Inspection Reports for Ross Memorial Health Care Ctr
1780 OLD HIGHWAY 41, KENNESAW, GA, 30152
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 8, 2024, found that all previously cited deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to maintenance issues affecting the safety and comfort of the environment, life safety code compliance including fire protection system maintenance, and infection control practices. Complaint investigations during this period were consistently unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record indicates improvement over time, with recent surveys confirming correction of prior deficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
95 residents
Based on a April 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2024
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 have been corrected.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Date: Apr 4, 2024
Visit Reason
A revisit survey was conducted on 4/4/2024 to verify correction of deficiencies cited during the 2/22/2024 recertification survey with complaints.
Findings
All deficiencies cited in the prior recertification survey with complaints were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 89
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
A standard survey was conducted from February 19, 2024, through February 22, 2024, including investigation of multiple complaint intake numbers which were found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00234214, GA00238150, GA00238626, GA00238791, and GA00242797 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to maintain a safe, clean, comfortable, homelike environment, with multiple needed repairs in resident rooms, hallways, therapy room, dining room, and beauty salon chair.
Deficiencies (1)
Facility failed to maintain a safe, clean, comfortable, homelike environment by not making needed repairs in multiple hallways and resident rooms, including gouged drywall, cracked bathroom vanity, damaged wheelchair parts, missing chair leg in beauty salon held up by bricks, cracked and loose tiles in dining room, and damaged nurses station doors.
Report Facts
Resident census: 89
Complaint intake numbers investigated: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed regarding facility repairs and maintenance issues |
| Beautician | Beautician | Interviewed regarding the beauty salon shampoo chair condition |
| Maintenance Worker | Maintenance Worker | Mentioned in relation to placing bricks under the beauty salon chair |
Inspection Report
Life Safety
Census: 88
Capacity: 100
Deficiencies: 3
Date: Feb 20, 2024
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 life safety requirements, including missing service tags on kitchen fire extinguishers, outdated hood suppression system servicing, lack of daily documentation for means of egress during renovations, and improper labeling of oxygen cylinders in storage.
Deficiencies (3)
K-class extinguisher missing required service tag with dates; hood suppression system last serviced in May 2023 but due in November.
Failed to create and document daily means of egress status during renovation in resident corridor #200.
Failed to assure labeling/signage of full and empty oxygen bottles in oxygen closet.
Report Facts
Census: 88
Total Capacity: 100
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Sep 22, 2022
Visit Reason
A revisit survey was conducted on 9/22/22 in conjunction with the investigation of Complaint Intake Number GA00227661.
Complaint Details
Complaint Intake Number GA00227661 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the recertification survey on 7/2/22 were found to be corrected. The complaint investigation was found to be unsubstantiated.
Inspection Report
Deficiencies: 0
Date: Sep 20, 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 findings or deficiencies.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Date: Sep 20, 2022
Visit Reason
A revisit survey was conducted on 9/22/22 to verify correction of deficiencies cited during the 7/2/22 recertification survey.
Findings
All deficiencies cited as a result of the 7/2/22 recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
A follow-up survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Life Safety
Census: 84
Capacity: 100
Deficiencies: 2
Date: Jul 7, 2022
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with emergency preparedness and fire safety requirements. Deficiencies included lack of a comprehensive emergency preparedness plan with required documentation and training, and failure to maintain sprinkler systems, specifically corroded sprinkler heads in one smoke compartment.
Deficiencies (2)
Emergency Preparedness Program was not in substantial compliance; lacked organized plan, documentation of establishment date, yearly approvals, updates, exercises, staff training, evacuation details, and agreements with other facilities.
Sprinkler system maintenance and testing deficiencies; corroded sprinkler heads in the porte cochere area with a yellow tag indicating non-compliance.
Report Facts
Census: 84
Total Capacity: 100
Smoke Compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A and Staff M confirmed emergency preparedness findings | ||
| Staff M confirmed sprinkler system findings |
Inspection Report
Renewal
Census: 82
Deficiencies: 5
Date: Jul 2, 2022
Visit Reason
A Licensure Survey was conducted from June 28, 2022 through July 2, 2022 to assess compliance with licensure requirements and facility regulations.
Findings
The facility was found deficient in multiple areas including failure to provide Skilled Nursing Facility Advance Beneficiary Notices, ineffective infection control and COVID-19 prevention measures, failure to assess residents' ability to self-administer medications, failure to conduct neurological assessments after unwitnessed falls, and failure to maintain hot water at safe temperatures in resident rooms.
Deficiencies (5)
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two residents.
Failure to have an effective infection control program and implement COVID-19 prevention measures including visitor screening, proper PPE use, and social distancing.
Failure to ensure assessments were completed to determine residents' ability to self-administer medications safely and accurately for two residents.
Failure to assess residents for neurological changes after unwitnessed falls for two residents.
Failure to monitor and maintain hot water at a safe temperature for six resident rooms.
Report Facts
Facility census: 82
Staff count: 98
Residents in day room: 8
Residents in dining room: 24
Residents in day room: 9
Unvaccinated residents in activities: 3
Unvaccinated residents in activities: 3
Unvaccinated residents in activities: 3
Unvaccinated residents in activities: 2
Unvaccinated residents in activities: 2
Hot water temperature: 121.2
Hot water temperature: 130.2
Hot water temperature: 120.9
Hot water temperature: 138.1
Hot water temperature: 124.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HHH | MDS Nurse and Medicare Manager | Responsible for presenting SNF ABN to residents; noted Business Office Manager had passed away |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding SNF ABN process, infection control, COVID-19 measures, medication self-administration, and neurological assessments |
| Administrator | Administrator | Interviewed regarding SNF ABN, infection control, medication self-administration, neurological assessments, and hot water temperature issues |
| LPN KK | Licensed Practical Nurse | Observed not wearing eye protection during COVID-19 outbreak; interviewed about PPE use |
| CNA MM | Certified Nurse Aide | Observed not wearing eye protection; interviewed about PPE use |
| RN TT | Registered Nurse | Interviewed about visitor screening, PPE use, outbreak status, neurological assessments |
| Medical Director JJJ | Medical Director | Interviewed about lack of assessment for medication self-administration |
| Maintenance CC | Maintenance Staff | Responsible for checking and adjusting hot water temperatures |
| Maintenance Director BB | Maintenance Director | Interviewed about hot water temperature issues and monitoring |
Inspection Report
Routine
Census: 82
Deficiencies: 11
Date: Jul 2, 2022
Visit Reason
A standard survey was conducted from June 28, 2022 through July 2, 2022, including complaint investigations for multiple complaint intake numbers.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies in resident self-administration of medications, Medicaid/Medicare coverage notifications, abuse reporting and investigation, PASARR screening, quality of care related to falls, hot water temperature safety, infection prevention and control including COVID-19 protocols, infection preventionist qualifications, COVID-19 reporting, testing, and vaccination policies and documentation.
Deficiencies (11)
Failed to ensure assessments were completed to determine residents' ability to self-administer medications safely and accurately for two residents.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for two residents.
Failed to ensure allegations of abuse were reported to the facility Administrator and State Survey Agency and failed to thoroughly investigate abuse allegations.
Failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for two residents.
Failed to assess residents for neurological changes after unwitnessed falls for two residents.
Failed to monitor and maintain hot water at a safe temperature for six resident rooms.
Failed to establish and maintain an effective infection prevention and control program, including proper COVID-19 screening, PPE use, social distancing, and outbreak management.
Failed to designate at least one qualified infection preventionist responsible for the facility's infection prevention and control program.
Failed to timely inform residents, representatives, and families of confirmed COVID-19 cases and mitigating actions.
Failed to perform routine and outbreak COVID-19 testing for all staff and residents per CMS guidelines.
Failed to develop and implement policies and procedures to ensure all residents and staff were offered COVID-19 vaccination with education and documentation of vaccination status.
Report Facts
Resident census: 82
Staff count: 98
Hot water temperature: 138.1
Hot water temperature: 130.2
Hot water temperature: 124.1
Staff vaccination rate: 98.5
Staff total: 132
Residents with unknown vaccination status: 7
Unvaccinated staff: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BBB | Licensed Practical Nurse | Named in abuse allegation and investigation |
| DON | Director of Nursing | Named in multiple interviews related to deficiencies |
| Administrator | Named in multiple interviews related to deficiencies | |
| LPN KK | Licensed Practical Nurse | Named in relation to COVID-19 vaccination and PPE use |
| CNA WW | Certified Nurse Aide | Named in relation to COVID-19 vaccination status |
| CNA XX | Certified Nurse Aide (agency) | Named in relation to COVID-19 vaccination status |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Date: Mar 18, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00212249 and #GA00212790.
Complaint Details
Complaints #GA00212249 and #GA00212790 were investigated and found to be unsubstantiated.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 67
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
An Abbreviated/Partial Extended survey was conducted from 12/1/2020 through 12/3/2020 to investigate multiple complaint intake numbers.
Complaint Details
Complaints GA00209586, GA00207963, GA00206579, GA00205511, GA00205366, GA00205348, GA00205087 and GA00203241 were unsubstantiated.
Findings
All complaints investigated during the survey were unsubstantiated and no regulatory violations were cited.
Report Facts
Complaint intake numbers investigated: 8
Inspection Report
Routine
Census: 73
Deficiencies: 0
Date: Nov 11, 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 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.
Report Facts
Total census: 73
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: Sep 29, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the Infection Control Focused Survey conducted on 2020-07-21.
Findings
All deficiencies cited in the previous Infection Control Focused Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 4
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection prevention and control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control regulations due to failure to screen state surveyors for COVID-19 symptoms, improper use of personal protective equipment (PPE) by environmental service staff, failure to perform hand hygiene, and inadequate cleaning of high-touch surfaces.
Deficiencies (4)
Failure to screen state surveyor for COVID-19 respiratory symptoms upon entry into the facility.
Environmental service staff not properly donning PPE, including wearing a surgical mask below the nose and cleaning resident rooms without gloves.
Environmental service staff moving between resident rooms without performing hand hygiene.
Environmental service staff not cleaning high-touch surfaces with disinfectant.
Report Facts
Resident census: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EVS AA | Environmental Service Staff | Observed not properly donning PPE, not performing hand hygiene, and not cleaning high-touch surfaces |
| EVS Director | Environmental Services Director | Provided expectations for cleaning and PPE use, confirmed EVS AA attended in-services |
| Administrator | Interviewed regarding discontinuation of COVID-19 screening questions | |
| Director of Nursing | Infection Control Preventionist | Interviewed regarding discontinuation of COVID-19 screening questions |
| Registered Nurse Supervisor | Conducted temperature check of surveyor but did not ask COVID-19 screening questions |
Inspection Report
Routine
Census: 83
Deficiencies: 0
Date: Apr 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on April 10, 2020.
Findings
The facility was found 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
Re-Inspection
Deficiencies: 0
Date: Aug 6, 2019
Visit Reason
A revisit survey was conducted on 8/5/19 through 8/6/19 to verify correction of deficiencies from the 5/31/19 Recertification Survey and to investigate complaints GA00197930 and GA00197233.
Complaint Details
Complaint Intake Numbers GA00197930 and GA00197233 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited in the 5/31/19 Recertification Survey were found to be corrected. The complaint investigations for GA00197930 and GA00197233 were unsubstantiated and no deficiencies were cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 6, 2019
Visit Reason
A revisit survey was conducted on 8/5/19 through 8/6/19 in conjunction with complaint investigations of Intake Numbers GA00197930 and GA00197233.
Complaint Details
Complaint Intake Numbers GA00197930 and GA00197233 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited as a result of the 5/31/19 Recertification Survey were found to be corrected. The complaint investigations were unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 16, 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 this follow-up visit.
Inspection Report
Life Safety
Census: 78
Capacity: 100
Deficiencies: 2
Date: May 29, 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 conduct required fire smoke detector sensitivity testing and failure to maintain fire protection systems, including loaded sprinkler heads that could delay activation, placing residents and staff at risk.
Deficiencies (2)
Failure to conduct required fire smoke detector sensitivity testing within the last 2 years.
Failure to maintain fire protection systems in optimum condition, including loaded sprinkler heads in corridor/hallway and Activities room.
Report Facts
Census: 78
Total Capacity: 100
Staff and Residents at risk: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire smoke detector testing and sprinkler system deficiencies during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2018
Visit Reason
A complaint survey was conducted on 2018-11-01 to investigate complaints #GA00192389 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaint #GA00192389; no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 1, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00192347 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation related to complaint #GA00192347; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 76
Deficiencies: 0
Date: May 31, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 12, 2018 Annual Survey.
Findings
All deficiencies cited as a result of the April 12, 2018 Annual Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 29, 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 deficiencies had been corrected at the time of the follow-up survey.
Inspection Report
Life Safety
Census: 73
Capacity: 100
Deficiencies: 3
Date: Apr 11, 2018
Visit Reason
A Life Safety Code Survey was 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 emergency lighting documentation, sprinkler system maintenance, and electrical safety requirements. Specific deficiencies included failure to document emergency light testing, sprinkler heads obstructed in two locations, and a voided circuit space in an electrical panel posing shock risk.
Deficiencies (3)
Failure to keep proper records of operational safety checks for emergency egress lighting.
Sprinkler heads found loaded in two separate locations, compromising fire protection readiness.
Voided circuit space in electrical panel could cause electrical shock to staff.
Report Facts
Staff and residents at risk: 30
Staff at risk: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews related to emergency lighting, sprinkler system, and electrical panel deficiencies. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 2, 2017
Visit Reason
A follow-up to the Recertification survey of August 3, 2017 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected, and the facility was found to be in substantial compliance as of September 15, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 25, 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
Life Safety
Census: 87
Capacity: 100
Deficiencies: 3
Date: Jul 31, 2017
Visit Reason
The Life Safety Code Survey was 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 fire safety requirements, including failure to properly maintain fire protection equipment such as sprinkler systems and electrical utilities, which could place residents and staff at risk.
Deficiencies (3)
Sprinkler system maintenance and testing not properly conducted; a loaded sprinkler head in the laundry could impair the sprinkler system.
Failure to assure all fire protection equipment was properly maintained, risking 16 residents and staff in the event of fire.
Utilities - Gas and Electric: Failure to assure against shock or electrical hazard; a multiple-outlet power strip was found on the floor in the dietary manager's office.
Report Facts
Residents at risk: 16
Staff at risk: 16
Staff at risk: 10
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