Inspection Report Summary
The most recent inspection on January 24, 2025 found no deficiencies and substantiated no complaints. Prior inspections showed a pattern of deficiencies primarily related to fire safety code compliance and medication and food safety practices, with issues such as unsecured hazardous materials, incomplete medication audits, and fire alarm and sprinkler system maintenance. Earlier complaint investigations were mostly unsubstantiated, though a substantiated abuse allegation in early 2023 resulted in a cited deficiency for failure to protect a resident and timely report the incident. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated improvement over time, correcting prior deficiencies noted in medication management and fire safety during subsequent revisit surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
120 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 2
Dec 11, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements, including care plan development and infection prevention and control practices.
Findings
The facility was found deficient in updating resident care plans timely after significant events, specifically for a resident with communication impairments, and failed to ensure proper infection prevention practices by not labeling or bagging urinals in shared bathrooms, posing potential infection risks.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to update resident care plans when significant events occurred, specifically for resident R84 with communication impairments. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure urinals in shared bathrooms were bagged and labeled, risking transmission of infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 27
Resident care plan date: Nov 13, 2025
Resident BIMS score: 6
Resident bathrooms observed: 19
Urinals unlabeled/unbagged: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GG | Certified Nursing Assistant (CNA) | Mentioned in relation to communication attempts with resident R84 |
| FF | Licensed Practical Nurse (LPN) | Mentioned in relation to communication methods with resident R84 |
| EE | Unit Manager (UM) | Discussed communication interventions and care plan updates for resident R84 |
| Social Services Director | Discussed communication assessments and TTY device for resident R84 | |
| MDS Director | Responsible for updating care plan for resident R84 | |
| Administrator | Provided statements regarding care plan updates and infection control expectations | |
| Director of Education and Infection Prevention | Discussed infection prevention policies and responsibilities for labeling and bagging urinals | |
| Maintenance Director | Confirmed unlabeled and unbagged urinals in shared bathrooms | |
| Maintenance Supervisor | Confirmed unlabeled and unbagged urinals in shared bathrooms |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 10, 2025
Visit Reason
The inspection was conducted to investigate allegations of potential abuse involving one resident (R6) at the facility.
Findings
The facility failed to ensure allegations of potential abuse were thoroughly investigated for resident R6. The investigation revealed incomplete documentation of interviews and delayed recognition of the resident's fracture, with some interviews conducted verbally and not documented.
Complaint Details
The complaint investigation involved allegations of abuse for resident R6. The investigation was completed by a team including the Director of Nursing, Administrator, and Social Services Director. The Administrator confirmed all reportable instances were reported to the state within required timeframes. Some interviews were verbal and not documented.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure allegations of potential abuse were thoroughly investigated for one resident (R6). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Assessment Reference Date: Jan 21, 2024
BIMS score: 6
Incident report number: 202501357
Date of incident report follow-up: Feb 6, 2025
Date of survey completion: Jul 10, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Completed investigation regarding resident R6's leg pain and fracture; conducted interviews with staff |
| Administrator | Administrator and Abuse and Neglect Coordinator | Reported all allegations to the state and participated in the investigation team |
| Social Services Director | Social Services Director | Part of the investigation team and responsible for typing the investigation summary |
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 0
Jan 24, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00253487 and GA00252479.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00253487 and GA00252479 were investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 30, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for A.G. Rhodes Home, Inc - Cobb, summarizing deficiencies identified during the inspection completed on 08/30/2024.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Aug 30, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the July 25, 2024 recertification survey.
Findings
All deficiencies cited in the previous recertification survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 116
Capacity: 130
Deficiencies: 5
Aug 26, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety and related National Fire Protection Association standards at A.G. Rhodes Home Cobb.
Findings
The facility was found not in substantial compliance with fire safety requirements, including missing fire alarm electrical breaker lock-out device and identification label, missing smoke detector near smoke doors, fire alarm system in trouble mode, sprinkler piping with non-system items attached, smoke doors failing to close properly, and unsafe electrical equipment usage.
Severity Breakdown
F: 2
D: 2
E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide fire alarm electrical breaker lock-out device, fire alarm system electrical breaker identification label, and missing smoke detector on the third floor north hall within 5 feet of smoke doors and smoke wall. | F |
| Failed to ensure the fire alarm was not in trouble mode; second-floor fire alarm annunciator panel showed 'communication fault'. | F |
| Failed to maintain automatic sprinkler piping free of external non-system items; low voltage wire zip tied to sprinkler piping in third-floor biohazard room. | D |
| Failed to ensure required smoke doors close properly in third-floor east hall, second-floor east hall, and second-floor south hall. | E |
| Failed to properly use power strip at third-floor nursing station, missing electrical outlet cover and junction box cover in first-floor service hall mechanical room, and missing globe on light fixture in third-floor biohazard room. | D |
Report Facts
Census: 116
Total Capacity: 130
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 0
Aug 1, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00249049.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00249049 was investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Facility census: 105
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 4
Jul 30, 2024
Visit Reason
A State Licensure survey was conducted at A.G. Rhodes Home, Inc-Cobb from July 30, 2024 through August 1, 2024 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including incomplete controlled drug shift audit records with missing signatures on medication carts, unsecured hazardous materials in the janitorial room and resident's room, and failure to properly label, date, and discard expired food items in the kitchen. Additionally, kitchen staff were observed not wearing required hairnets and beard guards during food preparation.
Deficiencies (4)
| Description |
|---|
| Missing signatures on controlled drug shift audit sheets for eight of twelve medication carts, risking residents not receiving prescribed medications. |
| Janitorial room on the third floor was unlocked and taped open, with hazardous cleaning chemicals accessible to residents with severe cognitive impairment. |
| Dakin wound care solution was left unsecured on a resident's nightstand, posing a chemical hazard. |
| Failure to discard expired frozen/refrigerated food items, failure to label and date items in refrigerators, and failure to maintain sanitary conditions including kitchen staff not wearing hairnets and beard guards. |
Report Facts
Missing signatures: 108
Facility census: 105
Residents affected by kitchen deficiencies: 99
Expired food items: 19
Expired pie crust: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Verified missing signatures on narcotic count sheets and explained CMA limitations. |
| Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and suggested staffing issues. | |
| Environmental Services Director | Reported lack of key for janitorial room and confirmed hazard for dementia residents. | |
| LPN CC | Licensed Practical Nurse | Confirmed Dakin solution was left in resident's room and should not be stored bedside. |
| Cook DD | Cook | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage. |
| Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food. | |
| District Manager | Confirmed cleaning and inventory schedule and Kitchen Director's responsibilities. |
Inspection Report
Routine
Census: 105
Deficiencies: 4
Jul 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to accident hazards, respiratory care, pharmaceutical services, and food safety in the nursing home.
Findings
The facility was found to have multiple deficiencies including unsecured hazardous materials accessible to residents with cognitive impairment, improper care of oxygen concentrator filters, incomplete controlled drug shift audit records with missing signatures, and failure to properly label, date, and discard expired food items while also not maintaining proper sanitary conditions in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to keep potentially hazardous materials in a secured area; janitorial room unlocked and treatment solution left in resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly care for oxygen concentrator filters; filters were covered with a white-gray fuzzy substance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly keep a complete record of the controlled drug shift audit; missing signatures on audit sheets for eight of twelve medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to discard frozen/refrigerated food items by expiration date, failed to label and date items in refrigerators, and failed to maintain sanitary conditions by kitchen staff not wearing hairnets and beard guards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 105
Missing signatures: 98
Number of medication carts with missing signatures: 8
Number of residents affected by food safety deficiency: 99
Number of residents using oxygen: 8
Number of rooms on third floor: 24
Residents with severe cognitive impairment on third floor: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored at bedside |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter condition and cleaning schedule |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets and explained CMA limitations |
| Director of Nursing (DON) | Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and commented on possible staffing issues |
| DD | Kitchen staff | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food |
| DM | District Manager | Confirmed cleaning and inventory schedule and responsibilities |
| Environmental Services Director | Environmental Services Director | Confirmed janitorial room key situation and accident hazard potential |
Inspection Report
Routine
Census: 105
Deficiencies: 4
Jul 23, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to accident hazards, respiratory care, pharmaceutical services, and food safety in the nursing home.
Findings
The facility was found to have multiple deficiencies including unsecured hazardous materials accessible to residents with cognitive impairment, improper care of oxygen concentrator filters, incomplete controlled drug shift audit records with missing signatures, and failure to properly discard expired food, label and date food items, and maintain sanitary conditions in the kitchen.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to keep potentially hazardous materials in a secured area; janitorial room unlocked and hazardous treatment solution left in resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly care for oxygen concentrator; filters were not cleaned timely and covered with a white-gray fuzzy substance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly keep a complete record of the controlled drug shift audit; missing signatures on audit sheets for eight of twelve medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to discard frozen/refrigerated food items by expiration date, failed to label and date items in refrigerators, and failed to maintain proper sanitary conditions including kitchen staff not wearing hairnets and beard guards. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 105
Missing signatures: 15
Missing signatures: 11
Missing signatures: 29
Missing signatures: 17
Missing signatures: 6
Missing signatures: 19
Missing signatures: 1
Rooms on third floor: 24
Residents on third floor: 23
Oxygen liters per minute: 2
Expired food items: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored at bedside |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter was covered with white-gray fuzzy substance and described cleaning schedule |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets and explained CMA limitations |
| Director of Nursing (DON) | Director of Nursing | Verified missing signatures on Controlled Drug Shift Audit sheets and commented on possible staffing issues |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates, discarded expired food, and confirmed cleaning schedule |
| DM | District Manager | Confirmed cleaning and inventory schedule and responsibility for labeling, storing, and discarding food |
| DD | Kitchen staff | Observed preparing food without hairnet and beard restraint; confirmed in-service training on labeling and storage |
| Environmental Services Director | Confirmed janitorial room key situation and accident hazard potential |
Inspection Report
Routine
Census: 105
Deficiencies: 4
Jul 23, 2024
Visit Reason
A standard survey was conducted from July 23 through July 25, 2024, including investigation of two complaint intake numbers which were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsecured hazardous materials, improper care of oxygen concentrators, incomplete controlled drug shift audit records, and unsanitary food storage and preparation practices.
Complaint Details
Complaint Intake Numbers GA00244050 and GA00248854 were investigated in conjunction with the standard survey and were both unsubstantiated.
Severity Breakdown
E: 2
D: 1
F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to keep potentially hazardous materials in a secured area; janitorial room unlocked and hazardous treatment solution left in resident's room. | E |
| Failed to properly care for oxygen concentrator; filters were not cleaned timely and were covered with a white-gray fuzzy substance. | D |
| Failed to properly keep a complete record of the controlled drug shift audit; missing signatures on audit sheets for eight of twelve medication carts. | E |
| Failed to discard frozen/refrigerated food items by expiration date, failed to label and date items in refrigerators, and failed to maintain sanitary conditions by ensuring kitchen staff wore hairnets and beard guards. | F |
Report Facts
Residents present: 105
Missing signatures: 15
Missing signatures: 11
Missing signatures: 29
Missing signatures: 17
Missing signatures: 6
Missing signatures: 19
Missing signatures: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Confirmed Dakin solution was left in resident's room and should not be stored bedside. |
| BB | Licensed Practical Nurse (LPN)/Unit Manager | Verified oxygen concentrator filter was covered with white-gray fuzzy substance. |
| AA | Licensed Practical Nurse (LPN) | Verified missing signatures on narcotic count sheets. |
| Director of Nursing | Director of Nursing (DON) | Verified missing signatures on Controlled Drug Shift Audit sheets and noted possible staffing issues. |
| DD | Cook | Observed preparing food without hairnet and beard restraint; confirmed in-service on labeling and storage but admitted lapses. |
| KD | Kitchen Director | Confirmed responsibility for checking expiration dates and discarding expired food items. |
| DM | District Manager | Confirmed cleaning and inventory conducted twice weekly and responsibility of Kitchen Director. |
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Nov 14, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00238243 and #GA00235219.
Findings
The complaints were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00238243 and #GA00235219 were investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 113
Inspection Report
Routine
Census: 114
Deficiencies: 0
Aug 30, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal regulations related to emergency 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, including implementation of CMS and CDC recommended practices for COVID-19.
Report Facts
Census: 114
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 30, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 27, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00235451 at A.G. Rhodes Home - Cobb.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint #GA00235451 was investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 28, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for A.G. Rhodes Home, Inc - Cobb, related to regulatory compliance following an inspection.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 28, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for A.G. Rhodes Home, Inc - Cobb, related to regulatory compliance.
Findings
No specific deficiencies or findings are detailed in the document; the form appears to be a blank or template Statement of Deficiencies and Plan of Correction.
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 9, 2023
Visit Reason
A complaint survey was conducted at A.G. Rhodes-Cobb from March 8, 2023 through March 9, 2023 to investigate an allegation of physical abuse by a staff member against a resident.
Findings
The facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to report the alleged abuse to the State Agency within the required two-hour timeframe. The investigation included interviews, review of incident reports, and confirmation that the alleged perpetrator was placed on a do not return list pending investigation.
Complaint Details
The complaint involved Resident #1 who alleged that on 1/16/2023, a Certified Nursing Assistant (CNA#1) grabbed her by the neck and threw her from side to side on the bed. The allegation was substantiated by interviews and incident reports. The alleged perpetrator was an agency CNA placed on a do not return list. The facility failed to report the allegation to the State Agency within the required two-hour timeframe.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to report an alleged allegation of abuse to the State Agency within the two-hour required timeframe. | SS= D |
Report Facts
Brief Interview for Mental Status (BIMS) score: 12
Date of alleged abuse incident: Jan 16, 2023
Date of incident report: Jan 16, 2023
Date of police incident report: Jan 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Reported the abuse allegation to the Director of Social Work after delay due to busy holiday shift. |
| LPN #4 | Unit Manager | Received abuse allegation report from LPN #2 and reported to the Director of Nursing. |
| Director of Nursing | DON | Interviewed resident and family, reported abuse to State Agency and police, and expected immediate reporting of abuse allegations. |
| Administrator | Facility Administrator | Emphasized importance of resident care and timely reporting of incidents. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged staff-to-resident physical abuse incident involving resident R#1.
Findings
The facility failed to protect resident R#1 from physical abuse by a staff member and failed to report the alleged abuse to the State Agency within the required two-hour timeframe. The alleged abuse involved a contract agency CNA who was reported to have roughly handled R#1 by the neck and thrown her on the bed. The facility updated R#1's care plan and placed the alleged perpetrator on a do not return list pending investigation.
Complaint Details
The complaint involved an allegation by resident R#1 that a Certified Nursing Assistant (CNA#1) from a contract agency physically abused her by grabbing her by the neck and throwing her on the bed. The allegation was reported late to the State Agency, violating the two-hour reporting requirement. The police were notified, and no visible injuries were found. The alleged perpetrator was placed on a do not return list. Interviews with staff and R#1 confirmed the incident and delays in reporting due to holiday and busy day circumstances.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse to proper authorities within the required two-hour timeframe. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of alleged abuse incident: Jan 16, 2023
Date of Facility Incident Report: Jan 16, 2023
Date of police Incident/Investigation Report: Jan 16, 2023
Date of survey completion: Mar 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA#1 | Certified Nursing Assistant | Alleged perpetrator of physical abuse against resident R#1 |
| LPN#2 | Licensed Practical Nurse | Received abuse report from R#1 and attempted to report to Director of Social Work |
| LPN#4 | Unit Manager | Reported the abuse allegation to the Director of Nursing |
| DON | Director of Nursing | Interviewed resident R#1, reported abuse to State Agency and police, and oversaw investigation |
| Administrator | Facility Administrator | Oversaw facility compliance and reporting expectations |
| Director of Social Work | Abuse Coordinator | Responsible for abuse reporting and training department heads on reporting requirements |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Mar 9, 2023
Visit Reason
A complaint survey was conducted at A.G. Rhodes Home from March 8, 2023 through March 9, 2023, investigating Complaint Intake Number GA00232098 which was substantiated with deficiency cited.
Findings
The facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to report an alleged abuse allegation to the State Agency within the required two-hour timeframe for one of three sampled residents. The alleged abuse involved a Certified Nursing Assistant (CNA#1) physically mishandling Resident #1, and the facility did not report the incident timely as required by policy and regulations.
Complaint Details
Complaint Intake Number GA00232098 was substantiated. The allegation involved physical abuse by an agency CNA against Resident #1 on 1/16/2023. The facility failed to report the allegation to the State Agency within two hours as required. Resident #1 was moderately cognitively impaired and required extensive assistance. The alleged perpetrator was placed on a 'do not return' list pending investigation. Interviews with staff and the resident confirmed the abuse allegation. The police were notified due to the severity of the allegation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a resident from physical abuse by a staff member and failure to report the alleged abuse to the State Agency within the two-hour required timeframe. | SS= D |
Report Facts
Resident census: 108
Complaint Intake Number: GA00232098 substantiated complaint investigated
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA#1) | Alleged perpetrator of physical abuse against Resident #1; agency CNA placed on 'do not return' list | |
| Licensed Practical Nurse (LPN#2) | Received abuse allegation report from Resident #1 and attempted to report to Director of Social Work | |
| Unit Manager (LPN#4) | Informed about abuse allegation and reported to Director of Nursing | |
| Director of Nursing (DON) | Interviewed Resident #1, family, and staff; reported abuse to State Agency and police | |
| Abuse Coordinator (Director of Social Work) | Responsible for reporting abuse allegations to State Agency within required timeframe | |
| Administrator | Oversight of facility compliance and reporting expectations |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 3, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for A.G. Rhodes Home, Inc - Cobb, indicating regulatory oversight and corrective actions following an inspection.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 88
Deficiencies: 0
Aug 3, 2022
Visit Reason
A revisit survey was conducted from 8/2/22 through 8/3/22 to verify correction of deficiencies cited in the 5/25/22 standard survey.
Findings
All deficiencies cited as a result of the 5/25/22 standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 11, 2022
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 as noted by the surveyor.
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 8
Jun 8, 2022
Visit Reason
An abbreviated survey was conducted to verify the removal of an Immediate Jeopardy (IJ) related to COVID-19 outbreak and infection control deficiencies identified during a prior standard survey.
Findings
The facility failed to implement timely outbreak testing and contact tracing for COVID-19, failed to notify residents and families of confirmed infections, and staff were observed not following infection control protocols including screening and PPE use. The facility also had deficiencies related to sexual abuse investigations, accuracy of assessments, quality of care, fall prevention, and COVID-19 reporting and testing.
Severity Breakdown
G: 2
D: 3
J: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse by another resident, including failure to implement safeguards and properly investigate allegations. | G |
| Failure to report an incident of sexual abuse to the state agency. | G |
| Failure to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's use of splints or braces. | D |
| Failure to provide care and services in accordance with physician orders for compression stockings and elevation of lower extremities to reduce swelling. | D |
| Failure to ensure fall prevention interventions were added to the care plan and consistently implemented after resident falls. | D |
| Failure to establish and maintain an effective infection prevention and control program to prevent the spread of COVID-19, including failure to implement outbreak testing and contact tracing timely. | J |
| Failure to timely notify residents, representatives, and families of confirmed COVID-19 infections in the facility. | J |
| Failure to conduct routine and outbreak COVID-19 testing for all staff and residents in accordance with CDC and CMS requirements. | J |
Report Facts
Facility census: 92
Staff education completion: 149
Staff education completion percentage: 93.7
Staff tested: 170
Residents tested: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R#270 | Resident | Resident involved in sexual abuse incidents |
| R#23 | Resident | Resident victim of sexual abuse by R#270 |
| R#58 | Resident | Resident exposed to sexual abuse by R#270 |
| Police Detective WWW | Investigated sexual abuse allegations involving R#270 | |
| Administrator | Facility Administrator involved in sexual abuse investigation and COVID-19 outbreak management | |
| Director of Nursing | Involved in sexual abuse investigation and COVID-19 outbreak management | |
| Social Worker VVV | Provided insight on sexual abuse assessment and trauma | |
| Director of Clinical Services | Involved in sexual abuse investigation and COVID-19 outbreak management | |
| LPN AAA | Licensed Practical Nurse | Provided care and documentation related to falls and splint use |
| CNA RR | Certified Nursing Assistant | Documented splint application incorrectly |
| CNA BBB | Certified Nursing Assistant | Documented splint application incorrectly |
| CNA CCC | Certified Nursing Assistant | Documented splint application incorrectly |
| LPN QQ | Licensed Practical Nurse | Unaware of splint use for resident R#20 |
| MDS Coordinator RN DDD | Registered Nurse | Responsible for MDS assessment and documentation |
Inspection Report
Renewal
Census: 17
Deficiencies: 3
May 25, 2022
Visit Reason
The inspection was a Licensure Survey conducted from May 16, 2022 through May 25, 2022 to assess compliance with infection control and other regulatory requirements.
Findings
The facility failed to implement an effective infection control program to prevent the spread of COVID-19, resulting in an Immediate Jeopardy situation due to multiple residents and staff testing positive. Observations and interviews revealed failures in screening, PPE use, social distancing, and visitor guidance during an outbreak.
Severity Breakdown
Scope/Severity: J: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to have an effective infection control program to prevent the spread of COVID-19. | Scope/Severity: J |
| Failure to report COVID-19 infections to residents and their families. | Scope/Severity: J |
| Failure to conduct COVID-19 testing for residents and staff as required. | Scope/Severity: J |
Report Facts
Residents testing positive for COVID-19: 4
Staff testing positive for COVID-19: 3
Residents observed during communal activity: 17
Staff observed during communal activity: 5
County COVID-19 positivity rate: 10.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nurse Assistant | Interviewed regarding screening and PPE use; noted not fit-tested for N95 mask. |
| CNA MM | Certified Nurse Assistant | Interviewed about screening, PPE use, and outbreak protocols; noted wearing mask for which he was fit-tested. |
| CNA VV | Certified Nurse Assistant | Interviewed about screening and PPE use; acknowledged not wearing mask for which she was fit-tested. |
| Activity Assistant CC | Observed entering facility without mask or screening; acknowledged failure to self-screen. | |
| RN WW | Registered Nurse | Interviewed about screening and PPE requirements for COVID hall staff. |
| CNA XX | Certified Nurse Assistant | Interviewed about screening and mask use; stated not all staff were screened. |
| RN BB | Director of Nursing | Observed not wearing eye protection at nursing station. |
| LPN QQ | Licensed Practical Nurse | Interviewed about PPE encouragement; acknowledged not wearing eye protection. |
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 6
May 25, 2022
Visit Reason
A standard survey was conducted from 5/16/2022 through 5/25/2022, including investigation of multiple complaint intake numbers, with substantiation of one complaint. The visit included an immediate jeopardy related to COVID-19 outbreak and infection control failures.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to prevent sexual abuse of residents, failure to report abuse, inaccurate resident assessments, failure to provide ordered care such as TED hose and elevation for edema, inadequate fall prevention interventions, and significant infection control failures related to COVID-19 including delayed outbreak testing, inadequate staff screening, improper PPE use, lack of social distancing, and failure to notify residents and families of COVID-19 cases.
Complaint Details
Complaint Intake Numbers GA00214188, GA00214760, GA00216099, GA00217822, GA00219920, GA00220413, and GA00221481 were investigated. GA00221481 was substantiated with citations and all other complaints were unsubstantiated.
Severity Breakdown
Scope/Severity: J: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to protect residents from sexual abuse by another resident, including exposure and inappropriate touching. | — |
| Failure to report an incident of abuse involving resident exposure to genitals to the state agency. | — |
| Inaccurate Minimum Data Set (MDS) assessment for a resident regarding use of splints or braces. | — |
| Failure to provide ordered care including application of TED hose and elevation of lower extremities for edema. | — |
| Failure to implement and document appropriate fall prevention interventions after resident falls. | — |
| Failure to implement effective infection prevention and control program to prevent spread of COVID-19, including failure to screen staff, enforce PPE use, maintain social distancing, conduct timely outbreak testing, and notify residents and families of COVID-19 cases. | Scope/Severity: J |
Report Facts
Residents tested positive for COVID-19: 4
Staff tested positive for COVID-19: 3
Resident census: 104
Nursing staff scheduled but not tested: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| R#270 | Resident | Resident involved in sexual abuse incidents. |
| CNA SSS | Certified Nursing Assistant | Witnessed sexual abuse and exposure by R#270. |
| Police Detective WWW | Investigated sexual abuse allegations involving R#270. | |
| Administrator | Informed of immediate jeopardy and involved in abuse and COVID-19 outbreak response. | |
| Director of Nursing (DON) | Involved in abuse investigation and COVID-19 outbreak response. | |
| Director of Clinical Services (DCS) | Involved in abuse investigation and COVID-19 outbreak response. | |
| ICP DD | Infection Control Preventionist | Responsible for COVID-19 testing and infection control program. |
Inspection Report
Complaint Investigation
Deficiencies: 8
May 25, 2022
Visit Reason
The inspection was conducted due to complaints and allegations of sexual abuse and failure to report abuse, as well as concerns related to infection control and other care deficiencies.
Findings
The facility failed to protect residents from sexual abuse by another resident, failed to report an incident of abuse to the state, failed to ensure accurate assessments, failed to provide care according to physician orders, failed to implement fall prevention interventions, and failed to maintain an effective infection control program including COVID-19 screening, testing, and notification.
Complaint Details
The complaint investigation was triggered by allegations of sexual abuse by resident R#270 against other residents, failure to report abuse, and infection control deficiencies related to COVID-19 outbreaks and testing failures.
Severity Breakdown
Level of Harm - Actual harm: 2
Level of Harm - Minimal harm or potential for actual harm: 3
Level of Harm - Immediate jeopardy to resident health or safety: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to protect residents from sexual abuse by another resident, including inappropriate touching and exposure. | Level of Harm - Actual harm |
| Failed to timely report an incident of abuse involving exposure of genitals to the state department. | Level of Harm - Actual harm |
| Failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the use of splints or braces for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide care and services according to physician orders for treatment of swelling and thrombosis, including application of TED hose and elevation of lower extremities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure fall prevention interventions were added to the care plan and consistently implemented for a resident at risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have an effective infection control program to prevent the spread of COVID-19, including failure to screen employees, enforce social distancing, and ensure proper use of PPE during an outbreak. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to notify residents, representatives, and family members timely of confirmed COVID-19 infections in the facility. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to conduct routine and outbreak COVID-19 testing for all staff and residents in accordance with CDC and CMS requirements. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents affected by sexual abuse: 4
Residents tested positive for COVID-19: 4
Staff tested positive for COVID-19: 3
Nursing staff scheduled but not tested on 5/16/22: 32
Facility census: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA SSS | Certified Nursing Assistant | Observed resident R#270 exposing himself to resident R#58 |
| Police Detective WWW | Investigated sexual abuse allegations involving resident R#270 | |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding handling of sexual abuse and infection control |
| Administrator | Facility Administrator | Provided statements regarding sexual abuse investigation and COVID-19 outbreak |
| Social Worker VVV | Social Worker | Provided statements regarding assessment of sexual abuse victims |
| ICP DD | Infection Control Preventionist | Provided statements regarding COVID-19 testing and outbreak management |
Inspection Report
Renewal
Census: 17
Deficiencies: 5
May 16, 2022
Visit Reason
The inspection was a Licensure Survey conducted from May 16, 2022 through May 25, 2022 to assess compliance with infection control and other regulatory requirements during a COVID-19 outbreak.
Findings
The facility failed to maintain an effective infection control program to prevent the spread of COVID-19, resulting in an Immediate Jeopardy situation due to multiple residents and staff testing positive. Deficiencies included failure to screen employees properly, inadequate use of PPE, lack of social distancing, and failure to inform residents and families about the outbreak.
Severity Breakdown
J: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to have an effective infection control program to prevent the spread of COVID-19, including failure to implement outbreak testing and contact tracing timely. | J |
| Failure to ensure employees entering the facility were screened for signs and symptoms of COVID-19 prior to entry and care provision. | J |
| Failure to ensure proper social distancing during communal activities. | J |
| Failure to ensure proper use of personal protective equipment (PPE) during the COVID-19 outbreak, including lack of eye protection and improper mask use by staff. | J |
| Failure to provide visitors with proper visitation instructions and guidance during outbreak status, including hand sanitizing, mask protocol, and social distancing. | J |
Report Facts
Residents testing positive for COVID-19: 4
Staff testing positive for COVID-19: 3
Residents observed in communal activity: 17
Staff observed in communal activity: 5
County COVID-19 transmission rate: 10.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA RR | Certified Nurse Assistant | Interviewed regarding screening process and PPE use; noted not fit-tested for N95 mask. |
| CNA MM | Certified Nurse Assistant | Interviewed about screening, PPE use, and outbreak protocols; noted wearing fit-tested mask but no eye protection. |
| CNA VV | Certified Nurse Assistant | Interviewed about screening and PPE; admitted not wearing fit-tested mask or eye protection. |
| Activity Assistant CC | Activity Assistant | Observed entering facility without screening or mask; acknowledged failure to self-screen. |
| RN WW | Registered Nurse | Stated staff dedicated to COVID hall required to wear N95 mask and goggles. |
| RN BB | Director of Nursing | Observed not wearing eye protection at nursing station. |
| LPN KK | Licensed Practical Nurse | Observed serving lunch without eye protection. |
| CNA LL | Certified Nurse Assistant | Observed serving lunch without eye protection. |
| CNA MM | Certified Nurse Assistant | Observed serving lunch without eye protection. |
| Dietitian JJ | Dietitian | Observed working in dining room without eye protection. |
| Director of Dining Services II | Director of Dining Services | Observed working in dining room without eye protection. |
| Physical Therapy Assistant GGG | Physical Therapy Assistant | Observed wearing N95 mask improperly and no eye protection. |
| Certified Occupational Therapy Assistant TT | Certified Occupational Therapy Assistant | Observed with mask under chin. |
| Certified Occupational Therapy Assistant HHH | Certified Occupational Therapy Assistant | Observed wearing mask inappropriately and no eye protection. |
| Volunteer D | Volunteer | Observed not wearing eye protection while giving communion. |
Inspection Report
Life Safety
Census: 104
Capacity: 130
Deficiencies: 1
May 16, 2022
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and building rehabilitation standards.
Findings
The facility was found not in substantial compliance with the Life Safety Code requirements due to failure to document daily inspections of means of egress in areas undergoing construction or modifications. Specifically, a temporary wood frame and sheetrock wall isolating an office from resident rooms lacked documented daily inspection.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document a means of egress for daily inspection of areas undergoing construction, alterations, repair, or additions to ensure instant usability in emergencies. | SS= D |
Report Facts
Census: 104
Total Capacity: 130
Smoke Compartments affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance manager | Interviewed regarding lack of documentation of daily inspections | |
| Staff M | Confirmed findings during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 18, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00212976.
Findings
The complaint was substantiated but no deficiencies were cited during the investigation.
Complaint Details
Complaint number GA00212976 was substantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00209717, GA00209884, GA00203581, and GA00209341.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints GA00209717, GA00209884, GA00203581, and GA00209341 were investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 82
Deficiencies: 0
Nov 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 97
Deficiencies: 0
Oct 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 16, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted in conjunction with a Covid-19 Focused Infection Control Survey to investigate complaints GA00208614 and GA00208923.
Findings
Complaint GA00208614 was substantiated with no deficiencies found, and complaint GA00208923 was unsubstantiated.
Complaint Details
Complaint GA00208614 was substantiated with no deficiencies, and complaint GA00208923 was unsubstantiated.
Inspection Report
Routine
Census: 92
Deficiencies: 0
Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on June 23-24, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 27, 2020
Visit Reason
An abbreviated survey was conducted to investigate complaint # GA00201716.
Findings
The complaint investigation was concluded and found to be unsubstantiated.
Complaint Details
Complaint # GA00201716 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 27, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies identified in the prior survey dated October 3, 2019.
Findings
All deficiencies identified in the October 3, 2019 survey were found to be corrected during the November 27, 2019 revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 18, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 114
Capacity: 130
Deficiencies: 3
Oct 1, 2019
Visit Reason
A 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) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with interior wall and ceiling finishes, sprinkler system maintenance, and smoke barrier doors. Specific deficiencies included missing ceiling tiles in a janitor's closet, a missing fire sprinkler escutcheon plate near the nurses station, and gaps in a rated fire/smoke door allowing potential smoke spread.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Interior wall and ceiling finishes did not assure proper fire sprinkler system protection due to missing ceiling tiles in a kitchen janitor's closet. | D |
| Fire sprinkler system was not maintained at optimum readiness; a fire sprinkler escutcheon plate was missing in the ceiling near the nurses station. | D |
| Smoke barrier door in the hallway had two gaps that could allow smoke spread between compartments. | D |
Report Facts
Staff at risk: 6
Staff and residents at risk: 40
Residents at risk: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 29, 2019
Visit Reason
A complaint survey was conducted on 5/29/19 to investigate complaint GA00195560 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint GA00195560 was investigated and no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint number GA00192589.
Findings
The complaint was investigated and found to be unsubstantiated.
Complaint Details
Complaint number GA00192589 was investigated and determined to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 6, 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 have been corrected as of the follow-up survey date.
Inspection Report
Follow-Up
Deficiencies: 1
Aug 10, 2018
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
The facility failed to have all required safety information instructions posted, specifically the K-Class Fire Extinguisher Placard signage was not posted above the extinguisher in the kitchen, which could place 40 staff and residents at risk in the event of fire.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| K-Class Fire Extinguisher Placard signage was not posted above the extinguisher in the kitchen. | SS= D |
Report Facts
Staff and Residents at risk: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the follow-up POC tour. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 8, 2018
Visit Reason
A complaint survey was conducted on 8/8/2018 to investigate complaints #GA00190208 and GA00189884 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey conducted on 8/8/2018 to 8/9/2018.
Complaint Details
Complaints #GA00190208 and GA00189884 were investigated and found to have no deficiencies.
Inspection Report
Annual Inspection
Census: 117
Deficiencies: 0
Jun 21, 2018
Visit Reason
A standard survey was conducted from June 18, 2018 through June 21, 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 Healthcare Portion of Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Inspection Report
Life Safety
Census: 117
Capacity: 130
Deficiencies: 3
Jun 18, 2018
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 fire safety requirements, including missing K-Class extinguisher signage, a missing sprinkler escutcheon plate in the kitchen, and open circuit spaces in an electrical panel, all of which could place staff and residents at risk.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| K-Class extinguisher placard signage was not posted above the extinguisher in the kitchen. | SS= D |
| A sprinkler escutcheon plate was missing in the kitchen near the dietary manager's office. | SS= D |
| Two open/voided circuit spaces (Circuit Spaces 77 & 83) were present in electrical panel 1LA-2 SEC.2. | SS= D |
Report Facts
Staff and residents at risk: 40
Staff at risk: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2018
Visit Reason
The visit was conducted to investigate Complaint GA00183360 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the monitoring visit.
Complaint Details
Complaint GA00183360 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 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
Routine
Census: 104
Deficiencies: 0
Sep 8, 2017
Visit Reason
A standard survey was conducted at A.G. Rhodes Home, Inc. - Cobb from September 5, 2017 through September 8, 2017 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 43, Subpart B for Long Term Care Facilities.
Findings
The standard survey revealed the facility was in compliance with health regulations for Medicare/Medicaid at the time of inspection.
Inspection Report
Life Safety
Census: 105
Capacity: 130
Deficiencies: 5
Sep 5, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety and related National Fire Protection Association standards at the facility.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with fire alarm strobes not synchronizing, loaded sprinkler heads possibly delaying activation, smoke/fire wall penetrations compromising smoke barriers, unsafe placement of electrical equipment, and unauthorized use of a portable space heater.
Severity Breakdown
E: 1
D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Fire Alarm strobes were not firing in synchronization on multiple floors, potentially threatening residents and staff. | E |
| Loaded sprinkler heads in the Dining Room possibly delaying proper activation of the sprinkler system. | D |
| Smoke/fire wall penetrations in two locations on the first floor compromising smoke barriers. | D |
| Unsafe placement of a Multiple-Outlet Power Strip with Battery Backup on the floor under the Nurses Station on the 2nd floor. | D |
| Portable space heater operating under the counter in the physical therapy department without documentation of safe temperature limits. | D |
Report Facts
Residents at risk due to fire alarm strobes issue: 40
Staff at risk due to fire alarm strobes issue: 20
Residents at risk due to sprinkler system issue: 40
Residents at risk due to smoke barrier issue: 40
Residents at risk due to electrical equipment placement: 65
Residents and staff at risk due to portable space heater: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 4, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate complaint GA00177934 at A.G. Rhodes-Cobb Health and Rehab.
Findings
The facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B.
Complaint Details
Investigation of complaint GA00177934; facility found in compliance.
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 0
Jun 9, 2017
Visit Reason
An abbreviated survey was conducted on June 9, 2017 to investigate two allegations.
Findings
One of two allegations was substantiated, but no regulatory deficiency was cited. The facility was found to be in substantial compliance with Medicare/Medicaid regulations.
Complaint Details
One of two allegations was substantiated during the investigation.
Report Facts
Resident Census: 110
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 3, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00164332 and GA00159539.
Findings
The complaints were 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
Complaints GA00164332 and GA00159539 were investigated and found not substantiated.
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