of medications and therapies.
Failed to ensure updated Level I PASARR for a resident with newly diagnosed major depressive disorder.
Failed to develop comprehensive care plans for two residents, potentially leading to unmet care needs.
Failed to identify need to transfer a resident to hospital after change in condition with altered mental status.
Failed to ensure narcotics were signed out properly, risking drug diversion.
Failed to administer physician ordered insulin for one resident, with multiple missed doses and no physician notification.
Failed to ensure all food in freezer, refrigerator, and dry storage was labeled, dated, and not expired.
Failed to ensure garbage was properly disposed of for two of three dumpsters, with open doors and missing drain plug.
Failed to ensure glucometer was cleaned properly after blood glucose testing, risking cross contamination.
Report Facts
Residents present: 116
Sample residents reviewed: 36
Missed insulin doses: 10
Opened food items without date: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Observed not signing out narcotic medication prior to administration |
| LPN2 | Licensed Practical Nurse | Observed not signing out narcotic medication prior to administration |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments and care plan development | |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for MDS accuracy, care plans, and medication administration |
| Social Services Director | Social Services Director | Interviewed regarding PASARR screening requirements |
| Unit Manager 1 | Unit Manager | Interviewed regarding resident condition and communication with dialysis |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding resident R171's condition and dialysis refusal |
| Medical Director | Medical Director | Interviewed regarding awareness of resident R171's condition |
| Dietary Manager | Dietary Manager | Interviewed regarding food labeling and dumpster conditions |
| LPN4 | Licensed Practical Nurse | Observed performing blood glucose monitoring and glucometer cleaning |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding medication ordering and insulin supply |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 11, 2023
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
Plan of Correction
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Roselane Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The document does not provide specific findings or deficiencies details; it serves as a cover sheet for the Statement of Deficiencies and Plan of Correction.
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the June 2, 2023 recertification survey.
Findings
All deficiencies cited in the June 2, 2023 recertification survey were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 18, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected. The report includes details about corridor doors and compliance with fire safety regulations.
Deficiencies (1)
Corridor doors did not meet NFPA 101 requirements for smoke resistance and fire protection as evidenced by non-compliance found during a Federal Monitoring LSC survey on 7/11/2023.
Report Facts
Survey completion date: Jul 18, 2023
Federal Monitoring LSC survey date: Jul 11, 2023
Inspection Report
Life Safety
Census: 124
Capacity: 137
Deficiencies: 1
Date: Jul 11, 2023
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted following a state agency survey to assess compliance with Medicare/Medicaid participation requirements related to life safety from fire and related codes.
Findings
The facility was found not in substantial compliance with life safety code requirements due to failure to maintain latches and smoke resistance of corridor doors. Six doors had deficiencies including holes near door handles, missing latching hardware, and lack of smoke detectors in certain rooms.
Deficiencies (1)
Facility failed to maintain the latches and smoke resistance of doors protecting corridor openings, affecting six doors with holes near door handles and missing latching hardware.
Report Facts
Number of doors affected: 6
Census: 124
Total capacity: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Maintenance Director | Present when deficiencies were identified |
Inspection Report
Renewal
Deficiencies: 2
Date: Jun 2, 2023
Visit Reason
A licensure survey was conducted from 5/30/23 through 6/2/23 to assess compliance with regulatory requirements and facility licensure standards.
Findings
The facility failed to provide adequate nursing care related to pain management and comprehensive care planning for two residents. Specifically, there was a delay in assessing and treating a resident with a fractured femur, resulting in uncontrolled pain for approximately two days, and failure to develop a comprehensive care plan for dialysis care for another resident.
Deficiencies (2)
Failure to thoroughly assess a resident after a significant change in condition and ensure timely pain management, resulting in delayed x-ray and uncontrolled pain for approximately two days.
Failure to develop a comprehensive care plan for dialysis care and treatment for a resident with end stage renal disease.
Report Facts
Sampled residents: 24
Pain level: 9
Pain level: 4
Pain level: 8
Medication dose: 500
Medication dose: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Licensed Practical Nurse | Examined resident's foot after incident, reported incident to physician, and administered Tylenol |
| LPN #22 | Licensed Practical Nurse | Completed SBAR indicating resident had uncontrolled pain, failed to assess resident on 4/24/23 and 4/25/23 |
| LPN #17 | Unit Manager | Stated nurses were expected to assess injured area and pain level every shift and document findings |
| LPN #21 | Staff Development Coordinator | Stated documentation was expected to include pain level and signs of injury after incident |
| CNA #9 | Certified Nursing Assistant | Reported resident's pain to nurses and confirmed reporting incident to LPN #10 |
| Director of Nursing | Director of Nursing | Reviewed medical record and found limited assessments and documentation after incident |
| Administrator | Facility Administrator | Expected nurses to assess resident's condition and provide documentation after incident |
| Physician (MD) | Attending Physician | Ordered acetaminophen and x-ray after being notified of resident's pain and incident |
| RN #1 | Registered Nurse, MDS Nurse | Reported care plan did not include dialysis or monitoring of shunt for resident #66 |
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 5
Date: Jun 2, 2023
Visit Reason
A standard annual survey was conducted from May 30, 2023 through June 2, 2023, including investigation of three complaint intake numbers in conjunction with the survey.
Complaint Details
Complaint Intake Numbers GA00235443, GA00235351, and GA00234820 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to develop comprehensive care plans related to dialysis, failure to provide adequate pain management after a significant injury, failure to prevent urinary tract infections related to catheter care, and failure to ensure binding arbitration agreements were explained in a manner residents understood.
Deficiencies (5)
Failed to ensure Minimum Data Set (MDS) assessments were accurate for two residents.
Failed to develop comprehensive care plans related to dialysis care and treatment for one resident.
Failed to provide effective pain management and timely assessment after a resident sustained a fractured femur, resulting in uncontrolled pain for approximately two days.
Failed to ensure appropriate catheter care to prevent urinary tract infections, including keeping catheter drainage bag below bladder level and tubing free from contamination risk.
Failed to ensure binding arbitration agreement was explained in a form the resident understood.
Report Facts
Resident census: 113
Sampled residents: 24
Pain rating: 9
Pain rating: 8
Medication dose: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #9 | Certified Nursing Assistant | Reported resident's pain and incident to nurse for Resident #26 |
| LPN #10 | Licensed Practical Nurse | Assessed Resident #26's foot after incident and reported to physician |
| LPN #22 | Licensed Practical Nurse | Provided pain medication and documented assessments for Resident #26 |
| LPN #17 | Unit Manager | Provided expectations for nursing assessments after incidents |
| LPN #21 | Staff Development Coordinator | Provided training and expectations for nursing documentation and catheter care |
| Director of Nursing | Director of Nursing | Provided oversight and expectations for nursing assessments and care plans |
| Administrator | Facility Administrator | Oversaw facility operations and staff training |
| Admissions Director | Admissions Director | Responsible for explaining binding arbitration agreements to residents |
| RN #1 | Registered Nurse | MDS nurse responsible for assessments |
Inspection Report
Life Safety
Census: 113
Capacity: 137
Deficiencies: 5
Date: May 31, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain fire alarm system testing records, sprinkler system maintenance, corridor door latching, electrical safety, and emergency backup electrical system testing.
Deficiencies (5)
Fire alarm system had not undergone required smoke detector sensitivity testing every other year.
Fire sprinkler systems were yellow tagged without proper documentation.
Resident room door #209 would not latch properly to resist passage of smoke.
Multiple Outlet Power Supply (MOPS) found on floor in Kitchen manager's office, posing electrical shock hazard.
Emergency backup electrical system 36-month, 4-continuous hour load test had not been performed as required.
Report Facts
Smoke Compartments affected: 1
Census: 113
Total licensed beds: 137
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews. |
Inspection Report
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Roselane Health Center by Harborview, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Date: Mar 7, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint investigation on 1/6/2023.
Complaint Details
The revisit survey was conducted following a complaint investigation dated 1/6/2023; all cited deficiencies were corrected.
Findings
All deficiencies cited during the 1/6/2023 complaint investigation were found to be corrected during the revisit survey.
Report Facts
Census: 111
Inspection Report
Abbreviated Survey
Census: 117
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate allegations GA00231429 and GA00231711.
Findings
The investigations GA00231429 and GA00231711 were found to be unsubstantiated according to the survey results.
Report Facts
Resident Census: 117
Inspection Report
Abbreviated Survey
Census: 108
Deficiencies: 1
Date: Jan 6, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations related to resident abuse and mistreatment at Roselane Health Center by Harborview.
Complaint Details
The visit was complaint-related, investigating allegations of abuse and mistreatment involving resident #11. The family member alleged mistreatment, but the facility did not report the allegation to the State Agency. Police investigated and found no evidence of abuse. The facility staff misunderstood the allegation and failed to report it timely.
Findings
The facility failed to report an allegation of mistreatment made by a family member regarding resident #11 to the State Agency as required by policy and state law. The investigation found no evidence of mistreatment by police, but the facility did not follow reporting procedures, placing residents at risk.
Deficiencies (1)
Failure to ensure all alleged violations involving abuse or mistreatment were reported immediately to the administrator and State Agency as required by law and facility policy.
Report Facts
Resident census: 108
Resident reviewed for abuse: 1
Date of allegation note: Sep 21, 2022
Police trespass warning expiration: Jan 15, 2033
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director DD | Executive Director | Involved in deescalating situation and interview regarding allegation reporting |
| DON AA | Director of Nursing | Reviewed nurses' notes monthly and interviewed regarding failure to report allegation |
Inspection Report
Abbreviated Survey
Census: 108
Deficiencies: 2
Date: Jan 6, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from January 4 to January 6, 2023, investigating multiple complaint allegations on behalf of the Georgia Department of Community Health.
Complaint Details
The complaint investigation revealed that a family member alleged mistreatment of resident #11, but the facility failed to report this allegation to the State Agency. The allegation involved the resident's granddaughter accusing staff of mistreatment and was documented in nursing progress notes dated 9/21/2022. Police were called and issued a trespass warning to the granddaughter. The facility staff and administration misunderstood the allegation and did not report it as required, but acknowledged the policy requires reporting any accusation of mistreatment.
Findings
The facility failed to ensure residents and their responsible parties were informed of all rules and regulations governing resident conduct prior to or upon admission, and failed to report an allegation of mistreatment to the State Agency as required by policy.
Deficiencies (2)
Failed to ensure residents and their responsible party had the right to be informed of all rules and regulations governing resident conduct and responsibilities during stay, and receipt acknowledged in writing for 2 of 20 residents reviewed.
Failed to report alleged violations involving abuse or mistreatment immediately or within required timeframes to the administrator and State Agency for 1 of 20 residents reviewed.
Report Facts
Residents reviewed for notices: 20
Residents with deficient notification: 2
Residents reviewed for abuse: 20
Residents with deficient abuse reporting: 1
Census: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Director of Admission Marketing | Interviewed regarding admission packet completion and notification process |
| DD | Executive Director | Interviewed regarding admission process and abuse allegation reporting |
| AA | Director of Nursing (DON) | Interviewed regarding abuse allegation reporting and review of progress notes |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00229423, #GA00228207, #GA00227968, and #GA00225895.
Complaint Details
Complaints #GA00229423, #GA00228207, #GA00227968, and #GA00225895 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaints investigated during the abbreviated survey were unsubstantiated and no deficiencies were cited.
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