Inspection Reports for Rosemont at Stone Mountain
5160 SPRING VIEW AVENUE, GA, 30083
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Deficiencies: 0
Jun 5, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Re-Inspection
Census: 131
Deficiencies: 0
Jun 2, 2025
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the standard survey conducted on March 20, 2025.
Findings
All deficiencies cited as a result of the standard survey on March 20, 2025 were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 136
Capacity: 149
Deficiencies: 4
Apr 2, 2025
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 with life safety requirements, including blocked exits, damaged fire alarm components, improperly maintained sprinkler systems with tagged risers, and electrical panel voids. These deficiencies potentially affect residents across multiple smoke compartments.
Severity Breakdown
E: 1
D: 2
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Two exits were partially blocked in the kitchen and Activity room/dining room. | E |
| Fire alarm system was not properly maintained; a smoke detector in the Biohazard room was damaged. | D |
| Sprinkler system was not properly maintained; one dry riser and the wet riser were yellow tagged as non-compliant, one dry system was red tagged as non-operational, and the facility was placed under fire watch. | F |
| Electrical components were not properly maintained; voids were observed in the electrical panel. | D |
Report Facts
Census: 136
Total Capacity: 149
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interview |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 20, 2025
Visit Reason
An annual licensure survey was conducted at Stone Mountain Run of Journey from March 17, 2025 to March 20, 2025.
Findings
There were no deficiencies cited during the annual licensure survey.
Inspection Report
Annual Inspection
Census: 131
Deficiencies: 4
Mar 20, 2025
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health from March 17, 2025 through March 20, 2025 to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with multiple deficiencies identified including failure to assess resident self-administration of medications, failure to immediately report an allegation of potential sexual abuse, unsafe bed frame size relative to air mattress, and inaccurate pneumococcal vaccine consents.
Complaint Details
The complaint investigation involved an allegation of potential sexual abuse by Resident 103 against Resident 113. The facility delayed reporting the allegation to the Administrator and State Survey Agency, potentially delaying the investigation.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to determine if one resident was clinically appropriate to self-administer medications, leaving medications unattended at bedside without assessment. | SS= D |
| Failure to ensure facility staff reported an allegation of potential sexual abuse immediately to the Administrator. | SS= D |
| Failure to ensure one resident's bed frame was not bigger than the air mattress, creating potential injury risk. | SS= D |
| Failure to ensure accurate consents and education were provided for pneumococcal vaccines prior to administration. | SS= D |
Report Facts
Facility census: 131
Residents sampled for medication self-administration assessment: 41
Residents involved in sexual abuse allegation: 7
Inches of bed frame exposed: 12
BIMS score for Resident 33: 4
BIMS score for Resident 103: 7
BIMS score for Resident 113: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Mentioned in relation to medication self-administration assessment and abuse reporting findings | |
| Licensed Practical Nurse (LPN) 3 and Unit Manager (UM) | Mentioned regarding education on medication administration policies | |
| Administrator | Facility abuse coordinator involved in abuse allegation reporting and investigation | |
| Licensed Practical Nurse/Wound Nurse (LPN/WN) | Confirmed bed frame size issue and informed maintenance | |
| Certified Nursing Assistant (CNA) 13 | Confirmed bed frame size issue | |
| Physical Therapist (PT) | Confirmed mattress too small for bed frame during range-of-motion exercises |
Inspection Report
Follow-Up
Deficiencies: 0
Dec 19, 2023
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The Emergency Preparedness Program was reviewed and found to be in substantial compliance with regulatory requirements. All previously cited deficiencies were corrected.
Inspection Report
Deficiencies: 0
Dec 15, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Rosemont at Stone Mountain, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or details are provided in the text or image.
Inspection Report
Re-Inspection
Census: 138
Deficiencies: 0
Dec 15, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 27, 2023 Recertification Survey conducted in conjunction with a Complaint Investigation.
Findings
All deficiencies cited in the prior October 27, 2023 Recertification Survey and Complaint Investigation were found to be corrected during this revisit survey.
Complaint Details
The prior inspection was conducted in conjunction with a Complaint Investigation; deficiencies from that investigation were corrected as verified by this revisit.
Report Facts
Census: 138
Inspection Report
Life Safety
Census: 143
Capacity: 148
Deficiencies: 5
Oct 31, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety code requirements, including inoperative exit signage, improper closing devices on fire-rated doors, damaged storage and shower doors not closing properly, unsealed penetrations in rated walls, and uncovered open electrical circuits.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Exit sign in the 500 hallway was inoperative and other exit signs in the kitchen were not functioning. | SS= D |
| Fire rated doors in the laundry area lacked proper self-closing devices. | SS= D |
| Multiple storage doors in the 500 and 600 hallways and a shower door in the 700 hallway were damaged and did not close or latch properly. | SS= D |
| Multiple penetrations through the rated wall in the exterior storage room by sprinkler piping were not properly sealed. | SS= D |
| Open circuits in the electrical panel in the rear exterior electrical room were uncovered. | SS= D |
Report Facts
Census: 143
Total Capacity: 148
Residents at risk due to exit sign deficiency: 30
Residents and staff at risk due to fire door deficiency: 10
Residents at risk due to storage door deficiency: 30
Residents at risk due to wall penetration deficiency: 10
Staff at risk due to electrical panel deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M interviewed and confirmed findings during facility tour |
Inspection Report
Annual Inspection
Deficiencies: 2
Oct 27, 2023
Visit Reason
The inspection was conducted as a State Licensure survey from October 24 through October 27, 2023, to determine compliance with the State Long Term Care Requirements.
Findings
The facility failed to maintain five of 35 wheelchairs in good repair, specifically with cracked and/or peeling armrests, placing residents at risk for skin injury. The facility also failed to provide a policy, procedure, or maintenance audit log for wheelchair maintenance.
Deficiencies (2)
| Description |
|---|
| Facility failed to provide equipment in good repair for five of 35 wheelchairs with cracked and/or peeling armrests. |
| Facility failed to provide a policy, procedure, or maintenance audit log for wheelchair maintenance. |
Report Facts
Wheelchairs with cracked and/or peeling armrests: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed and confirmed cracked and/or peeling armrests on wheelchairs |
| Administrator | Administrator | Acknowledged cracked and/or peeling armrests and monthly audit for wheelchair maintenance |
Inspection Report
Routine
Census: 144
Deficiencies: 1
Oct 27, 2023
Visit Reason
A standard survey was conducted at Rosemont at Stone Mountain from October 24, 2023, through October 27, 2023, including investigation of multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to wheelchair maintenance. Five of 35 wheelchairs had cracked and/or peeling armrests, placing residents at risk for skin injury. The facility failed to provide a policy, procedure, or maintenance audit log for wheelchair maintenance.
Complaint Details
Multiple complaints were investigated; all but one complaint (GA00237097) were unsubstantiated. Complaint GA00237097 was substantiated but no regulatory violations were cited related to the complaint survey.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to provide equipment in good repair for five of 35 wheelchairs with cracked and/or peeling armrests. | D |
Report Facts
Resident census: 144
Wheelchairs with deficiencies: 5
Total wheelchairs observed: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding wheelchair conditions and maintenance audits | |
| Administrator | Interviewed acknowledging wheelchair armrest conditions and maintenance audits |
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Nov 29, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on 2022-09-16.
Findings
All deficiencies cited as a result of the 9/16/22 complaint survey were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey on 9/16/22; all cited deficiencies were corrected.
Report Facts
Census: 143
Inspection Report
Deficiencies: 0
Nov 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Renewal
Deficiencies: 1
Sep 16, 2022
Visit Reason
The inspection was a Partial/Extended Licensure Survey conducted from September 13 through September 16, 2022, to assess compliance with licensure requirements.
Findings
The facility failed to maintain an effective pest control program as live cockroaches were observed in two of ten sampled resident rooms (Rooms 307 and 508). Interviews and observations confirmed ongoing pest issues despite pest control efforts and policy implementation.
Deficiencies (1)
| Description |
|---|
| Failure to maintain an effective pest control program resulting in presence of live cockroaches in resident rooms. |
Report Facts
Sampled resident rooms with pests: 2
Pest control visits per week: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged presence of cockroaches and stated actions to address pest control. | |
| Maintenance Director | Provided information on pest control improvements and coordination with pest control company. | |
| Social Services Director | Reported resident council meeting discussions about pest control and food storage. | |
| Licensed Practical Nurse A | Licensed Practical Nurse | Confirmed ongoing roach issues and described typical locations of roaches. |
Inspection Report
Routine
Census: 138
Deficiencies: 4
Sep 16, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey in conjunction with a Partial/Extended Survey were conducted to assess compliance with emergency preparedness, infection control, and quality of care regulations.
Findings
The facility was found not in compliance with emergency preparedness policies and procedures, including failure to update emergency preparedness and communication plans annually. Additionally, a staff member was found sleeping on duty, which posed a risk to resident care. The facility also failed to maintain an effective pest control program, with live cockroaches observed in resident rooms.
Severity Breakdown
F: 2
D: 1
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure emergency preparedness policies and procedures were reviewed and updated annually. | F |
| Failure to ensure emergency preparedness communication plan was reviewed and updated annually. | F |
| Failure to provide quality of care related to a staff member sleeping while on duty. | D |
| Failure to maintain an effective pest control program; live cockroaches observed in resident rooms. | E |
Report Facts
Census: 138
Deficiency count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in finding related to sleeping on the job and subsequent termination |
| LPN C | Licensed Practical Nurse | Interviewed regarding staff sleeping incident and enforcement of policy |
| Administrator | Facility Administrator interviewed regarding emergency preparedness and staff sleeping incidents | |
| Maintenance Director | Interviewed regarding pest control program and pest control company changes | |
| Social Services Director | Interviewed regarding resident complaints about staff sleeping and pest control | |
| LPN A | Licensed Practical Nurse | Interviewed about pest control issues in the facility |
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
May 18, 2022
Visit Reason
A revisit survey was conducted on 5/17/2022 through 5/18/2022 to verify correction of deficiencies cited during the Recertification Survey of 3/9/2022.
Findings
All deficiencies cited as a result of the Recertification Survey of 3/9/2022 were found to be corrected.
Inspection Report
Routine
Deficiencies: 1
Mar 9, 2022
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically focusing on the implementation of care plans for residents.
Findings
The facility failed to implement a comprehensive care plan for one resident diagnosed with dementia, despite policy requirements and triggered care area assessments. Interviews with staff confirmed the absence of an appropriate care plan for the resident's dementia diagnosis.
Deficiencies (1)
| Description |
|---|
| Failure to implement a care plan for one resident with a diagnosis of dementia. |
Report Facts
Sample size: 51
BIMS score: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Verified absence of care plan for resident #32's dementia diagnosis | |
| Social Worker | Discussed care plan updates and acknowledged dementia care plan status for resident #32 | |
| Director of Nursing | Director of Nursing | Expected care plans and assessments to be accurate and reflect resident needs |
Inspection Report
Routine
Census: 143
Deficiencies: 7
Mar 9, 2022
Visit Reason
A standard routine survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and long term care requirements.
Findings
The survey identified multiple deficiencies including failure to maintain resident dignity by not providing privacy bags for catheter urine bags, unsanitary environmental conditions with dust and grime on air conditioning vents and filters, failure to provide written bed-hold policy notices upon resident hospital transfers, incomplete quarterly assessments, lack of comprehensive care plans for dementia, medication administration errors exceeding 5%, and failure to ensure dietary staff wore hair coverings during food preparation.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to maintain dignity by not providing privacy bags for catheter urine bags for resident R#28. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment evidenced by dust, grime, missing caulk, and spills in multiple resident rooms. | SS=D |
| Failure to provide written bed-hold policy notice to residents R#13 and R#144 upon hospital transfer. | SS=D |
| Failure to complete required quarterly Minimum Data Set (MDS) assessment for resident R#1. | SS=D |
| Failure to implement a comprehensive care plan for dementia diagnosis for resident R#32. | SS=D |
| Medication error rate of 22.86% with 8 errors in 35 opportunities for residents R#35, R#47, and R#135. | SS=E |
| Failure to ensure dietary staff member wore hair covering during tray line food preparation and handling. | SS=F |
Report Facts
Resident census: 143
Medication error rate: 22.86
Sample size: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Confirmed resident R#28 did not have privacy bag during catheter change |
| Director of Nursing | Director of Nursing (DON) | Confirmed all residents with indwelling catheter urine bags should have privacy bags; unable to provide bed-hold policy evidence |
| Business Office Manager | Business Office Manager (BOM) | Responsible for giving bed-hold policy; confirmed no written bed-hold policy given at hospital transfer |
| MDS Coordinator | Minimum Data Set Coordinator | Confirmed quarterly MDS assessment for resident R#1 was not completed |
| Social Worker | Social Worker | Responsible for cognitive care plans; confirmed no dementia care plan for resident R#32 |
| LPN DD | Licensed Practical Nurse | Observed medication administration errors including omitted eye drops and improper nasal spray technique |
| LPN EE | Licensed Practical Nurse | Observed improper G-tube medication administration technique |
| Cook AA | Cook | Observed with hair uncovered during tray line food preparation |
| Regional Dietary Director CC | Regional Dietary Director | Confirmed staff are expected to cover hair before entering kitchen |
| Dietary Manager BB | Dietary Manager | Confirmed hair covering required before kitchen entry |
| Administrator | Facility Administrator | Confirmed hair covering required and bed-hold policy not given at hospital transfer |
Inspection Report
Life Safety
Census: 143
Capacity: 149
Deficiencies: 0
Mar 7, 2022
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 substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified Beds: 149
Census: 143
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 14, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00219692, initiated on December 2, 2021, and concluded on January 14, 2022.
Findings
The complaint #GA00219692 was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00219692 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Census: 125
Deficiencies: 0
Sep 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 7/16/21 Recertification Survey and the Complaint Investigation conducted on July 13, 2020.
Findings
All deficiencies cited in the prior Recertification Survey and Complaint Investigation were found to be corrected during the revisit survey.
Complaint Details
The revisit survey confirmed correction of deficiencies cited as a result of the Complaint Investigation conducted on July 13, 2020.
Inspection Report
Re-Inspection
Census: 125
Deficiencies: 0
Sep 9, 2021
Visit Reason
A revisit survey was conducted from 09/07/2021 through 09/09/2021 to verify correction of deficiencies cited during the 07/16/2021 Recertification Survey.
Findings
All deficiencies cited as a result of the 07/16/2021 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 9, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00217523 and #GA00217263.
Findings
Complaint #GA00217523 was unsubstantiated with no regulatory violations cited. Complaint #GA00217263 was substantiated but no regulatory violations were cited.
Complaint Details
Complaint #GA00217523 was unsubstantiated. Complaint #GA00217263 was substantiated. No regulatory violations were cited for either complaint.
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Jul 16, 2021
Visit Reason
A complaint and Focused Infection Control Survey was conducted from July 13, 2021 to July 16, 2021 to investigate concerns related to dish machine temperature and infection control.
Findings
The facility failed to maintain the dish machine at the required wash cycle temperature of 120 degrees Fahrenheit, with temperatures recorded below this level for multiple days over several months. This posed a potential risk to all residents eating meals from the kitchen.
Complaint Details
The visit was complaint-related and focused on infection control. The complaint was substantiated by observations and temperature records showing the dish machine was not operating at the required temperature.
Deficiencies (1)
| Description |
|---|
| Dish machine wash cycle did not reach the required 120 degrees Fahrenheit, with temperatures recorded as low as 100 degrees Fahrenheit on multiple days. |
Report Facts
Census on first day: 131
Days with dish machine temperature below 120°F in July 2021: 10
Days with dish machine temperature 110-118°F in June 2021: 12
Days with dish machine temperature 100-110°F in May 2021: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding dish machine issues and aware of the situation | |
| Acting Director of Dining Services | Observed dish machine temperature and stated she would call Maintenance Director | |
| Divisional Manager | Acknowledged temperature problem and coordinated contractor visit | |
| Maintenance Director | Interviewed about dish machine maintenance and unaware of prior issues |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 1
Jul 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from July 13, 2021 through July 16, 2021, including investigation of multiple complaint intake numbers, to assess compliance with Medicare regulations related to infection control and long term care facility requirements.
Findings
The facility was found not in substantial compliance with Medicare regulations due to failure to maintain the dish machine at the required wash cycle temperature of 120 degrees Fahrenheit, with temperatures recorded as low as 100 degrees Fahrenheit on multiple days. This deficiency had the potential to affect all residents eating meals from the kitchen.
Complaint Details
Multiple complaint intake numbers were investigated, with all but one found unsubstantiated. One complaint (GA00213650) was substantiated with deficiency related to infection control.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain the dish machine wash cycle at the manufacturer-specified temperature of 120 degrees Fahrenheit, with observed temperatures as low as 100 degrees Fahrenheit. | SS=F |
Report Facts
Census: 131
Days with dish machine wash temperature below 120°F: 10
Days with dish machine wash temperature at 100°F: 9
Days with dish machine wash temperature 110-118°F: 12
Days with dish machine wash temperature 100-110°F: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Acting Director of Dining Services | Stated she would call Maintenance Director to look at the dish machine | |
| Administrator | Made aware of the dish machine temperature issue and interviewed regarding corrective actions | |
| Divisional Manager | Acknowledged temperature problem and stated contractors were coming to inspect | |
| Maintenance Director | Interviewed about dish machine maintenance and unaware of equipment issues |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 18, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00212149, #GA00212327, #GA00212333, and #GA00212821.
Findings
Complaints #GA00212149, #GA00212327, and #GA00212821 were unsubstantiated with no regulatory violations. Complaint #GA00212333 was substantiated without deficiency.
Complaint Details
Investigation of complaints #GA00212149, #GA00212327, #GA00212333, and #GA00212821. Complaints #GA00212149, #GA00212327, and #GA00212821 were unsubstantiated. Complaint #GA00212333 was substantiated without deficiency.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 11, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of the Complaint Investigation conducted on December 23, 2020.
Findings
All deficiencies cited during the prior Complaint Investigation were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a Complaint Investigation from December 23, 2020. All deficiencies from that investigation were corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 11, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the COVID-19 Focused Infection Control Survey and a Complaint Investigation conducted on December 18, 2020.
Findings
All deficiencies cited as a result of the COVID-19 Focused Infection Control Survey and the Complaint Investigation were found to be corrected.
Complaint Details
Deficiencies cited as a result of a Complaint Investigation conducted on December 18, 2020 were found to be corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 11, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in previous COVID-19 Focused Infection Control Survey and Complaint Investigation.
Findings
All deficiencies cited in the COVID-19 Focused Infection Control Survey on December 18, 2020, and the Complaint Investigation on December 23, 2020, were found to be corrected. Complaints investigated were unsubstantiated with no deficiencies cited.
Complaint Details
Complaints GA00210722, GA00212026, GA00211223, and GA00211746 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Census: 108
Deficiencies: 0
Jan 7, 2021
Visit Reason
A follow-up visit to the Focused Infection Control Survey conducted in October 2020 to verify correction of previously cited deficiencies.
Findings
The deficiency cited for F882 during the prior survey was corrected as of this follow-up inspection.
Report Facts
Resident Census: 108
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 2
Dec 18, 2020
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 not to be in compliance with infection control regulations, specifically failing to ensure staff wore face masks and eye protection appropriately, and failing to implement a pneumococcal vaccination policy consistent with current CDC recommendations.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff failed to wear face masks and eye protection appropriately, risking spread of infections including COVID-19 to eight sampled residents. | E |
| Facility failed to develop and implement a pneumococcal vaccination policy based on current CDC immunization schedules and failed to ensure one resident received pneumococcal vaccination within recommended schedule. | E |
Report Facts
Total census: 113
Number of sampled residents affected: 8
Number of sampled residents reviewed for pneumococcal vaccination: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Observed wearing face mask below nose and mouth and not wearing eye protection |
| CNA BB | Certified Nursing Assistant | Observed wearing face mask below nose and mouth while assisting residents |
| CNA CC | Certified Nursing Assistant | Observed not wearing face shield or safety goggles while caring for quarantined residents |
| Administrator | Interviewed regarding staff mask policies and agency CNA compliance | |
| Assistant Director of Nursing | ADON | Interviewed regarding staff mask policies and pneumococcal vaccination procedures |
| Regional Nurse Consultant | RNC | Interviewed regarding infection control practices and eye protection requirements |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 1
Dec 15, 2020
Visit Reason
An abbreviated investigation was initiated due to multiple complaint allegations and concluded on December 23, 2020, to assess pest control issues and other concerns at the facility.
Findings
The facility failed to maintain an effective pest control program as evidenced by multiple observations of live roaches in residents' rooms and hallways, particularly on the 300 hall. Interviews with residents and staff confirmed ongoing pest issues, and pest control services were disrupted due to nonpayment and COVID-19 restrictions.
Complaint Details
The investigation included multiple complaint allegations identified by GA numbers, some of which were substantiated with deficiencies related to pest control issues.
Severity Breakdown
Level D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain an effective pest control program, with roaches observed in residents' rooms and hallways on the 300 hall. | Level D |
Report Facts
Resident census: 112
Pest control bill amount: 400
Pest control service cost: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse FF | Licensed Practical Nurse | Confirmed bugs crawling on the floor in room 306 |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Reported roach problem on 300 hall and feeding pump poles attracting roaches |
| Certified Nursing Assistant EE | Certified Nursing Assistant | Confirmed crawling roach in room 308 |
| Certified Nursing Assistant DD | Certified Nursing Assistant | Observed removing crawling roach from light fixture in room 308 |
Inspection Report
Routine
Census: 130
Deficiencies: 0
Oct 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted at Rosemont At Stone Mountain from October 26 through October 29, 2020, including investigation of multiple complaint intake numbers in conjunction with the COVID-19 focused infection control survey.
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.
Complaint Details
Multiple complaint intake numbers were investigated; several were substantiated without deficiency and others were unsubstantiated.
Report Facts
Complaint intake numbers investigated: 21
Inspection Report
Abbreviated Survey
Census: 138
Deficiencies: 1
Oct 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19 preparedness and prevention.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations due to failure to ensure a qualified Infection Preventionist was on staff, which potentially contributed to the spread of COVID-19 among residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a qualified Infection Preventionist was on staff, including lack of evidence of specialized training, insufficient hours worked on-site, and inadequate oversight of the Infection Prevention and Control Program. | F |
Report Facts
Residents testing positive for COVID-19: 22
Total census: 138
Infection Preventionist work hours: 8
Infection Preventionist work hours: 16
Recommended Infection Preventionist work hours: 15
Recommended Infection Preventionist work hours: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Oversaw Infection Prevention and Control Program but lacked specialized training and could not provide credentials for Infection Preventionist | |
| Nurse Practitioner (NP) 1 | Believed Administrator oversaw Infection Prevention and Control program and requested more training to take active role | |
| Regional Nurse Consultant (RNC) | Provided expectations for Infection Preventionist role and recommended work hours | |
| RN8 | Infection Prevention and Control nurse | Responsible for tracking infections, logging data, and training staff; uncertain about completion of CDC training and hours worked |
Inspection Report
Complaint Investigation
Census: 145
Deficiencies: 0
Jul 9, 2020
Visit Reason
The visit was conducted as a COVID-19 Focused Infection Control Survey related to complaint number GA00204110 to assess the facility's infection control practices and processes.
Findings
No regulatory violations were cited during the survey. The complaint was unsubstantiated with no deficiencies found.
Complaint Details
Complaint number GA00204110 was investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Census: 145
Inspection Report
Routine
Census: 145
Deficiencies: 0
Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's 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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 6, 2019
Visit Reason
A complaint survey was conducted from 2019-06-29 through 2019-08-05 to investigate complaints #GA00195950 and GA00197802.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
The survey investigated complaints #GA00195950 and GA00197802 and found no deficiencies.
Report Facts
Complaint numbers: 2
Inspection Report
Re-Inspection
Census: 138
Deficiencies: 0
Mar 4, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 1/10/19 Standard Survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 145
Capacity: 149
Deficiencies: 0
Jan 10, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Routine
Census: 144
Deficiencies: 2
Jan 10, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities, including review of abuse reporting and resident safety.
Findings
The facility failed to report an allegation of misappropriation of resident property to the State Survey Agency for one resident. Additionally, the facility failed to provide adequate supervision to a resident with a history of non-compliance with smoking policies, resulting in unsafe smoking practices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of misappropriation of resident property to the State Survey Agency for one resident. | SS=D |
| Failure to ensure adequate supervision and assistance to prevent accidents related to smoking for one resident with a history of non-compliance. | SS=D |
Report Facts
Resident census: 144
Disputed withdrawal amount: 1160
Number of residents who smoke: 23
Number of residents non-compliant with smoking policy: 8
Designated smoking times daily: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding failure to report misappropriation allegation and investigation details | |
| Business Office Manager | Interviewed regarding resident #70's missing debit card and investigation | |
| Social Service Director | Interviewed regarding grievance process and smoking policy enforcement | |
| Certified Nurse Assistant (CNA) AA | Reported resident #70's missing money to nurse | |
| Licensed Practical Nurse (LPN) DD | Interviewed regarding resident #128's smoking non-compliance and room searches | |
| Activity Director | Responsible for smoking assessments and supervision of smoking sessions | |
| Director of Nursing (DON) | Interviewed regarding smoking policy enforcement and resident #128's non-compliance |
Inspection Report
Original Licensing
Deficiencies: 0
Jan 10, 2019
Visit Reason
Licensure survey conducted to determine compliance with State Long Term Care Requirements.
Findings
No State health deficiencies were cited during the licensure survey conducted from January 7, 2019 through January 10, 2019.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 14, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00192505 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint investigation for complaints #GA00192505; no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 23, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA 00190685 and determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA 00190685 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 9, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00189568 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00189568 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 12, 2018
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 survey tags have been corrected.
Inspection Report
Routine
Census: 138
Deficiencies: 0
Feb 23, 2018
Visit Reason
A standard survey was conducted at Rosemont at Stone Mountain from February 20, 2018 through February 23, 2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found to be in substantial compliance with the Health portion of Medicare/Medicaid regulations at 42 C.F.R. Part 483 Subpart B.
Inspection Report
Life Safety
Census: 138
Capacity: 149
Deficiencies: 3
Feb 20, 2018
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety and sprinkler system requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found not in substantial compliance due to failure to replace two dry sprinkler heads on the outside front porch, failure to maintain proper closing and latching of the outside riser and storage room doors, and failure to seal penetrations around sprinkler piping through the fire barrier inside the outside storage room. These deficiencies could place staff and residents at risk in the event of fire or smoke migration.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to replace 2 dry sprinkler heads on the outside front porch which were busted due to extreme cold temperatures. | SS= D |
| Failed to maintain proper closing and latching of the outside doors at the sprinkler riser room and the storage room; storage door needs a self-closer. | SS= D |
| Failed to seal penetrations around sprinkler piping through the fire barrier inside the outside storage room. | SS= D |
Report Facts
Census: 138
Total Capacity: 149
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 139
Deficiencies: 0
Feb 7, 2018
Visit Reason
An abbreviated survey was conducted at Rosemont at Stone Mountain on February 6th and 7th, 2018 to investigate complaint GA00184854.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Investigation of complaint GA00184854; facility found in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 16, 2018
Visit Reason
A complaint survey was conducted on 1/16/18 to investigate complaint GA 00183977 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B.
Findings
No regulatory violations were cited as a result of the complaint investigation.
Complaint Details
Complaint GA 00183977 was investigated and found to have no regulatory violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 20, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181053 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Rosemont At Stone Mountain.
Complaint Details
Complaint #GA00181053 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2017
Visit Reason
A complaint survey was conducted to investigate allegations identified as GA00180044.
Findings
The allegations were found to be unsubstantiated, and no deficiencies were identified during the investigation.
Complaint Details
The complaint allegations were unsubstantiated with no deficiencies found.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 22, 2017
Visit Reason
A follow-up to the Recertification survey of June 29, 2017 was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of August 13, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 17, 2017
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 10, 2017
Visit Reason
An abbreviated survey was conducted from 8/8/17 through 8/10/17 at Rosemont at Stone Mountain to investigate complaint GA00178174.
Findings
The complaint was not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
Complaint Details
Complaint GA00178174 was investigated and found not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 21, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00175919 at Rosemont at Stone Mountain.
Findings
No health deficiencies were cited during the abbreviated survey.
Complaint Details
Complaint GA00175919 was investigated and no health deficiencies were found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 6, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00176796 at Rosemont at Stone Mountain.
Findings
The complaint was not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
Complaint Details
Complaint GA00176796 was investigated and found not substantiated.
Inspection Report
Life Safety
Census: 138
Capacity: 149
Deficiencies: 6
Jun 27, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with several Life Safety Code requirements including emergency lighting, fire alarm system maintenance, corridor door smoke resistance, securing electrical multi-taps, conducting quarterly fire drills, and proper signage for oxygen storage. These deficiencies could place residents at risk in the event of fire or power outage.
Severity Breakdown
SS=F: 3
SS=E: 2
SS=D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain emergency lighting of means of egress and medication preparation areas; no record of 90-minute emergency lighting test within last 12 months. | SS=F |
| Failed to maintain fire alarm system testing and maintenance; smoke detector sensitivity testing documentation not available. | SS=F |
| Failed to maintain corridor doors to resist passage of smoke; multiple doors had gaps greater than 0.5 inch. | SS=E |
| Failed to properly secure electrical multi-taps off the floor throughout the facility. | SS=E |
| Failed to conduct required quarterly fire drills during the fourth quarter of 2016 for all three shifts. | SS=F |
| Failed to provide required oxygen storage location precautionary signage readable from five feet. | SS=D |
Report Facts
Residents at risk: 138
Residents at risk: 14
Residents at risk: 8
Certified beds: 149
Census: 138
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Staff interviewed and confirmed multiple findings including emergency lighting, fire alarm system, corridor doors, electrical multi-taps, fire drills, and oxygen storage signage. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 20, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA0000176336 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Rosemont at Stone Mountain.
Complaint Details
Complaint #GA0000176336 was investigated and found to have no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 19, 2017
Visit Reason
The inspection was conducted to investigate a complaint #GA00173961 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00173961 was investigated and found to have no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 25, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate Complaint #GA00173007.
Findings
The complaint was not substantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #GA00173007 was investigated and found to be not substantiated.
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