Rockdale Healthcare Center: DNR Error Risked Resident's Life - GA
The error involved a resident identified in inspection records as R71. She had a signed Full Code Advance Directive on file. A staff member, entering information into the facility's electronic medical record system, discontinued the wrong directive and placed a DNR order in the system instead. The staff member acknowledged the mistake, describing it as a human error. She said she should have entered the Full Code directive and entered the DNR instead.
What made the error dangerous was where the wrong information appeared. The DNR designation sat not only in the resident's orders but in the banner at the top of her electronic record, the first place staff look in an emergency.
The Unit Manager of the 200 Hall confirmed how the system works. In an interview with inspectors, she said staff responding to a medical emergency would go first to the EMR orders and the dashboard header to determine a resident's code status. If the banner showed DNR, that is what staff would follow. For R71, the banner showed DNR. Her actual wish was to be resuscitated.
The Unit Manager stated directly what the consequence could have been: in an emergency, staff would not have attempted to resuscitate R71.
CMS inspectors classified the violation as causing minimal harm or potential for actual harm, with few residents affected. The inspection was conducted January 29, 2026, in response to a complaint.
The record does not indicate whether R71 ever experienced a medical emergency while the wrong directive was active, or how long the error remained in the system before it was caught.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rockdale Healthcare Center from 2026-01-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Rockdale Healthcare Center in CONYERS, GA was cited for violations during a health inspection on January 29, 2026.
The error involved a resident identified in inspection records as R71.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.