Inspection Reports for Pruitthealth – Bethany
466 SOUTH GRAY STREET, MILLEN, GA, 30442
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 1, 2025, found no deficiencies, confirming that previously cited issues were corrected. Prior inspections showed a mixed history with several deficiencies related mainly to infection control during medication administration, documentation of vaccine consent, and fire safety maintenance including sprinkler head cleanliness and power strip placement. A substantiated complaint investigation in mid-2024 identified Immediate Jeopardy conditions related to neglect during care that resulted in a resident’s fatal fall, but the facility took corrective actions and removed the Immediate Jeopardy shortly thereafter. Other complaint investigations were mostly unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The trend indicates improvement as recent surveys have verified correction of earlier cited deficiencies.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
83 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - BETHANY, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
A revisit survey was conducted from 6/30/2025 to 7/1/2025 to verify correction of deficiencies cited in the 5/8/2025 recertification survey with complaints.
Findings
All deficiencies cited as a result of the 5/8/2025 recertification survey with complaints were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 1, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags had been corrected as of the follow-up survey date.
Inspection Report
Life Safety
Census: 75
Capacity: 100
Deficiencies: 2
Date: May 19, 2025
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 fire safety requirements, specifically failing to maintain clean sprinkler heads and ensuring no power strips were on the floor, affecting 15 and 5 individuals respectively in the affected areas.
Deficiencies (2)
Facility failed to ensure sprinkler heads were clean, with sprinkler heads under the front porch roof area full of dirt and dust.
Facility failed to ensure that there were no power strips on the floor in the activities office.
Report Facts
Number of individuals affected by dirty sprinkler heads: 15
Number of individuals affected by power strips on floor: 5
Census: 75
Total licensed capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of dirty sprinkler heads and power strips on the floor during the tour of the facility |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 8, 2025
Visit Reason
A State Licensure survey was conducted from May 5, 2025, through May 8, 2025, to assess compliance with state health regulations at Pruitthealth Bethany.
Findings
The survey identified deficiencies including failure to maintain infection control during medication administration for one resident and failure to document consent or refusal for influenza and pneumococcal vaccines for three residents, potentially increasing their risk of infection.
Deficiencies (2)
Failure to ensure infection control during medication administration, including handling pills with bare hands and not discarding dropped pills.
Failure to offer or document consent/refusal for influenza and pneumococcal vaccines for three residents, increasing risk of influenza and pneumonia.
Report Facts
Residents observed for infection control: 3
Residents with vaccine consent/refusal documentation issues: 3
Sample residents reviewed for vaccine documentation: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided expectations regarding medication administration and vaccine consent procedures |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Observed administering medication improperly by handling pills with bare hands |
| Registered Nurse-Clinical Competency Coordinator | Registered Nurse-Clinical Competency Coordinator | Provided information regarding flu and pneumococcal vaccine documentation |
| Registered Nurse 1 | Registered Nurse | Described admission process for vaccination documentation |
Inspection Report
Routine
Census: 76
Deficiencies: 4
Date: May 8, 2025
Visit Reason
A standard survey was conducted by Healthcare Management Solutions, LLC, on behalf of the Georgia Department of Community Health, at Pruitthealth Bethany from May 5, 2025, through May 8, 2025, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found noncompliant with several Medicare/Medicaid regulations including failure to monitor targeted behaviors for antidepressant use, failure to maintain infection control during medication administration, inadequate antibiotic stewardship program, and failure to document consent or refusal for influenza and pneumococcal vaccinations for some residents.
Deficiencies (4)
Failure to monitor targeted behaviors for the use of an antidepressant medication for one of five residents reviewed for unnecessary medications.
Failure to ensure infection control during medication administration for one of three residents observed, including touching pills with bare hands.
Failure to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing antibiotics for two of three residents reviewed.
Failure to offer or provide documentation of consent or refusal for influenza and/or pneumococcal vaccines for three of five residents reviewed.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents sampled: 23
Residents observed for medication administration: 3
Residents reviewed for antibiotic stewardship: 3
Residents reviewed for vaccination documentation: 5
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Confirmed no targeted behavior monitoring for R40 and discussed infection control and antibiotic stewardship issues. | |
| Licensed Practical Nurse 5 | Observed handling pills with bare hands during medication administration to R20. | |
| Registered Nurse-Clinical Competency Coordinator | Provided information regarding flu and pneumococcal vaccines. | |
| Registered Nurse 1 | Described admission process for vaccination documentation. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the prior survey dated July 11, 2024.
Findings
All deficiencies cited in the July 11, 2024 survey were found to be corrected during the revisit survey on September 5, 2024.
Inspection Report
Abbreviated Survey
Census: 85
Deficiencies: 4
Date: Jul 24, 2024
Visit Reason
An abbreviated survey was conducted from July 22 to July 24, 2024, to verify the removal of an Immediate Jeopardy identified during a complaint survey conducted from July 2 to July 11, 2024.
Complaint Details
The visit was complaint-related due to an Immediate Jeopardy identified on July 9, 2024, related to neglect causing serious injury and death of resident R1 on June 30, 2024. The Immediate Jeopardy was validated as removed on July 12, 2024.
Findings
The facility failed to protect a resident (R1) from neglect during Activities of Daily Living care, resulting in a fall with fatal injuries. The Immediate Jeopardy was removed by July 12, 2024, after corrective actions including staff education, care plan updates, and audits. The facility remained out of compliance at a lower scope and severity for deficiencies related to abuse, care planning, accident hazards, and administration.
Deficiencies (4)
Failed to protect resident R1 from neglect during ADL care, resulting in a fall with fatal head injury.
Failed to develop an accurate person-centered comprehensive care plan specifying two-person assistance for R1.
Failed to provide adequate assistance for bed mobility for R1, resulting in fall and death.
Failed to ensure facility administration oversight to prevent neglect resulting in resident fall and death.
Report Facts
Resident census: 85
Length of head laceration: 14
Time to death post fall: 50
Staff in-serviced: 69
Residents interviewed for abuse/neglect: 40
Residents body audited: 43
Residents requiring two-person assist: 35
Residents requiring one-person assist: 24
Residents independent with ADL: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in neglect incident causing resident fall and death; terminated on July 10, 2024 |
| Senior Nurse Consultant | Informed of Immediate Jeopardy on July 9, 2024; provided education and oversight | |
| Area Vice President | Reviewed policies and conducted meetings related to the incident and corrective actions | |
| Director of Health Services | DHS | Resigned July 9, 2024; involved in education and oversight |
| Interim Administrator | Administrator | Assumed role July 9, 2024; educated on incident and responsibilities |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 4
Date: Jul 2, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint number GA00248212, which was substantiated. The investigation focused on a fall incident involving resident R1 during Activities of Daily Living (ADL) care.
Complaint Details
Complaint number GA00248212 was substantiated. The investigation revealed Immediate Jeopardy conditions related to neglect and inadequate care resulting in a resident fall and death. The Immediate Jeopardy was identified as existing on 2024-06-30 and was ongoing at the time of exit on 2024-07-11.
Findings
The facility was found to have Immediate Jeopardy noncompliance related to neglect during ADL care, failure to develop an accurate care plan specifying two-person assistance, and failure to provide adequate supervision to prevent a fall resulting in resident R1's death. The facility administration failed to ensure resident safety and effective oversight.
Deficiencies (4)
Failure to protect resident R1 from neglect during ADL care, resulting in a fall with fatal injuries.
Failure to develop an accurate person-centered comprehensive care plan specifying the need for two-person assistance with ADL care for resident R1.
Failure to provide adequate assistance and supervision to prevent resident R1 from falling during ADL care.
Failure of facility administration to ensure resident safety and effective oversight as required by job descriptions.
Report Facts
Resident census: 85
Date of fall incident: Jun 30, 2024
Laceration size: 14
Time to death post-fall: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA CC | Certified Nursing Assistant | Named in neglect finding for providing unassisted ADL care leading to resident fall |
| LPN BB | Licensed Practical Nurse | Provided care and assessment after fall; interviewed regarding incident |
| RN EE | Registered Nurse | Assessed resident after fall and provided emergency care |
| RN AA | Registered Nurse/Weekend Supervisor | Responded to fall incident, called 911, and assisted with emergency care |
| Administrator HH | Facility Administrator | Responsible for facility oversight; suspended CNA CC pending investigation |
| DHS | Director of Health Services | Responsible for nursing services oversight; involved in investigation and suspension of CNA CC |
Inspection Report
Deficiencies: 0
Date: Nov 14, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a healthcare facility inspection conducted at PruittHealth - Bethany.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 0
Date: Nov 14, 2023
Visit Reason
A revisit survey was conducted on 11/13/23 through 11/14/23 to verify correction of deficiencies cited in the previous 9/28/23 survey.
Findings
All deficiencies cited as a result of the 9/28/23 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Sep 28, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth-Bethany from September 25, 2023 through September 28, 2023 to assess compliance with state health regulations.
Findings
The facility failed to ensure residents' rooms and bathrooms were safe and maintained, with multiple maintenance issues including missing threshold strips, missing baseboards, rusted assistive devices, rust-colored substances on toilets and faucets, peeling paint on heaters, holes in floors, buckling doors, and broken or missing bathroom tiles.
Deficiencies (9)
Missing threshold strips on one or both sides of bathroom entrances in multiple resident rooms creating uneven surfaces.
Missing baseboards in resident rooms 101, 103, and 127.
Over the toilet assistive device in disrepair with rust-colored substance on all four legs.
Bathroom toilets with rust-colored substance covering the inside surface in several resident rooms.
Bathroom sink faucets rusted and/or constantly dripping in multiple resident rooms.
Rust-colored heaters on walls with peeling paint in multiple resident rooms.
Holes in floors filled with white caulking where old heaters were removed in rooms 121 and 123.
Doors buckling with loose laminate and sharp edges, including holes in bathroom doors.
Broken or missing bathroom tiles in several resident rooms.
Report Facts
Rooms with deficiencies: 24
Work orders pending: 25
Sinks needing replacement: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Provided statements regarding temporary fixes, condition of facility, and number of sinks needing replacement. |
Inspection Report
Standard Survey Complaint Investigation
Census: 85
Deficiencies: 2
Date: Sep 28, 2023
Visit Reason
A standard survey was conducted from September 25 through September 28, 2023, including investigation of three complaint intake numbers (GA00235237, GA00235306, GA00235340) which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00235237, GA00235306, and GA00235340 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe and poorly maintained resident rooms and bathrooms, missing physician orders for oxygen administration and tracheostomy care, and multiple maintenance issues such as rust, missing threshold strips, and damaged fixtures.
Deficiencies (2)
Residents' rooms and bathrooms were unsafe and not maintained to promote a pleasant and homelike environment in 24 of 53 rooms, including missing threshold strips, missing baseboards, rusted assistive devices, rust-colored substances on toilets and faucets, rust-colored heaters with peeling paint, holes in floors, buckling doors, and broken or missing bathroom tiles.
Failure to have a physician order for administering oxygen for one resident and failure to have a physician order for tracheostomy size and type for another resident, placing residents at risk for respiratory issues.
Report Facts
Resident census: 85
Rooms with deficiencies: 24
Work orders pending: 25
Oxygen liters: 3
Sinks needing replacement: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance issues and work orders | |
| Licensed Practical Nurse 2 | LPN | Confirmed no physician order for oxygen for resident R66 |
| Director of Nursing | DON | Confirmed lack of physician orders for oxygen and tracheostomy care for residents R66 and R81 |
| Minimum Data Set Coordinator | Confirmed no physician orders for tracheostomy size and type for resident R81 |
Inspection Report
Life Safety
Census: 83
Capacity: 100
Deficiencies: 12
Date: Sep 27, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including obstructions in fire doors, patient room doors, corridors, exit discharge, fire alarm system battery markings, sprinkler system maintenance, smoke barrier sealing, and electrical safety issues.
Deficiencies (12)
Fire doors blocked by a wheelchair in Short Hills Hall affecting 20 patients.
Patient room door obstructed by privacy curtain in room 137 affecting 20 patients.
Corridor obstructed by stored items (patient scales) in nursing station common area affecting 40 patients.
Exit discharge blocked by a chair at chapel exit affecting 30 patients.
Fire alarm batteries not properly marked affecting 83 patients.
Sprinkler head flow obstructed by fixture/object in riser room affecting 25 patients.
Sprinkler system yellow tagged due to replacement of sprinkler heads affecting entire building (83 patients).
Wires supported by sprinkler piping affecting entire building (83 patients).
Fire/smoke wall not properly sealed in nursing station commons area affecting 30 patients.
Multi tap (Multiple Outlet Power Strips) improperly installed in activity and finance offices affecting 10 staff and patients.
Exposed wires in kitchen disconnect affecting 15 patients.
J boxes missing covers in infirmary and nursing common area attic affecting 20 patients.
Report Facts
Patients affected: 20
Patients affected: 20
Patients affected: 40
Patients affected: 30
Patients affected: 83
Patients affected: 25
Patients affected: 83
Patients affected: 83
Patients affected: 30
Staff and patients affected: 10
Patients affected: 15
Patients affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour on 09/27/2023 |
Inspection Report
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility PRUITTHEALTH - BETHANY, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Life Safety
Census: 78
Capacity: 100
Deficiencies: 0
Date: Apr 19, 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 compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Report Facts
Certified beds: 100
Census: 78
Inspection Report
Original Licensing
Census: 78
Deficiencies: 1
Date: Apr 14, 2022
Visit Reason
A Licensure Survey was conducted from 04/11/22 through 04/14/22 to assess compliance with licensure requirements.
Findings
The facility failed to ensure proper consistency of pureed meats for nine residents on pureed texture diets, posing a choking risk and potentially decreasing resident intake. The pureed food was observed to be dry, flaky, and not smooth as required.
Deficiencies (1)
Failure to ensure proper consistency of pureed meats for nine residents on pureed texture diets, resulting in a product that was dry, flaky, and not smooth.
Report Facts
Residents on pureed texture diets: 9
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Provided information about the broken Robot Coupe and pureed food preparation |
| Dietary Aide 1 | Dietary Aide | Observed pureeing diced chicken with a small blender |
| Speech Therapist | Speech Therapist | Provided observations on resident swallowing and pureed food texture |
| Certified Nurse Aide 2 | Certified Nurse Aide | Assisted resident with pureed meal and commented on food texture |
Inspection Report
Routine
Census: 77
Deficiencies: 5
Date: Apr 14, 2022
Visit Reason
A standard survey was conducted from 4/11/22 through 4/14/22 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to assess resident for self-administration of medications, failure to encode and transmit resident assessments timely, failure to maintain nutritional status for a resident with significant weight loss, failure to maintain respiratory equipment and emergency tracheostomy supplies, and failure to provide pureed food in proper consistency.
Deficiencies (5)
Failure to ensure one resident had a physician's order and was assessed for self-administration of medications prior to bedside storage and self-administration.
Failure to encode and transmit Minimum Data Set (MDS) assessments timely for two residents.
Failure to maintain acceptable nutritional parameters resulting in significant weight loss for one resident.
Failure to maintain oxygen equipment including changing and dating tubing, cleaning filters, and storing nasal cannula tubing properly for three residents; failure to maintain emergency tracheostomy equipment for one resident.
Failure to provide pureed meats with proper smooth consistency for nine residents on pureed texture diets.
Report Facts
Resident census: 77
Residents reviewed for self-administration: 24
Weight loss: 10.4
Residents on pureed texture diets: 9
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Noted missing ambu bag in emergency tracheostomy kit and lack of documentation for kit checks |
| LPN2 | Licensed Practical Nurse | Confirmed improper oxygen equipment maintenance and incorrect oxygen flow rate for resident |
| Director of Nursing | Director of Nursing | Confirmed deficiencies in medication self-administration assessment, oxygen equipment maintenance, and emergency trach kit management |
| Dietary Manager | Dietary Manager | Reported broken Robot Coupe blender affecting pureed food consistency |
| Speech Therapist | Speech Therapist | Confirmed improper texture of pureed food |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Verified resident self-administered medication without assessment |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Assisted resident with pureed meal and noted resident's dislike of grainy texture |
Inspection Report
Deficiencies: 0
Date: Nov 3, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility PRUITTHEALTH - BETHANY, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Date: Nov 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 28, 2020 Complaint Survey.
Complaint Details
This revisit survey followed a complaint survey conducted on August 28, 2020. The deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited as a result of the August 28, 2020 Complaint Survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 3
Date: Aug 28, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint intake #GA00207476 and #GA00203326. The visit was complaint-related due to concerns about resident safety and care related to bedrails and mattress use.
Complaint Details
Complaint intake #GA00207476 was substantiated with deficiencies related to resident safety and care planning. Complaint intake #GA00203326 was unsubstantiated.
Findings
The facility was found to be out of compliance with federal regulations related to bedrails and comprehensive care plans. A resident (R#1) was found deceased with her head and neck entrapped between the assist rail and mattress due to a gap caused by a standard mattress placed on a bariatric bed. The facility failed to develop and implement appropriate care plans, obtain informed consent for assistive devices, and ensure proper mattress and bedrail safety. Immediate Jeopardy was identified and removed after corrective actions including audits, staff education, and family notification were implemented.
Deficiencies (3)
Failure to develop and implement a comprehensive care plan for assist rails for one resident (R#1).
Failure to ensure correct installation, use, and maintenance of bedrails, including risk of entrapment between mattress and assist rails.
Failure to obtain informed consent and attempt alternatives prior to use of assist rails for 12 residents.
Report Facts
Resident census: 72
Beds with assist rails: 12
Beds with air mattresses and assist rails: 2
Residents assessed for assist rails: 13
Residents with informed consent obtained: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Described process for obtaining physician orders and care plan updates for assist rails |
| Hospice RN SS | Hospice Registered Nurse | Primary nurse for R#1 who ordered mattress but did not request bariatric bed or assist rails |
| DHS | Director of Health Services | Provided oversight and described facility processes for equipment ordering and care planning |
| Maintenance Director | Maintenance Director | Responsible for bed equipment installation and monthly audits |
| CCC | Clinical Competency Coordinator | Provided education and oversight of care plan updates and staff training |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy and involved in investigation |
| OT RR | Occupational Therapist | Conducted assessments for assist rails and alternatives |
| Family of R#1 | Reported no notification or consent given for assist rails |
Inspection Report
Renewal
Deficiencies: 6
Date: Aug 28, 2020
Visit Reason
A Licensure Survey was conducted from 8/18/2020 through 8/28/2020 to assess compliance with safety regulations and proper use of assist rails and equipment in the facility.
Findings
The facility failed to provide an environment free from the risk of entrapment between the assist rail and air mattress for one resident, resulting in a fatality, and failed to obtain informed consent or attempt alternative methods for the use of assist rails for 12 of 13 residents. Multiple deficiencies were found related to documentation, assessment, and safety monitoring of assistive devices and bedrails.
Deficiencies (6)
Failure to provide an environment free from risk of entrapment between assist rail and air mattress for one resident resulting in death.
Failure to obtain informed consent and attempt alternative methods for use of assist rails for 12 of 13 residents.
Lack of documentation of physician orders, assessments, and care plans for assist rails prior to use.
Failure to complete timely Restraint-Adaptive Equipment Use Assessments and document alternatives to assist rails.
Inadequate communication and documentation processes for ordering, delivering, and installing assistive devices and bedrails.
Maintenance department lacked tracking system for modified beds and equipment, leading to residents being placed in beds with inappropriate equipment.
Report Facts
Residents with assist rails lacking informed consent: 12
Residents assessed with assist rails: 13
Dates of survey: Survey conducted from 2020-08-18 through 2020-08-28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN EE | Licensed Practical Nurse | Stated expectation for staff to be alert to resident environment concerns and report immediately. |
| Hospice RN SS | Hospice Registered Nurse | Primary nurse for resident #1, made equipment recommendations, did not request assist rails or bariatric bed, and did not report safety concerns. |
| Social Services (SS) | Social Services Staff | Assisted with resident #1's room move, did not observe concerns with assist rails or bariatric bed. |
| LPN HH | Licensed Practical Nurse | Signed for low air flow mattress delivery, did not verify correct mattress size or notify maintenance. |
| CNA AA | Certified Nursing Assistant | Provided care to resident #1, observed bedrails and mattress but did not report concerns. |
| CNA BB | Certified Nursing Assistant in training | Found resident #1 on floor, alerted charge nurse, had no training on bedrails safety. |
| RN FF | Registered Nurse | Responded to resident #1 fall, observed gap between mattress and assist rail. |
| RN JJ | Agency Rapid Response Nurse | Assigned to resident #1's hall, assisted after fall, observed gap between mattress and assist rail. |
| Rehab Manager | Rehabilitation Manager | Reported lack of documentation and process for occupational therapy assessments and equipment use. |
| Director of Health Services (DHS) | Director of Health Services | Described process failures in equipment ordering, delivery, installation, safety assessments, and care plan updates. |
| Maintenance Director | Maintenance Director | Reported lack of tracking system for modified beds and equipment, monthly bed inspections do not track care plans or orders. |
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted on July 30-31, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 71
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 0
Date: Jun 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's 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 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 10, 2020
Visit Reason
An unannounced abbreviated/partial extended survey was conducted to investigate complaint #GA00202635.
Complaint Details
Investigation of complaint #GA00202635; no deficiencies were found.
Findings
No deficiencies were cited during the investigation.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 2019
Visit Reason
A follow-up to the Recertification survey of August 15, 2019 was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 29, 2019.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 1, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The Emergency Preparedness plan was reviewed and found to be in substantial compliance with the requirements set forth in Appendix Z. All previously cited survey tags were noted as corrected.
Inspection Report
Life Safety
Census: 86
Capacity: 100
Deficiencies: 5
Date: Aug 14, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain handrails, vertical openings, fire alarm systems, sprinkler systems, and smoking regulations, placing residents and staff at risk in the event of a fire.
Deficiencies (5)
Failed to maintain handrails or its components; handrail was off and laying on stairs outside the Nurses Station exit.
Failed to maintain vertical openings; ceiling tiles missing from the telephone room (IT closet).
Failed to maintain fire alarm system and/or its components; smoke detector in oxygen room was within 3 feet of HVAC discharge vent.
Failed to maintain fire sprinkler systems and/or its components; painted sprinkler heads found in the back hall of kitchen.
Failed to find smoking policy; employee at nurses station desk was unable to locate the smoking policy.
Report Facts
Census: 86
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the tour of the facility |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 7, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194933 from March 6, 2019 to March 7, 2019.
Complaint Details
Complaint GA00194933 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was found to be unsubstantiated with no deficiencies identified during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 30, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00191418.
Complaint Details
Complaint GA00191418 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 13, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 9, 2018
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the standard survey of 5/24/18.
Findings
All deficiencies cited as a result of the standard survey of 5/24/18 were found to be corrected during the revisit survey.
Inspection Report
Life Safety
Census: 77
Capacity: 100
Deficiencies: 6
Date: May 22, 2018
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 not in substantial compliance with fire safety requirements including missing door closers on fire doors, maintenance issues with sprinkler systems, doors failing to close securely, improper use and placement of power strips, and improper storage and handling of oxygen cylinders.
Deficiencies (6)
Door closer for fire door in attic fire wall is missing and door closer missing from the Director of Nursing's office door.
Loaded fire sprinkler head in dietary manager's office, sprinkler heads needing adjustment, missing escutcheon plate, and wiring on sprinkler pipes above clean linen closet.
Fire door will not close secure coming out of kitchen serving line exit, infirmary fire doors will not close secure, janitor door not closing secure in Brannon Hall.
Power strip located on the floor under a desk in the dietary manager's office.
Oxygen cylinders mixed empty with full and signage on oxygen cylinder storage room needs updating.
Some oxygen cylinders in storage closet were not secured and were free standing.
Report Facts
Census: 77
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 6, 2017
Visit Reason
A desk review revisit survey was conducted to verify correction of deficiencies cited during the 5/22/17 through 5/25/17 Recertification Survey.
Findings
All deficiencies cited as a result of the previous recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 29, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 76
Capacity: 100
Deficiencies: 9
Date: May 25, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety and related NFPA standards at Pruitt Health-Bethany.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including malfunctioning egress doors, emergency lighting failures, vertical opening penetrations, sprinkler system issues, corridor door deficiencies, smoke compartment failures, and improper use of electrical equipment.
Deficiencies (9)
Egress door from main dining room to exterior was inoperable due to faulty keypad.
Exit light #19 would not work on 12 volt DC when tested.
Vertical opening in ceiling around sprinkler head into attic of Treatment Room.
Electrical wires and other items laying on or attached to fire sprinkler piping in attic area.
Sprinkler heads loaded with lint and storage heights exceeding 18 inch limit in multiple locations.
Resident door of room 114 would not latch securely due to decorations hung over door.
Door into room 136 had a gap at top leading edge preventing smoke tight seal.
Power strips not mounted off floor in multiple office locations.
Extension cord found in use behind piano in Chapel.
Report Facts
Census: 76
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Apr 2, 2017
Visit Reason
A complaint survey was conducted at Pruitt Health Bethany on April 2, 2017, related to complaint numbers GA00163280 and GA00158669.
Complaint Details
Complaint survey was unsubstantiated with no deficiencies.
Findings
The complaint survey was unsubstantiated with no deficiencies found at the facility.
Report Facts
Complaint numbers: GA00163280 and GA00158669
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