Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rockdale Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple serious conditions, including post-stroke hemiplegia and chronic systolic CHF, had conflicting advance directive documentation in the record. Earlier documentation and care plans reflected DNR status, but a later POLST and advance directive signed by the resident and a physician changed the status to Full Code. Despite this, the EMR orders and header continued to display DNR due to staff error in discontinuing the wrong directive and failing to update the system. Staff interviews confirmed that they rely on the EMR banner and orders to determine code status, meaning they would see DNR when the resident’s current directive was Full Code.
A resident with moderate cognitive impairment and her POA reported that staff copied private documents delivered by law enforcement without obtaining prior permission, contrary to facility policy requiring privacy in resident communications. Interviews with the resident, POA, Administrator, and SW confirmed that the documents were copied before consent was obtained.
A resident with multiple diagnoses, including dementia and aphasia, was transferred to another facility without the responsible party being notified on the day of discharge. Although the social worker discussed the transfer in advance, there was no documentation of the specific discharge date, and the family only discovered the resident had been moved after arriving at the facility. Staff and administrative interviews confirmed the notification lapse.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident was not adequately prepared for a safe transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences.
The facility failed to provide timely Medicare Part A discharge notifications for three residents, potentially leading to a lack of understanding of appeal rights and billing for non-covered services. The Business Office Manager and Social Services Director confirmed the oversight, and the Administrator acknowledged the deficiency.
The facility failed to maintain sanitary practices in the kitchen, affecting 101 residents. A staff member was observed without a beard net, and a fan was blowing debris towards the food prep area. An unsealed bag of food thickener and unrefrigerated soy sauce were found in the dry storage room. The Dietary Manager acknowledged the issues and mentioned that beard nets were on order.
The facility failed to provide adequate ADL care for two residents, resulting in dirty fingernails and lack of personal hygiene. One resident with severe cognitive impairment and another with hemiplegia were both found with unclean nails, despite the facility's policy requiring nail care during bathing. Interviews with staff and the DON confirmed that nail care was expected but not consistently provided.
A resident with cognitive impairments was found with zinc oxide ointment at their bedside without a physician's order or self-administration assessment, contrary to facility policy. Staff interviews confirmed that medications should not be at the bedside without proper authorization, indicating a lapse in adherence to medication management protocols.
The facility did not ensure PTAC filters were clean in two resident rooms, as observed with a thick layer of debris on the filters. This was contrary to the facility's policy and manufacturer's recommendations for monthly maintenance. Staff interviews revealed confusion about cleaning responsibilities, and the Maintenance Director confirmed the issue. The Administrator noted the importance of regular filter checks for air quality.
A facility failed to accurately code all high-risk medications on the admission assessment for a resident with serious health conditions. The resident was taking several high-risk medications, including an anticoagulant, which was not documented in the 5-day admission MDS. This oversight was identified through a review of the EMR and interviews, highlighting a deficiency in the facility's adherence to its Resident Assessment policy.
The facility failed to create comprehensive care plans for two residents, neglecting to address high-risk medications. One resident's plan lacked interventions for diuretic and anticoagulant risks, while another's omitted psychotropic medication usage. Staff interviews revealed lapses in care plan updates and oversight responsibilities.
A facility failed to administer medications to a resident with chronic respiratory issues due to communication lapses and procedural non-adherence. Additionally, another resident with severe cognitive impairment did not receive podiatrist-recommended foot care due to a breakdown in communication and documentation processes, leaving the resident's skin condition untreated.
A resident with COPD and chronic respiratory failure was not administered oxygen as prescribed, with an LPN providing only 1 LPM instead of the ordered 3 LPM. The oxygen canister was also found unsecured on the floor. Interviews confirmed the deviation from the physician's order and facility policy.
A resident receiving hospice care for Alzheimer's and congestive heart failure was prescribed Ativan for agitation without a 14-day stop date, contrary to facility policy. The oversight occurred because the hospice team prescribed the medication, and the facility's EHR system did not list the hospice doctor, leading to the facility MD being recorded as the prescriber. Staff interviews confirmed awareness of the policy, but it was not applied in this case.
Failure to Update EMR to Reflect Resident’s Current Advance Directive and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s current advance directive and code status were accurately and consistently documented in the electronic medical record (EMR). The facility’s policy on Advance Directives states that a resident’s choice about advance directives will be respected, including Do Not Resuscitate (DNR) orders. One resident was admitted and re-admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, acute chronic systolic congestive heart failure, and hypertensive heart and chronic kidney disease with heart failure. The admission record documented the resident’s code status as DNR, and the care plan reflected that the resident/family desired DNR status, with interventions to follow facility protocol for DNR and not resuscitate the resident per resident/family request. The Annual MDS showed a BIMS score of 10, indicating moderately impaired cognition. Subsequently, physician orders and POLST forms in the record showed conflicting code statuses over time. There was a physician order for Full Code that was later discontinued, followed by an order for DNR, and the EMR header documented the code status as DNR. One POLST documented DNR/Allow Natural Death, while a later POLST documented Full Code/Attempt Resuscitation and was signed by a physician and the resident. The Social Services Assistant confirmed that the later Full Code advance directive should have rendered the prior DNR directive null and void and acknowledged that the EMR had not been updated to reflect the current Full Code status. The Interim DON confirmed that the EMR still showed a DNR order and DNR status in the header despite a current Full Code advance directive on file, and stated she had inadvertently discontinued the wrong advance directive and entered the DNR order in error. The Unit Manager confirmed that staff rely on the EMR orders and banner/header to determine a resident’s advance directive and that, for this resident, staff would see DNR in both locations while the current status was actually Full Code.
Failure to Ensure Resident Privacy in Receiving Mail
Penalty
Summary
The facility failed to ensure that a resident was allowed to receive mail and packages without staff opening or copying the documents without the resident's or their representative's permission. According to the facility's policy, residents are entitled to communicate privately and receive their personal mail unopened unless otherwise directed by a physician or the resident, with such direction documented in the medical record. In this case, a resident with a history of cerebral infarction, slurred speech, and a BIMS score indicating moderate cognitive impairment, reported with her daughter that on two occasions, the Social Worker (SW) took documents delivered by the Sheriff, made copies of them, and kept them in the resident's file without obtaining prior permission from the resident or her designated power of attorney (POA). Interviews with the resident, her daughter (the POA), the Administrator, and the SW confirmed that the documents were copied before the resident's consent was obtained. The Administrator acknowledged that the police officer brought the documents to his office, after which the SW made copies and then delivered the originals to the resident. The SW also confirmed that she copied the documents prior to obtaining permission. The facility's own policy and the resident's admission packet both state that residents are to be afforded privacy in their communications, including mail, which was not followed in this instance.
Failure to Notify Responsible Party of Resident Discharge
Penalty
Summary
The facility failed to notify a resident's responsible party on the day the resident was discharged and transferred to another facility, as required by the facility's own policy. Record review showed that while the social worker spoke to the family member about the transfer and obtained agreement, the documentation did not specify the details of why, where, or when the transfer would occur. Nursing notes confirmed the resident was discharged and transported to another nursing home, but there was no indication that the family was notified on the day of discharge. Interviews revealed that the resident's representative was confused about the transfer and was not informed of the actual discharge date. The representative only learned of the transfer after arriving at the facility and finding the resident had already been moved. Staff interviews confirmed that the responsible party was not contacted on the day of discharge, and the administrator verified this lapse in notification. The resident involved had diagnoses including coronary artery disease, dementia, and aphasia.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to ensure the resident's readiness and safety during the transition were not followed, resulting in a deficiency related to the transfer/discharge process.
Failure to Provide Timely Medicare Part A Discharge Notifications
Penalty
Summary
The facility failed to provide timely notifications of discontinuation of Medicare Part A benefits for three residents, which could lead to a lack of understanding of appeal rights and potential billing for services not covered. Resident 36's Medicare stay ended on 8/17/2024, but there was no evidence of a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) or a Notice of Medicare Non-Coverage (NOMNC) being provided before discharge. The facility provided a NOMNC form dated 6/13/2024, which was not timely. Similarly, Resident 81's Medicare stay ended on 8/6/2024, and no SNF-ABN or NOMNC was provided before discharge, with the facility providing a NOMNC form dated 5/30/2024. Resident 605 was discharged from the facility on 6/1/2024, with no evidence of a NOMNC form being provided before discharge. The facility provided a NOMNC form that documented services ended on 3/17/2024, which was not relevant to the discharge date. Interviews with the Business Office Manager and Social Services Director confirmed the lack of timely notifications, and the Administrator acknowledged the deficiency, stating that the Social Services Director was expected to provide these notifications prior to discharge from Medicare Part A services.
Sanitary Practices Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, which had the potential to affect 101 of 103 residents receiving an oral diet. Observations revealed that a staff member was in the kitchen food preparation area without a beard net, and a fan was blowing debris from its blades and wire cage towards the food preparation area. Additionally, an unsealed bag of instant food thickener was found open in the dry storage room, and a soy sauce bottle labeled 'Refrigerate after opening' was left unrefrigerated with over half of the product used. The Dietary Manager acknowledged that staff should always wear hair nets in the kitchen and mentioned that they were out of beard nets, but had ordered more. The manager also noted that the fan should not be directed towards the food prep area.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents, R72 and R83, as observed during a survey. R72, who has severe cognitive impairment and is dependent on assistance for ADLs, was found with dirty fingernails containing dark debris on multiple occasions. Despite the facility's policy requiring nail care during bathing, interviews with staff, including CNAs and the Director of Nursing (DON), confirmed that nail care was expected but not consistently provided. R72's family also noted the lack of nail care, indicating that they had to clean his hands during visits. Similarly, R83, who has little cognitive impairment but requires assistance due to hemiplegia and muscle weakness, was observed with long, dirty fingernails. R83 was not aware that staff could provide nail care, and his family had been responsible for this task. The DON acknowledged that nail care is part of ADL care and should have been completed by the nursing staff. These observations and interviews highlight the facility's failure to adhere to its policies regarding personal hygiene and ADL support for residents.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to adequately assess a resident, identified as R24, for self-administration of medication, which placed the resident at risk for inappropriate and unsafe medication use. The facility's policy on self-administration of medication requires a written order from the attending physician and approval from the Interdisciplinary Care Plan Team before a resident can self-administer or retain medication in their room. However, R24, who has diagnoses including cognitive-communication deficit, dementia, and mild cognitive impairment, was found with two boxes of zinc oxide ointment on their bedside table without a physician's order or a care plan area for self-administration of medication. Interviews with facility staff, including a Registered Nurse/Unit Manager, the Director of Nursing, and the Administrator, confirmed that residents are not permitted to have medications at their bedside without a physician's order and a self-administration assessment. The staff also indicated that medications found at the bedside should be removed and reported to the charge nurse or unit manager. Despite these protocols, R24's possession of the medication was not addressed, highlighting a lapse in the facility's adherence to its own policies and procedures regarding medication management.
Failure to Maintain Clean PTAC Filters in Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment by not ensuring that the packaged terminal air conditioner (PTAC) filters were free of debris in two resident rooms. Observations revealed a thick layer of white, fuzzy substance on the PTAC filters in these rooms. This deficiency was identified through staff interviews, record reviews, and observations, indicating a lapse in the facility's adherence to its policy on environmental services and the manufacturer's recommendations for monthly maintenance of PTAC filters. The facility's policy, dated April 2022, emphasized the responsibility of the housekeeping, laundry, and maintenance departments to ensure a safe and sanitary environment, including conducting preventative maintenance. However, interviews with staff revealed a lack of clarity regarding the responsibility and frequency of cleaning the air filters. The Maintenance Director confirmed the presence of debris on the filters, and the Administrator acknowledged that the filters should be checked monthly to maintain good air quality, which is crucial for preventing respiratory issues among residents.
Failure to Accurately Code High-Risk Medications on Admission Assessment
Penalty
Summary
The facility failed to ensure that all high-risk medications were accurately coded on the admission assessment for a resident, identified as R309. This deficiency was identified through observations, interviews, and record reviews, including the facility's policy titled Resident Assessment. The policy mandates that assessments be accurate and in compliance with state and federal regulations. However, the review of the Electronic Medical Record (EMR) for R309 showed that while the resident was taking several high-risk medications, including a diuretic, opioid, and hypoglycemic medication, the anticoagulant medication was not documented in the 5-day admission Minimum Data Set (MDS). R309 was admitted with multiple serious diagnoses, including acute respiratory failure, acute embolism and thrombosis of deep veins, sepsis, and chronic heart failure. The physician orders for R309 included high-risk medications such as vancomycin, furosemide, oxycodone-acetaminophen, and apixaban. Despite these orders, the MDS assessment failed to reflect the use of the anticoagulant, which is crucial for providing person-centered care. The MDS Director confirmed that the assessment information is gathered from various sources and should be completed and transmitted within specific timeframes, yet the omission of the anticoagulant was noted.
Failure to Develop Comprehensive Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, R309 and R83, which addressed all high-risk medications. For R309, the care plan did not include interventions for the risk associated with diuretic and anticoagulant medications or the use of oxygen, despite the resident's complex medical history, including acute respiratory failure, heart failure, and sepsis. Interviews with facility staff revealed that any nurse could update the care plan, and care plans were supposed to be reviewed quarterly and during specific meetings, but this was not adequately done for R309. Similarly, for R83, the care plan lacked documentation addressing the use of psychotropic medications, despite the resident's diagnoses of hemiplegia and muscle weakness, and a cognitive assessment indicating little to no impairment. The Director of Nursing confirmed the absence of a comprehensive care plan for R83's psychotropic medications and was unaware of this oversight, indicating a lapse in the responsibility of the MDS and Social Service departments to ensure care plans were developed and updated.
Medication and Podiatry Care Deficiencies
Penalty
Summary
The facility failed to administer ordered medications to a resident, R553, who was admitted with chronic obstructive pulmonary disease and chronic respiratory failure. Despite the availability of home medications brought by the resident's son, the medications were not administered due to a lack of communication and procedural adherence. The Registered Nurse (RN) confirmed that the medications were not given because the pharmacy could not dispense them on time, and the Director of Nursing (DON) was not informed about the availability of home medications, which could have been administered with a provider's order. Another deficiency involved resident R50, who was admitted with multiple diagnoses including malignant neoplasm of the colon and severe cognitive impairment. The facility failed to implement podiatrist-recommended care for R50's dry and flaky skin on the feet. Despite repeated podiatry consultations recommending routine nail care and moisturizing, these treatments were not carried out. Interviews revealed that the nursing staff was unaware of these recommendations due to a breakdown in communication and documentation processes, as the podiatry notes were not reviewed or incorporated into the care plan. The Social Service Director (SSD) and the DON acknowledged the failure in the process of handling podiatry notes and orders. The SSD was responsible for scheduling podiatry visits and ensuring that any orders were communicated to the nursing staff. However, the SSD did not see any physician orders in the podiatry notes, and the DON confirmed that the notes should have been reviewed and acted upon by the nursing staff. This lack of communication and procedural adherence led to the neglect of necessary care for R50's skin condition.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure with hypoxia. The resident had a physician's order for oxygen to be administered at 3 liters per minute (LPM) continuously via nasal cannula. However, an observation revealed that an LPN was administering oxygen at only 1 LPM and then adjusted it to 2 LPM, which was not in accordance with the physician's order. Additionally, the oxygen canister was found sitting unsecured on the floor next to the resident's bed. Interviews with the LPN and the Director of Nursing confirmed that the oxygen was not being administered as ordered and that the canister was not secured, which was against the facility's policy titled Administration of Drugs. This policy mandates that drugs, including oxygen, be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director.
Failure to Implement 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to implement a 14-day stop date for a PRN psychotropic medication prescribed to a resident, identified as R10, which is a requirement according to the facility's policy on psychopharmacologic drugs. The policy mandates that PRN orders for psychotropic drugs are limited to 14 days unless the attending physician or prescribing practitioner documents a rationale for extending the order. In this case, the medication Ativan (lorazepam) was prescribed with an indefinite end date, which did not comply with the policy. R10, a resident with diagnoses including Alzheimer's Disease, dementia, and congestive heart failure, was receiving hospice care for end-of-life comfort measures. The resident's electronic health record showed a PRN order for Ativan to manage agitation, prescribed by the facility's MD, but without a specified stop date. Interviews with facility staff, including a registered nurse and the MD, revealed awareness of the 14-day stop date requirement, but it was not applied in this instance. The MD noted that the medication was frequently used for the resident's outbursts, and the oversight was attributed to the hospice team prescribing the medication. Further investigation revealed that the hospice RN Area Director was unaware of the 14-day stop date requirement for PRN psychotropic medications. The Director of Nursing confirmed the policy requirement and explained that the facility's EHR system did not include the hospice doctor's name, leading to the facility MD being listed as the prescribing physician. The Administrator also confirmed the expectation that all psychotropic medications should adhere to the 14-day stop date policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Conyers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westbury Center Of Conyers For Nursing And Healing | 1.8 mi | ★★★★★ | 8 | 0 |
| Pruitthealth - Lithonia, Llc | 6.4 mi | ★★★★★ | 9 | 0 |
| Parkside Post Acute And Rehabilitation | 9.1 mi | ★★★★★ | 0 | 0 |
| Pebblebrook Health Center At Park Springs | 10.1 mi | ★★★★★ | 0 | 0 |
| Riverside Health Care Center | 10.5 mi | ★★★★★ | 2 | 0 |
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