Inspection Report Summary
The most recent inspection on April 30, 2025, found that all previously cited life safety deficiencies had been corrected. Earlier inspections showed a pattern of deficiencies related mainly to fire safety system maintenance and environmental cleanliness, as well as resident care issues such as medication assessment and activities of daily living. Complaint investigations were mostly unsubstantiated, with one substantiated complaint that did not result in deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made improvements over time, especially with repeated corrections verified in follow-up surveys.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
7.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
84 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
A Life Safety Code revisit survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - AUGUSTA HILLS following a survey completed on April 25, 2025.
Findings
The document contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Date: Apr 25, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the February 27, 2025, Recertification with Complaints survey.
Findings
All deficiencies cited in the prior Recertification with Complaints survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Census: 80
Capacity: 126
Deficiencies: 4
Date: Mar 3, 2025
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, with deficiencies noted in hazardous area enclosure, smoke detection, sprinkler system maintenance, and smoke barrier construction affecting one of three smoke compartments.
Deficiencies (4)
Excessive storage in boiler/electrical room compromising hazardous area enclosure.
Missing smoke detection in day room off of A wing.
Sprinkler heads in kitchen loaded with grease and dust; improper amount of spare heads on site.
Penetrations in riser room ceiling not properly sealed compromising smoke barrier construction.
Report Facts
Smoke compartments affected: 1
Census: 80
Total licensed beds: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident environment cleanliness, activities of daily living assistance, and nutritional monitoring at Pruitthealth - Augusta Hills.
Findings
The facility failed to properly assess a resident for safe self-administration of wound care medications, maintain clean air filters and a homelike environment, provide adequate assistance with activities of daily living including showers, and conduct weekly weight monitoring for a resident with significant weight loss.
Deficiencies (4)
Facility failed to assess and determine if resident R732 was safe to self-administer wound care medications and allowed the resident to self-administer without physician orders or assessment.
Facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) unit filters and ensure a clean home-like environment on one of three halls (100 Hall).
Facility failed to ensure activities of daily living care, specifically showers and facial hair care, were provided for resident R44, leading to potential skin care issues and lack of self-confidence.
Facility failed to conduct weekly weights as recommended by the Registered Dietician for resident R74, who experienced a 13.4% weight loss in 30 days, risking significant decline in physical and nutritional health.
Report Facts
Residents sampled: 34
Weight loss percentage: 13.4
Weight measurements: 98
Weight measurements: 98.4
Weight measurements: 100
Weight measurements: 86.6
Weight measurements: 85.8
Days without shower documentation: 15
Days without shower documentation: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UU | Licensed Practical Nurse | Verified missing shower documentation for resident R44 |
| RR | Certified Nursing Assistant | Delivered food tray and stated she does not assist resident R74 with meals unless noticed |
| SS | Licensed Practical Nurse | Assisted roommate with eating, encouraged resident R74 to eat, confirmed resident on weight monitoring program |
| TT | Licensed Practical Nurse | Stated resident R74 did not flag for weekly weights |
| PP | Certified Nursing Assistant | Member of restorative team responsible for obtaining weights, unaware resident R74 required weekly weights |
| DHS | Director of Health Services | Confirmed resident R732 was not assessed for self-administration and confirmed weight loss for resident R74 |
| Administrator | Confirmed facility did not follow through with shower documentation audits and discussed filter cleaning responsibilities | |
| MD | Maintenance Director | Described filter cleaning schedule and acknowledged dirty PTAC filters |
| Housekeeping Director | Explained housekeeping responsibilities and delays in cleaning | |
| Registered Dietician | RD | Communicated weight monitoring recommendations and confirmed significant weight loss for resident R74 |
| DON | Director of Nursing | Discussed shower schedule documentation and audit follow-ups |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with healthcare facility regulations, including medication self-administration, environmental cleanliness, activities of daily living assistance, and nutritional care.
Findings
The facility was found deficient in several areas including failure to assess a resident for safe self-administration of wound care medications, failure to maintain clean air filters and a homelike environment, failure to provide scheduled showers and grooming assistance, and failure to conduct weekly weights for a resident with significant weight loss as recommended by the dietician.
Deficiencies (4)
Facility failed to assess and determine if resident R732 was safe to self-administer wound care medications and treatments.
Facility failed to maintain clean 'Packaged Terminal Air Conditioner' (PTAC) unit filters and ensure a clean home-like environment on one of three halls (100 Hall).
Facility failed to ensure activities of daily living care, specifically showers and facial hair grooming, were provided for resident R44.
Facility failed to conduct weekly weights as recommended by the Registered Dietician for resident R74, who experienced a 13.4% weight loss in 30 days.
Report Facts
Residents sampled: 34
Residents affected: 1
Residents affected: 1
Residents affected: 1
Weight loss percentage: 13.4
Weight entries: 5
Days without documented shower: 15
Days without documented shower: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UU | Licensed Practical Nurse (LPN) | Verified missing shower documentation for resident R44 |
| RR | Certified Nursing Assistant (CNA) | Delivered food tray to resident R74 and stated she does not assist with meals unless noticed |
| SS | Licensed Practical Nurse (LPN) | Assisted roommate and encouraged resident R74 to eat; confirmed resident on weight monitoring program |
| TT | Licensed Practical Nurse (LPN) | Stated resident R74 did not flag for weekly weights |
| PP | Certified Nursing Assistant (CNA) | Member of restorative team responsible for obtaining weights; unaware of resident R74's weekly weight requirement |
| DHS | Director of Health Services | Confirmed resident R732 was not assessed for self-administration and confirmed weight loss issues for resident R74 |
| Administrator | Confirmed policies on filter cleaning and shower audits; acknowledged documentation deficiencies | |
| MD | Maintenance Director | Described filter cleaning procedures and acknowledged unclean filters |
| Housekeeping Director | Described housekeeping responsibilities and acknowledged delays in cleaning | |
| Registered Dietician | RD | Recommended weekly weights and increased supplements for resident R74 |
| Director of Nursing | DON | Acknowledged lack of follow-through on shower documentation audits |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Pruitt Health Augusta Hills.
Findings
The facility was found deficient in several areas including failure to assess a resident's ability to self-administer medications and wound care, failure to provide adequate activities of daily living care such as showers and facial hair grooming, and failure to maintain clean environmental sanitation including air conditioner filters and resident room cleanliness.
Deficiencies (3)
Failure to assess and determine if resident R732 was able to safely self-administer medications and wound care treatments.
Failure to ensure activities of daily living care was provided for resident R44 related to showers and facial hair grooming.
Failure to maintain clean Packaged Terminal Air Conditioner (PTAC) unit filters and ensure a clean home-like environment on 100 Hall rooms 115, 116, and 117.
Report Facts
Sampled residents: 34
Residents with ADL care issues: 1
Days without documented bath or shower: 15
Days without documented bath or shower: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UU | Licensed Practical Nurse (LPN) | Verified missing documentation related to resident R44's shower care |
| Administrator | Interviewed regarding skin treatment and shower documentation deficiencies | |
| Director of Health Services (DHS) | Confirmed resident R732 was not assessed for self-administering wound care | |
| Director of Nursing (DON) | Discussed shower schedule documentation and audit follow-ups | |
| Maintenance Director (MD) | Interviewed about cleaning of PTAC filters and environmental sanitation | |
| Housekeeping Director | Explained housekeeping responsibilities and delays in cleaning resident rooms |
Inspection Report
Routine
Census: 82
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
A standard survey was conducted from February 25, 2025 through February 27, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Multiple complaint intake numbers were investigated; most were found unsubstantiated except one which was substantiated without deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to assess a resident's ability to self-administer medications, failure to maintain clean air conditioner filters and a clean environment, failure to provide adequate activities of daily living care including showers and facial hair care, and failure to conduct weekly weights for a resident with significant weight loss.
Deficiencies (4)
Failed to assess and determine if resident R732 was safe to self-administer wound care medications/treatments.
Failed to maintain clean Packaged Terminal Air Conditioner (PTAC) unit filters and ensure a clean home-like environment on 100 Hall.
Failed to ensure activities of daily living care including showers and facial hair care for resident R44.
Failed to conduct weekly weights as recommended by the Registered Dietician for resident R74 who experienced 13.4% weight loss in 30 days.
Report Facts
Resident census: 82
Weight loss percentage: 13.4
Days without documented showers: 15
Days without documented showers: 13
Weight entries for R74: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN SS | Licensed Practical Nurse | Confirmed resident R74 is on weight monitoring program and requires setup assistance with eating; observed resident ate less than 10% of breakfast and 25% of lunch. |
| CNA RR | Certified Nursing Assistant | Delivered food tray to resident R74 and stated she does not assist unless resident has not started eating. |
| LPN TT | Licensed Practical Nurse | Stated resident R74 did not flag as requiring weekly weights. |
| CNA PP | Certified Nursing Assistant | Member of restorative team responsible for obtaining weights; was not aware resident R74 required weekly weights and was pulled off floor. |
| Registered Dietician | Communicated recommendations for resident R74 including increased oral supplements and weekly weights. | |
| DHS | Director of Health Services | Confirmed resident R74 had significant weight loss and weights were not obtained weekly as recommended; explained CNA PP was responsible for weights. |
| Administrator | Confirmed skin treatment around gastrostomy tube should be done by nurses and resident R732 was not assessed for self-administration. | |
| Maintenance Director | Confirmed PTAC filters are cleaned monthly but filters in rooms 116 and 117 were dirty and needed cleaning. | |
| Housekeeping Director | Explained housekeeping responsibilities and acknowledged delay in cleaning room 115. | |
| Director of Nursing | Stated facility did not follow through with shower documentation audits. |
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA0000231743 and #GA00243432.
Complaint Details
Complaints #GA0000231743 and #GA00243432 were investigated and found to be unsubstantiated.
Findings
The complaints #GA0000231743 and #GA00243432 were unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PruittHealth - Augusta Hills, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report summarizes deficiencies found during the inspection completed on 2023-10-05 at PruittHealth - Augusta Hills. Specific deficiencies are not detailed in the provided text or image.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
A revisit survey was conducted from 9/25/23 through 10/5/23 to verify correction of deficiencies cited in the 8/17/23 Revisit Survey.
Findings
All deficiencies cited as a result of the 8/17/23 Revisit Survey were found to be corrected.
Report Facts
Census: 87
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 0
Date: Oct 5, 2023
Visit Reason
A revisit survey was conducted from 9/25/23 through 10/5/23 to follow up on deficiencies cited in the 6/15/23 Recertification Survey and to investigate multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00236395, GA00237264, GA00237450, GA00237561, GA00238539, GA00239041 were unsubstantiated. Intake Numbers GA00237785 and GA00239496 were substantiated without deficiencies.
Findings
All deficiencies cited in the 6/15/23 Recertification Survey were found to be corrected. Several complaint investigations were unsubstantiated, and two complaint intakes were substantiated without deficiencies.
Report Facts
Complaint Intake Numbers: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - AUGUSTA HILLS, indicating regulatory oversight and corrective actions following an inspection.
Findings
The document contains a summary statement of deficiencies identified during the inspection, but no specific deficiencies or findings are detailed on the page provided.
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 3
Date: Aug 17, 2023
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid regulations following a prior survey. The visit focused on the Recertification Survey.
Findings
The facility failed to maintain sanitary conditions in the kitchen, including inadequate cleaning of the oven, range, and refrigerator, uncovered prepared tea glasses during meal service, and improper storage of cleaning chemicals. These deficiencies had the potential to affect 79 residents receiving an oral diet.
Deficiencies (3)
Failed to ensure routine cleaning of the oven, range, and refrigerator.
Failed to cover prepared tea glasses during meal service.
Failed to store cleaning chemicals appropriately in the kitchen.
Report Facts
Residents affected: 79
Census: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook AA | Cook | Provided information on cleaning schedules and procedures |
| Dietary Aide BB | Dietary Aide | Provided information on cleaning responsibilities and chemical shelf replacement |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding cleaning practices and kitchen conditions |
| Maintenance Director | Maintenance Director | Mentioned in relation to cleaning and maintenance of kitchen equipment and shelves; not available for interview |
| Assisting Administrator | Assisting Administrator | Verified deficiencies and stated expectations for cleaning and maintenance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate medication administration practices and kitchen sanitation standards at Pruitthealth - Augusta Hills nursing home.
Findings
The facility failed to ensure the medication error rate was 5% or less, with a 6.45% error rate observed in eye drop administration for one resident. Additionally, the main kitchen was not kept clean and sanitary, with issues including rusty ceilings, rusty refrigerator racks, and stained stainless-steel prep tables, potentially affecting 73 of 81 residents receiving an oral diet.
Deficiencies (2)
Failed to ensure medication error rates were not 5 percent or greater, with a 6.45% error rate observed in eye drop administration.
Failed to ensure the main kitchen was kept clean and sanitary, including rusty ceilings, rusty refrigerator racks, and stained stainless-steel prep tables.
Report Facts
Medication error rate: 6.45
Residents affected by kitchen sanitation: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN DD | Licensed Practical Nurse | Observed administering eye drops incorrectly |
| Director of Health Services | Provided correct procedure for eye drop administration and expectations | |
| Dietary Manager | Acknowledged kitchen sanitation issues during interviews | |
| Administrator | Acknowledged kitchen sanitation issues and staff responsibilities |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
The inspection was conducted to evaluate medication administration practices and the cleanliness and sanitation of the main kitchen in the facility.
Findings
The facility failed to ensure the medication error rate was 5% or less, with a 6.45% error rate observed in eye drop administration for one resident. Additionally, the main kitchen was not kept clean and sanitary, with issues including rusty ceilings, rusty refrigerator racks, and stained stainless-steel prep tables, potentially affecting 73 of 81 residents receiving an oral diet.
Deficiencies (2)
Medication error rate exceeded 5%, specifically in the administration of eye drops to Resident #28.
Failure to maintain cleanliness and sanitation in the main kitchen, including rusty ceilings, rusty refrigerator racks, and stained stainless-steel prep tables.
Report Facts
Medication error rate: 6.45
Medication errors: 2
Residents affected: 73
Total residents receiving oral diet: 81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Observed administering eye drops incorrectly |
| Director of Health Services | Provided correct procedure for eye drop administration | |
| Dietary Manager | Acknowledged kitchen cleanliness issues | |
| Administrator | Acknowledged kitchen cleanliness issues and staff responsibilities |
Inspection Report
Life Safety
Census: 80
Capacity: 126
Deficiencies: 4
Date: Jun 15, 2023
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructions in means of egress, failure to maintain sprinkler system cleanliness and clearance, and improper installation of electrical equipment. Specific deficiencies included a cart obstructing smoke doors, dusty sprinkler heads, storage too close to sprinkler heads, and a multi power tap improperly installed.
Deficiencies (4)
300 hall smoke doors were obstructed by a cart.
Sprinkler head loaded with dust in the kitchen by the ice machine.
Storage within 18 inches of the sprinkler head in the 200 hall linen closet.
Multi power tap was on the floor in the therapy office and not installed properly.
Report Facts
Census: 80
Total Capacity: 126
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth-Augusta Hills from June 12, 2023 through June 15, 2023 to assess compliance with state health regulations.
Findings
The survey revealed that there were no State Health deficiencies cited during the inspection period.
Inspection Report
Routine
Census: 81
Deficiencies: 2
Date: Jun 15, 2023
Visit Reason
A standard survey was conducted from June 12, 2023 through June 15, 2023, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
Multiple complaint intake numbers were investigated; some were found unsubstantiated, while others were substantiated without deficiencies.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including a medication error rate exceeding 5% during eye drop administration and failure to maintain cleanliness and sanitation in the main kitchen, specifically regarding routine cleaning of ceilings, stainless steel surfaces, and refrigerators.
Deficiencies (2)
Failed to ensure the medication error rate was 5% or less; observed 2 errors in 31 opportunities for one resident, resulting in a 6.45% error rate during eye drop administration.
Failed to ensure the main kitchen was kept clean and sanitary, including inconsistent routine cleaning of the ceiling, stainless steel surfaces, and refrigerators, potentially affecting 73 of 81 residents receiving an oral diet.
Report Facts
Resident census: 81
Medication error rate: 6.45
Medication error opportunities: 31
Medication errors: 2
Residents potentially affected: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse | Observed administering eye drops incorrectly |
| Director of Health Services | Provided expectations on proper eye drop administration | |
| Dietary Manager | Acknowledged kitchen sanitation issues including rusty ceiling and refrigerator racks | |
| Administrator | Acknowledged kitchen sanitation deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Pruitthealth - Augusta Hills following a survey completed on 01/07/2022.
Findings
No health deficiencies were found during the survey.
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
The inspection was conducted as a licensure survey for the facility.
Findings
No deficiencies were identified during the licensure survey.
Inspection Report
Routine
Census: 74
Deficiencies: 0
Date: Jan 7, 2022
Visit Reason
A standard survey was conducted at Pruitthealth Augusta Hills from January 4, 2022, through January 7, 2022, including investigation of two complaints which were found unsubstantiated.
Complaint Details
Complaints #GA00219488 and #GA00219025 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. No regulatory violations were cited during the survey or complaint investigations.
Inspection Report
Life Safety
Census: 74
Capacity: 126
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and related federal regulations.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/18/2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 8/18/2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 8/18/2021 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 74
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/18/2021 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 8/18/2021; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 8/18/2021 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 26, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00217878.
Complaint Details
Complaint #GA00217878 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 18, 2021
Visit Reason
The inspection was conducted as a Licensure Survey to assess compliance with nursing care requirements, specifically related to pressure ulcer treatments and skin audits for residents at risk.
Findings
The facility failed to provide pressure ulcer treatments as recommended by the Wound Company Nurse Practitioner and failed to perform weekly skin audits to timely identify skin breakdown for three residents reviewed. One resident's pressure ulcer deteriorated from a Deep Tissue Injury to a Stage IV with osteomyelitis. Treatment inconsistencies and missed wound care were documented for multiple residents.
Deficiencies (2)
Failure to provide pressure ulcer treatments as recommended by the Wound Company NP and failure to perform weekly skin audits for timely identification of skin breakdown for resident #6.
Failure to provide wound care treatments as ordered for resident #8, including missed treatments and skin prep applications.
Report Facts
Pressure ulcer measurements: 7
White Blood Count: 21.34
Antibiotic therapy duration: 7
Antibiotic therapy duration: 10
Pressure ulcer measurements: 3.5
Pressure ulcer measurements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Director of Health Services | Provided facility pressure sore management policy and interviewed regarding wound care and treatment failures |
| Wound Company Nurse Practitioner | Nurse Practitioner | Provided wound assessments and treatment recommendations; interviewed regarding treatment failures and wound deterioration |
| Attending Physician | Physician | Interviewed regarding awareness of wound deterioration and treatment oversight |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 6
Date: Aug 18, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00212989, GA00213386, and GA00215752, with complaint GA00212989 substantiated.
Complaint Details
Complaint GA00212989 was substantiated.
Findings
The facility failed to provide pressure ulcer treatments as ordered or recommended and failed to perform weekly skin audits to identify skin breakdown timely for three residents (R#6, R#8, R#9). Resident R#6's sacral pressure ulcer deteriorated from a Deep Tissue Injury to a Stage IV with osteomyelitis. Resident R#8 and R#9 also had failures in treatment provision and skin audits.
Deficiencies (6)
Failure to provide pressure ulcer treatments as ordered or recommended for resident R#6, resulting in deterioration of a sacral pressure ulcer to Stage IV with osteomyelitis.
Failure to perform weekly skin audits for resident R#6 to identify skin breakdown timely.
Failure to provide pressure ulcer treatments as ordered or recommended for resident R#8 from April to August 2021.
Failure to perform weekly skin audits for resident R#8 to identify skin breakdown timely.
Failure to provide pressure ulcer treatments as ordered or recommended for resident R#9 from May to August 2021.
Failure to perform weekly skin audits for resident R#9 to identify skin breakdown timely.
Report Facts
Resident census: 80
Days treatments missed: 20
Days treatments missed: 6
Days treatments missed: 16
Days treatments missed: 4
Days treatments missed: 22
Days treatments missed: 18
Days treatments missed: 8
Days treatments missed: 27
Days treatments missed: 26
Days treatments missed: 18
Days treatments missed: 1
Days treatments missed: 1
Days treatments missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Provided facility pressure sore management policy and described treatment order entry process | |
| Licensed Practical Nurse (LPN) Treatment Nurse | Described wound treatment documentation and order entry process | |
| Wound Company Nurse Practitioner | Provided wound assessments and treatment recommendations | |
| Resident's Attending Physician | Interviewed regarding awareness of wound care and treatment |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Date: Feb 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 2/9/2021 to 2/15/2021, including an Abbreviated/Partial Extended Survey to investigate complaint GA00211518.
Complaint Details
Complaint GA00211518 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations. The complaint was unsubstantiated with no deficiencies identified.
Report Facts
Facility census: 69
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Jan 26, 2021
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.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00203259 and #GA00206581.
Complaint Details
Complaints #GA00203259 and #GA00206581 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints #GA00203259 and #GA00206581 were unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 23, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00208628, #GA00207025, #GA00199080, #GA00198557, and #GA00199666 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Routine
Census: 77
Deficiencies: 0
Date: Jun 3, 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 483.83 for emergency preparedness and 42 CFR 483.80 for infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 31, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00196765, GA00197017, and GA00198163 from 7/29/19 to 7/31/19.
Complaint Details
The complaints GA00196765, GA00197017, and GA00198163 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were unsubstantiated and no deficiencies were identified.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 22, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00195317 from March 20, 2019 to March 22, 2019.
Complaint Details
Complaint GA00195317 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was found to be unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 26, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA001941981 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA001941981 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Routine
Census: 79
Deficiencies: 0
Date: Nov 29, 2018
Visit Reason
A standard survey was conducted at Pruitthealth Augusta Hills from November 26, 2018 through November 29, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 80
Capacity: 124
Deficiencies: 2
Date: Nov 29, 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 due to failure to maintain fire sprinkler systems and components, including loaded sprinkler heads in multiple resident rooms, and failure to keep power strips off the floor under desks, posing fire risks to residents and staff.
Deficiencies (2)
Failure to maintain fire sprinkler systems and components, including loaded sprinkler heads in resident rooms 212 D, 106 D, 318 W, 312 W, and 310 D.
Failure to keep power strips off the flooring under desks in the Physical Therapy Office and Care Planning Office.
Report Facts
Census: 80
Total Capacity: 124
Number of deficient sprinkler heads: 5
Number of locations with power strips on floor: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who accompanied surveyor during facility tour and confirmed findings |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 23, 2018
Visit Reason
An abbreviated survey was conducted at Pruitt Health - Augusta Hills on 5/23/18 to investigate Complaint Intake Number GA000188509.
Complaint Details
Investigation of Complaint Intake Number GA000188509; no deficiencies were found.
Findings
Based on findings, no deficiencies were cited during the abbreviated survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 20, 2018
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 survey tags have been corrected.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: Mar 30, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey of 1/25/18.
Findings
All deficiencies cited as a result of the Recertification survey of 1/25/18 were found to be corrected.
Inspection Report
Follow-Up
Census: 84
Deficiencies: 4
Date: Mar 19, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies related to emergency preparedness and fire safety.
Findings
The facility was substantially compliant with the Emergency Preparedness plan; however, deficiencies remained in the fire sprinkler system maintenance and testing, and corridor door smoke tightness. Specifically, data plates for the fire sprinkler riser system were not installed, corroded and loaded sprinkler heads in the kitchen cooler and freezer were not corrected, wiring on sprinkler piping above ceilings was not removed, and a resident room door was not repaired to be smoke tight.
Deficiencies (4)
Failure to install data plates for the fire sprinkler riser system.
Corroded and loaded sprinkler heads in kitchen cooler and freezer not corrected.
Wiring on fire sprinkler piping above ceilings not removed.
Resident room door (room 106) not repaired at the top leading edge to be smoke tight.
Report Facts
Residents at risk: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the facility tour. |
Inspection Report
Routine
Census: 84
Deficiencies: 2
Date: Jan 25, 2018
Visit Reason
A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations related to long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies related to failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes, and failure to provide appropriate catheter care and infection control for residents with urinary catheters.
Deficiencies (2)
Failure to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes for residents with urinary catheters.
Failure to provide appropriate treatment and care for residents with urinary drainage catheters, including failure to change catheters as ordered and improper positioning of catheter tubing and drainage bags.
Report Facts
Resident census: 84
Residents sampled: 20
Residents with catheter deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding catheter care for Resident #36 |
| AA | Certified Nurse Assistant (CNA) | Interviewed regarding catheter care for Resident #36 |
| CC | Licensed Practical Nurse (LPN), Unit Manager | Interviewed regarding catheter care documentation for Resident #36 |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 25, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care standards, specifically regarding the care and management of urinary drainage catheters for sampled residents.
Findings
The facility failed to provide appropriate care for two residents with urinary catheters: Resident #36's suprapubic catheter was not changed as ordered by the physician, and Resident #109's Foley catheter tubing and drainage bag were found lying on the floor, violating infection control policies.
Deficiencies (2)
Failure to change Resident #36's suprapubic catheter monthly as ordered by the physician.
Resident #109's Foley catheter tubing and drainage bag were positioned on the floor, risking contamination and improper infection control.
Report Facts
Date of survey completion: Jan 25, 2018
Brief Interview for Mental Status (BIMS) score: 15
Brief Interview for Mental Status (BIMS) score: 3
Admission date: Aug 23, 2011
Admission date: Dec 4, 2017
Hospital admission period: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding catheter change for Resident #36; did not know when catheter was last changed. |
| AA | Certified Nursing Assistant (CNA) | Interviewed about catheter care for Resident #36; stated catheter bag should be off the floor. |
| DON | Director of Nursing | Confirmed no documentation of catheter changes for Resident #36. |
| CC | Licensed Practical Nurse (LPN), Unit Manager | Interviewed about catheter change for Resident #36; no documentation found to confirm catheter change. |
| Infection Control Coordinator | Registered Nurse (RN) | Interviewed about infection control practices; instructed staff to keep catheter bags off the floor. |
| LPN | Licensed Practical Nurse | Assigned to Resident #109; denied seeing catheter tubing or bag on the floor. |
| CNA | Certified Nurse's Assistant | Assigned to Resident #109; denied seeing catheter tubing or bag on the floor. |
Inspection Report
Life Safety
Census: 84
Capacity: 126
Deficiencies: 14
Date: Jan 23, 2018
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness, means of egress, emergency lighting, fire alarm system maintenance, sprinkler system maintenance, fire extinguisher placement, corridor doors, smoke barriers, electrical systems, HVAC maintenance, space heater use, and oxygen cylinder storage. These deficiencies could place residents at risk in the event of an emergency or fire.
Deficiencies (14)
Emergency Preparedness Plan was not site specific and did not address all identified hazards.
Light fixtures in dining room walking path lower than 6 feet 8 inches from floor.
Emergency lighting not provided from main entrance to public way.
Sleeping room smoke detectors not tested and no maintenance program in place.
Smoke detector outside Hall 200 corridor doors in air flow stream of HVAC supply.
Fire alarm inspection report identified 6 smoke detector sensitivity readings outside manufacturer's listing with no repairs made.
Fire sprinkler system deficiencies including improperly installed heads, corrosion, no data plate on riser, wiring on piping, untested backflow, and painted heads.
Fire extinguishers mounted too high.
Corridor smoke doors failed to latch or create smoke resistant seal.
Smoke barriers not properly constructed or maintained with penetrations and incomplete wall assemblies.
Electrical system deficiencies including use of extension cords as permanent wiring, flexible cords through ceilings, and open junction boxes with exposed wiring.
HVAC systems not serviced as required.
Space heater used in HR office.
Oxygen cylinders stored outside in open wooden structure with no protection from unauthorized entry.
Report Facts
Residents at risk: 84
Census: 84
Total capacity: 126
Smoke detector sensitivity readings out of range: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and interviews. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA 00181198 and #GA 00178115 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Investigation of complaints #GA 00181198 and #GA 00178115 found no deficiencies.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health Augusta Hills.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 20, 2017
Visit Reason
A follow-up inspection was conducted to verify correction of previously identified deficiencies.
Findings
The deficiencies identified in the prior inspection had been corrected as of the follow-up visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
The visit was a Health Revisit conducted to determine if all deficiencies cited during the Standard Survey of 1/27/2017 had been corrected.
Findings
It was determined that all deficiencies cited during the Standard Survey of 1/27/2017 had been corrected.
Inspection Report
Life Safety
Census: 85
Capacity: 94
Deficiencies: 0
Date: Jan 24, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and related standards during the survey.
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