Inspection Reports for The Cottages at Rockmart
750 GOODYEAR AVENUE, GA, 30153
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Jan 14, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey with complaints survey conducted on 11/24/2024.
Findings
All deficiencies cited as a result of the 11/24/2024 survey were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Census: 81
Deficiencies: 0
Jan 14, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey with complaints survey on 11/24/2024.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Report Facts
Census: 81
Inspection Report
Follow-Up
Deficiencies: 0
Jan 9, 2025
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 3
Nov 24, 2024
Visit Reason
A State Licensure survey was conducted at The Cottages at Rockmart from November 22, 2024, through November 24, 2024, to assess compliance with state health regulations.
Findings
The facility failed to store vaccines under proper temperature controls with twice daily monitoring, failed to ensure psychotropic medications had appropriate stop dates, and did not follow infection control procedures for glucometer disinfection and dryer lint screen cleaning.
Deficiencies (3)
| Description |
|---|
| Failed to store vaccines under proper temperature controls with twice daily monitoring in two of six refrigerators used to store medications and biologicals. |
| Failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for one resident. |
| Failed to ensure infection control process was followed by one LPN on cleaning and disinfecting a glucometer after use and failed to clean dryer lint screens from two of twelve dryers. |
Report Facts
Facility census: 78
Number of refrigerators with improper vaccine temperature monitoring: 2
Number of residents reviewed for unnecessary medications: 6
Number of dryers with unclean lint screens: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Confirmed vaccine storage and temperature documentation in Cottage D refrigerator |
| LPN CC | Licensed Practical Nurse | Confirmed vaccine storage and temperature documentation in Cottage B refrigerator |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding vaccine storage, medication stop dates, and infection control practices |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding vaccine storage and infection control practices |
| LPN FF | Licensed Practical Nurse | Observed not following infection control procedures for glucometer cleaning |
| Laundry Supervisor GG | Laundry Supervisor | Confirmed lint screens were not cleaned and responsible for staff education |
Inspection Report
Life Safety
Census: 15
Capacity: 15
Deficiencies: 3
Nov 23, 2024
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance in some buildings but not in substantial compliance in others due to fire alarm system trouble mode, outdated sprinkler system pressure gauge, and missing electrical outlet covers. Specific deficiencies were identified in buildings 3, 4, and 6.
Severity Breakdown
F: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire alarm system in building 4 was in trouble mode indicating sprinkler riser low pressure despite sprinkler gauge showing 190 PSI. | F |
| Automatic sprinkler system pressure gauge was out of date (dated 2018) and was not recalibrated or replaced after 5 years. | D |
| Missing electrical outlet cover for the clothes dryer outlet and a junction box behind the exit sign above the exit door next to the laundry room. | D |
Report Facts
Certified beds: 15
Census: 15
Sprinkler gauge pressure: 190
Sprinkler gauge date: 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to fire alarm system trouble mode, sprinkler gauge issues, and missing electrical outlet covers during facility tour |
Inspection Report
Routine
Census: 78
Deficiencies: 5
Nov 22, 2024
Visit Reason
A standard survey was conducted from 11/22/2024 through 11/24/2024, including investigation of three complaint intake numbers which were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to respiratory equipment sanitation, psychotropic medication stop dates, vaccine storage temperature monitoring, glucometer disinfection, and dryer lint screen cleaning.
Complaint Details
Complaint Intake Numbers GA000246112, GA000248283, and GA000245502 were investigated and found to be unsubstantiated.
Severity Breakdown
SS= D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure respiratory equipment was maintained in a sanitary manner for one resident receiving oxygen therapy. | SS= D |
| Failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for one resident. | SS= D |
| Failed to store vaccines under proper temperature controls with twice daily monitoring in two of six refrigerators used to store medications and biologicals. | SS= D |
| Failed to ensure infection control process was followed by one LPN on cleaning and disinfecting a glucometer after use and failed to use a barrier before placing the glucometer on surfaces. | SS= D |
| Failed to clean the dryer lint screens from two of twelve dryers. | SS= D |
Report Facts
Residents receiving oxygen therapy: 21
Residents reviewed for unnecessary medications: 6
Refrigerators used to store medications and biologicals: 6
Dryers: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Treatment Nurse | Responsible for cleaning oxygen concentrator filters; admitted filter cleaning was overlooked. |
| CNA EE | Certified Nursing Assistant | Cottage Guide who verified oxygen concentrator filter was full of lint. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding responsibilities for oxygen concentrator filter cleaning, psychotropic medication stop dates, vaccine storage, and glucometer disinfection. |
| LPN AA | Licensed Practical Nurse | Confirmed vaccine storage and temperature monitoring practices in Cottage D refrigerator. |
| LPN CC | Licensed Practical Nurse | Confirmed vaccine storage and temperature monitoring practices in Cottage B refrigerator. |
| Laundry Supervisor GG | Laundry Supervisor | Confirmed lint screens were not cleaned and stated staff education would be provided. |
| LPN FF | Licensed Practical Nurse | Observed failing to use barrier when placing glucometer and cleaning it after use. |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed regarding vaccine storage temperature monitoring. |
Inspection Report
Abbreviated Survey
Census: 76
Deficiencies: 0
Oct 2, 2024
Visit Reason
An Abbreviated/Extended Survey was conducted on October 2, 2024 to investigate complaint number GA00251161.
Findings
The complaint GA00251161 was found to be substantiated without any federal deficiency cited.
Complaint Details
Complaint number GA00251161 was investigated and found to be substantiated without federal deficiency cited.
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Apr 3, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00237760.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00237760 was investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 26, 2023
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 06/19/2023 and 06/25/2023 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period. | F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Nov 1, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for The Cottages at Rockmart facility, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 0
Nov 1, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 22-25, 2022 recertification survey.
Findings
All deficiencies cited in the August 2022 recertification survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 18, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 57
Capacity: 116
Deficiencies: 1
Sep 1, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements at 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements due to failure to ensure kitchen vent hood extinguishment systems were inspected as required by NFPA 96. The extinguishment systems were past due the six-month service inspection, with the last inspection in May 2021.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure kitchen vent hood extinguishment system inspection was up to date as required by NFPA 96. | SS=E |
Report Facts
Census: 57
Total Capacity: 116
Deficiency risk: 14
Deficiency risk: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding past due kitchen vent hood extinguishment system inspection |
Inspection Report
Renewal
Deficiencies: 4
Aug 25, 2022
Visit Reason
A Licensure Survey was conducted from 8/22/2022 through 8/25/2022 to assess compliance with licensure requirements and regulations.
Findings
The facility was found deficient in providing written transfer/discharge notices to residents and/or their representatives, failure to provide required range of motion services to a resident, failure to inform a resident about risks and benefits of assist/enabler bars, and improper labeling and storage of food items in snack and kitchen areas.
Deficiencies (4)
| Description |
|---|
| Failure to provide written transfer/discharge notice to three of 21 sampled residents and/or their representatives including reasons for transfer, place of transfer, and appeal information. |
| Failure to provide range of motion (ROM) services as required for one resident (R48) with multiple contractures. |
| Failure to ensure one resident (R14) was informed of the risks and benefits of assist or enabler bar use while in bed. |
| Failure to ensure foods were properly stored and labeled with expiration dates in snack and kitchen areas in two of four cottages, potentially affecting 30 of 58 residents. |
Report Facts
Sampled residents: 21
Residents affected by food storage deficiency: 30
Residents in facility: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Stated no written transfer/discharge notice was provided to residents or representatives, only verbal communication |
| Director of Nursing | Director of Nursing | Confirmed residents being emergently transferred and that written notice should have been provided; stated expectations for ROM and informed consent for enabler bars |
| Administrator | Administrator | Confirmed expectations for written transfer/discharge notices and proper food labeling and storage |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Observed resident R48's hands clenched and stated she was unaware ROM was required |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Stated no ROM was done on resident's hands |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Stated he did not monitor ROM completion and was unaware of ROM requirements |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Stated she stretches and massages resident's hands but was unaware of ROM requirements for ankles and feet |
| MDS Coordinator 2 | MDS Coordinator | Observed lack of ROM on resident R48 and reviewed ADL sheets showing missed ROM |
| Certified Food Manager | Certified Food Manager | Verified lack of expiration dates on snack packages and removed food for review |
| Registered Dietitian | Registered Dietitian | Verified lack of expiration dates on snack packages and removed food for review |
| Certified Dietary Manager | Certified Dietary Manager | Expected all resident food to be properly labeled, stored, and dated |
Inspection Report
Routine
Census: 57
Deficiencies: 6
Aug 25, 2022
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations and long term care requirements.
Findings
The facility was found not in substantial compliance with several regulatory requirements including failure to provide written transfer/discharge notices, inaccurate resident assessments, failure to coordinate PASARR reviews, inadequate range of motion services, lack of informed consent for bed rails, and improper food storage and labeling.
Severity Breakdown
Level E: 2
Level D: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide written transfer/discharge notice to three residents or their representatives. | Level E |
| Failed to ensure accurate assessment of insulin use and completion of Level II PASARR for one resident. | Level D |
| Failed to coordinate PASARR Level II reviews for two residents with new mental health diagnoses. | Level D |
| Failed to provide range of motion services as ordered for one resident with multiple contractures. | Level D |
| Failed to obtain informed consent and review risks and benefits for use of bed rails for one resident. | Level D |
| Failed to ensure proper labeling, dating, and storage of food items in snack and kitchen areas in two cottages. | Level E |
Report Facts
Resident census: 57
Deficiencies cited: 6
ROM frequency: 15
ROM frequency per shift: 5
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 9, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA00214262, #GA00214053, and #GA00225804.
Findings
The complaints investigated during the abbreviated survey were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaints #GA00214262, #GA00214053, and #GA00225804 were investigated and found to be unsubstantiated with no deficiencies cited.
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