Inspection Report Summary
The most recent inspection on April 30, 2025, found no deficiencies, with follow-up surveys confirming correction of prior issues. Earlier inspections identified deficiencies related to medication administration, environmental cleanliness, and Life Safety Code compliance, including problems with insulin pen use, air filter sanitation, corridor door maintenance, and fire safety measures. Complaint investigations were mostly unsubstantiated, with a few substantiated complaints that did not result in citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent surveys indicating that previously cited deficiencies have been addressed.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
61 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Apr 30, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - GRANDVIEW, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 61
Deficiencies: 0
Apr 30, 2025
Visit Reason
A Health revisit survey was conducted to verify correction of deficiencies cited in the prior Complaint Investigation survey that concluded on March 20, 2025.
Findings
All deficiencies cited as a result of the Complaint Investigation survey were found to be corrected during this revisit survey.
Complaint Details
This visit was a follow-up to a Complaint Investigation survey concluded on March 20, 2025. All prior deficiencies were corrected.
Report Facts
Facility census: 61
Inspection Report
Life Safety
Deficiencies: 0
Apr 28, 2025
Visit Reason
A Life Safety Code Revisit was conducted to verify correction of previously cited Life Safety Code deficiencies.
Findings
All previously cited Life Safety Code deficiencies had been corrected as of the revisit date.
Inspection Report
Renewal
Deficiencies: 0
Mar 20, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Pruitthealth-Grandview.
Findings
No State Health deficiencies were cited during the survey conducted from March 18 through March 20, 2025.
Inspection Report
Routine
Census: 60
Deficiencies: 2
Mar 20, 2025
Visit Reason
A standard survey was conducted at Pruitthealth-Grandview from March 18, 2025, through March 20, 2025, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found noncompliant with Medicare/Medicaid regulations due to deficiencies in medication administration related to insulin pen use for two residents and failure to maintain clean air filters in residents' rooms and common areas, potentially compromising resident health and safety.
Severity Breakdown
SS= D: 1
SS= F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to sanitize the insulin pen before attaching a new needle and improper administration technique leading to potential underdosing for two residents receiving insulin pens. | SS= D |
| Failure to maintain a clean, sanitary, and comfortable environment due to heavily soiled air filters in 42 residents' rooms and a dayroom, increasing risk of respiratory and allergy symptoms. | SS= F |
Report Facts
Residents present: 60
Residents receiving insulin pens: 19
Rooms with dirty air filters: 42
Rooms inspected on Hall A: 15
Rooms inspected on Hall B: 16
Rooms inspected on Hall C: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to swab insulin pen before use |
| LPN BB | Licensed Practical Nurse | Observed not holding insulin pen in place for recommended time during administration |
| Director of Nursing | Director of Nursing | Provided correct insulin pen administration procedure and confirmed annual competency checkoffs |
| Director of Housekeeping | Director of Housekeeping | Confirmed maintenance responsibility for cleaning air filters |
| Maintenance Director | Maintenance Director | Provided logbook documentation of air filter cleaning and replacement |
| Infection Preventionist | Infection Preventionist | Expected air filters to be clean and confirmed maintenance responsibility |
| Administrator | Administrator | Confirmed no specific policy on environmental maintenance and cleaning schedule for air filters |
Inspection Report
Routine
Deficiencies: 3
Mar 19, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in medication administration and environmental maintenance at the nursing facility.
Findings
The facility failed to properly sanitize insulin pens before use and did not hold the insulin pen in place for the recommended time during administration, potentially leading to incorrect dosing for two residents. Additionally, the facility failed to maintain clean air filters in residents' rooms, which posed a risk to residents' respiratory health.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to sanitize the insulin pen before attaching a new needle for Resident R34. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to hold the insulin pen in place for the recommended 6 to 10 seconds during administration for Resident R57, risking insulin leakage and underdosing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain clean PTAC air filters in 42 residents' rooms, resulting in heavily soiled filters that could compromise respiratory health. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 42
Rooms with dirty air filters: 42
Units of insulin administered: 7
Units of insulin prescribed: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed failing to swab insulin pen before use for Resident R34 |
| LPN BB | Licensed Practical Nurse | Observed withdrawing insulin pen immediately without holding for recommended time for Resident R57 |
| Director of Nursing | Director of Nursing | Provided information on correct insulin pen administration procedure |
| Director of Housekeeping | Director of Housekeeping | Confirmed maintenance responsibility for cleaning air filters |
| Maintenance Director | Maintenance Director | Provided logbook documentation and confirmed air filter cleaning schedule |
| Infection Preventionist | Infection Preventionist | Stated expectation that air filters be clean and maintenance responsibility |
Inspection Report
Life Safety
Census: 60
Capacity: 72
Deficiencies: 1
Mar 18, 2025
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with corridor door maintenance requirements affecting one of four smoke compartments. Specifically, two resident doors (rooms A3 and A5) would not properly close or latch, violating NFPA 101 Life Safety Code standards.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Corridor doors were not properly maintained, with two resident doors failing to close or latch properly. | SS= D |
Report Facts
Census: 60
Total Capacity: 72
Number of affected smoke compartments: 1
Number of resident doors not properly closing or latching: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of doors not properly closing or latching during facility tour |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Apr 17, 2024
Visit Reason
An Abbreviated Partial Extended Survey was conducted to investigate complaint GA00241901.
Findings
The complaint GA00241901 was unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaint GA00241901 was investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 28, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected. This was a desk review.
Inspection Report
Deficiencies: 0
Nov 21, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - GRANDVIEW, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report; only an initial comments section is present without further content.
Inspection Report
Re-Inspection
Census: 63
Deficiencies: 0
Nov 21, 2023
Visit Reason
A revisit survey was conducted at Pruitt Health Grandview on November 20-21, 2023, to verify correction of deficiencies cited during the October 5, 2023, Recertification survey combined with a Complaint survey.
Findings
All deficiencies cited in the October 5, 2023, Recertification and Complaint survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Nov 21, 2023
Visit Reason
The visit was a follow-up survey conducted as a desk review to verify correction of previously cited survey deficiencies.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 66
Capacity: 72
Deficiencies: 1
Nov 16, 2023
Visit Reason
A Life Safety Code Federal Monitoring Survey was conducted following a state agency survey to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements due to failure to protect hazardous areas as required by NFPA 101. Specifically, the door to the C Hall Storage Room was not self-closing or automatic closing, affecting one room.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The door to the C Hall Storage Room was not self-closing or automatic closing, failing to protect hazardous areas as required by 2012 NFPA 101 Section 19.3.2.1.3 and 19.3.2.1.5. | SS= D |
Report Facts
Census: 66
Total Capacity: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Present when deficiencies were identified |
Inspection Report
Life Safety
Census: 62
Capacity: 72
Deficiencies: 1
Oct 16, 2023
Visit Reason
A Life Safety Code Survey was 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 due to failure to maintain the proper integrity of electrical panel number 2 in the kitchen area, specifically open slots in the panel, which affects kitchen staff and the kitchen area.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Open slots in electrical panel number 2 in the kitchen area. | SS= D |
Report Facts
Census: 62
Certified beds: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of open slots in electrical panel #2 during facility tour |
Inspection Report
Routine
Deficiencies: 7
Oct 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, physician orders, use of bed rails, food safety, and infection prevention and control.
Findings
The facility failed to ensure accurate Minimum Data Set (MDS) assessments, timely care plan conferences, complete physician orders, proper use and documentation of bed rails, adherence to food safety and hand hygiene practices, and implementation of a water management program to prevent Legionella growth.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure accurate coding of Minimum Data Set (MDS) assessments for five residents, potentially affecting necessary care and services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop a baseline care plan within 48 hours of admission for one resident, increasing risk of ineffective and non-person-centered care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to conduct quarterly care plan conferences in a timely manner for 12 residents, risking lack of timely communication about care and treatment. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure physician orders were in place for two residents, risking inadequate care and services. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain physician orders, assess risks, obtain informed consent, and review risks and benefits for bed rails for 14 residents, increasing risk of entrapment and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain stove hood in good condition, ensure hand hygiene, and prevent foodborne illness during meal preparation and service for 58 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to have a documented water management program including measures to prevent growth of opportunistic water-borne pathogens such as Legionella, potentially affecting all 61 residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for MDS accuracy: 23
Residents reviewed for baseline care plan: 1
Residents reviewed for care plan conferences: 23
Residents reviewed for physician orders: 23
Residents reviewed for bed rail compliance: 23
Residents affected by food safety issues: 58
Residents affected by water management deficiencies: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN Charge Nurse 1 | Licensed Practical Nurse | Confirmed no physician order for dialysis for resident R45 and discussed bed rail use |
| LPN Charge Nurse 2 | Licensed Practical Nurse | Confirmed bed rail use and lack of consent for multiple residents |
| Director of Nursing | Director of Nursing | Discussed baseline care plan completion, physician orders, bed rail assessments and consents |
| MDS Coordinator | Minimum Data Set Coordinator | Confirmed inaccurate MDS coding and care plan conference issues |
| Dietary Manager | Dietary Manager | Discussed stove hood replacement and food safety practices |
| Assistant Dietary Manager | Assistant Dietary Manager | Observed during food service with improper glove use |
| Maintenance Director | Maintenance Director | Discussed water management and Legionella testing deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 5, 2023
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at PruittHealth Grandview.
Findings
The facility was cited for multiple deficiencies including failure to obtain physician orders, conduct assessments, and obtain consents for bed rails for 14 of 23 residents reviewed, lack of a documented water management program to prevent Legionella growth, and failure to maintain the kitchen stove hood and ensure proper hand hygiene practices during food handling.
Deficiencies (4)
| Description |
|---|
| Failure to obtain physician orders, conduct risk assessments, review risks and benefits, and obtain informed consent prior to bed rail installation for 14 of 23 residents, increasing risk of entrapment injuries. |
| Failure to have a documented water management program including measures to prevent growth of opportunistic water-borne pathogens such as Legionella and monitoring procedures. |
| Failure to maintain the kitchen stove hood in good condition; hood was covered with rust including vents. |
| Failure to adhere to proper hand hygiene practices during food handling, including failure to change gloves or sanitize hands between tasks and touching food with contaminated gloves. |
Report Facts
Residents reviewed for bed rail compliance: 23
Residents with bed rail deficiencies: 14
Residents affected by water management deficiency: 61
Residents provided meals from kitchen: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Charge Nurse 2 | Confirmed use of side rails for residents and necessity of bed rails | |
| Certified Nursing Assistant (CNA) 1 | Confirmed residents' use of side rails and need for assistance | |
| LPN Unit Manager 1 | Confirmed lack of annual side rail assessments and consents | |
| Administrator | Confirmed bed rail consents were not completed until 10/04/2023 | |
| Director of Nursing (DON) | Confirmed incomplete admission and annual assessments and consents for bed rails | |
| Maintenance Director | Unaware of Legionella testing requirements and water system monitoring | |
| Dietary Manager (DM) | Acknowledged stove hood needed replacement and stated expectations for hand hygiene | |
| Assistant Dietary Manager (ADM) | Observed not following proper glove use and hand hygiene during food service | |
| Dietary Aide (DA) 2 | Observed touching mask and handling food without changing gloves or sanitizing hands |
Inspection Report
Routine
Census: 61
Deficiencies: 7
Oct 5, 2023
Visit Reason
A standard survey was conducted at PruittHealth Grandview from October 2, 2023, through October 5, 2023, including investigation of Complaint Intake Number GA00238653 which was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to develop baseline care plans timely, untimely quarterly care plan conferences, missing physician orders for some residents, failure to properly assess and consent for bed rail use, inadequate hand hygiene and food handling practices in the kitchen, and lack of a documented water management program to prevent Legionella growth.
Complaint Details
Complaint Intake Number GA00238653 was investigated in conjunction with this standard survey and was unsubstantiated.
Severity Breakdown
D: 2
E: 4
F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure accurate coding of Minimum Data Set (MDS) assessments for 5 of 23 residents. | E |
| Failed to develop a baseline care plan within 48 hours of admission for 1 of 1 resident reviewed. | D |
| Failed to conduct quarterly care plan conferences in a timely manner for 12 of 23 residents reviewed. | E |
| Failed to ensure physician orders were in place for 2 of 23 residents. | D |
| Failed to obtain physician orders, assess risk, obtain informed consent, and attempt alternatives prior to installing bed rails for 14 of 23 residents reviewed. | E |
| Failed to maintain stove hood in good condition and adhere to hand hygiene and food handling practices to prevent food borne illness. | E |
| Failed to have a documented water management program to prevent growth and spread of Legionella and other opportunistic water-borne pathogens. | F |
Report Facts
Resident census: 61
Residents reviewed for MDS coding: 23
Residents with inaccurate MDS coding: 5
Residents with untimely quarterly care plan conferences: 12
Residents with missing physician orders: 2
Residents reviewed for bed rail issues: 23
Residents with bed rail deficiencies: 14
Residents provided meals from kitchen: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN Charge Nurse 1 | Licensed Practical Nurse Charge Nurse | Confirmed no physician order for dialysis for resident R45 |
| LPN Charge Nurse 2 | Licensed Practical Nurse Charge Nurse | Confirmed no physician order for dialysis for resident R45 and discussed bed rail use |
| Director of Nursing | Director of Nursing | Confirmed admitting nurse or nurse manager places orders and acknowledged missing baseline care plans and consents for bed rails |
| Dietary Manager | Dietary Manager | Discussed kitchen hygiene practices and stove hood replacement |
| Assistant Dietary Manager | Assistant Dietary Manager | Observed handling food with gloves improperly |
| Maintenance Director | Maintenance Director | Unaware of Legionella testing and water management program details |
| Minimum Data Set Coordinator | MDS Coordinator | Confirmed MDS coding errors and untimely care plan conferences |
Inspection Report
Routine
Census: 61
Deficiencies: 0
Oct 5, 2023
Visit Reason
A standard survey was conducted at PruittHealth Grandview from October 2, 2023, through October 5, 2023, including an investigation of Complaint Intake Number GA00238653.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B. Complaint Intake Number GA00238653 was investigated and found to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00238653 was investigated and found to be unsubstantiated.
Report Facts
Resident census: 61
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 18, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00236188, #GA00238044, and #GA00236335 at the facility.
Findings
Complaints #GA00238044 and #GA00236335 were substantiated with no deficiencies cited. Complaint #GA00236188 was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint #GA00236188 was unsubstantiated. Complaints #GA00238044 and #GA00236335 were substantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 13, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following a survey completed on 10/13/2022 at PruittHealth - Grandview.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 0
Oct 13, 2022
Visit Reason
A revisit was conducted at Pruitt Health Grandview to verify correction of deficiencies cited as a result of the recertification survey.
Findings
All deficiencies cited during the recertification survey were found to be corrected as of 10/5/22.
Inspection Report
Life Safety
Census: 50
Capacity: 72
Deficiencies: 0
Aug 23, 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 Emergency Preparedness Program requirements under 42 CFR § 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.70(a).
Report Facts
Certified beds: 72
Census: 50
Inspection Report
Renewal
Census: 57
Deficiencies: 2
Aug 21, 2022
Visit Reason
The inspection was a Licensure Survey conducted from August 19, 2022 to August 21, 2022 to assess compliance with state regulations for facility licensure renewal.
Findings
The facility was found deficient in nursing care related to failure to follow physician orders for antibiotic administration for one resident with recurring urinary tract infections, and in environmental sanitation and housekeeping due to unclean conditions in ten of sixteen resident rooms including stained privacy curtains, chipped paint, and dusty air conditioner vents.
Deficiencies (2)
| Description |
|---|
| Failure to follow physician orders for antibiotic use for one resident with recurring urinary tract infections. |
| Facility failed to maintain a safe, clean, and comfortable home-like environment in ten resident rooms, including dirty and stained privacy curtains, chipped paint on walls, and dusty air conditioner vents with debris. |
Report Facts
Sample size: 26
Facility census: 57
Number of affected resident rooms: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Registered Nurse | Verified missing documentation for prescribed antibiotics |
| AA | Housekeeper | Described cleaning procedures and responsibilities |
| Environmental Services Director | Described cleaning schedules and procedures | |
| Maintenance Director | Responsible for cleaning air conditioner vents and room repairs | |
| Administrator | Confirmed concerns and plans for curtain replacement |
Inspection Report
Routine
Census: 57
Deficiencies: 2
Aug 21, 2022
Visit Reason
A standard survey was conducted from August 19, 2022 through August 21, 2022, including investigation of Complaint Intake Number GA00218409, which was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain a safe, clean, and homelike environment in 10 of 16 resident rooms, and failure to ensure quality of care related to missed antibiotic administrations for one resident with recurring urinary tract infections.
Complaint Details
Complaint Intake Number GA00218409 was investigated in conjunction with the standard survey and was unsubstantiated.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe, clean, and homelike environment in ten of sixteen resident rooms, including dirty and stained privacy curtains, chipped paint on walls, and dusty air conditioner vents. | D |
| Facility failed to ensure quality of care by not following physician orders for antibiotic administration for one resident with recurring urinary tract infections. | D |
Report Facts
Resident census: 57
Resident sample size: 26
Missed antibiotic doses: 5
Resident rooms with deficiencies: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Housekeeper | Interviewed regarding cleaning procedures and responsibilities for privacy curtains and air conditioner vents |
| AA | Registered Nurse (RN) and Director of Nursing (DON) | Verified missing documentation for prescribed antibiotics for resident #35 |
| Environmental Services Director | Interviewed about cleaning schedules and procedures including deep cleaning and curtain replacement | |
| Maintenance Director | Responsible for cleaning air conditioner vents and room repairs | |
| Administrator | Interviewed about ordering new privacy curtains and expectations for clean environment | |
| Senior Nurse Consultant (SNC) | Explained notation system on Medication Administration Record |
Inspection Report
Routine
Census: 57
Deficiencies: 2
Aug 20, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations related to maintaining a safe, clean, and homelike environment and to evaluate quality of care regarding medication administration for residents.
Findings
The facility failed to maintain a safe, clean, and homelike environment in 10 of 16 resident rooms due to dirty privacy curtains, chipped paint, and dusty air conditioner vents. Additionally, the facility failed to follow physician orders for antibiotic administration for one resident with recurring urinary tract infections, with missing medication doses and documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain a safe, clean, and comfortable home-like environment in ten of 16 resident rooms including dirty and stained privacy curtains, chipped paint on walls, and air conditioner vents with dust and debris. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure quality of care related to not following physician orders for antibiotic use for one resident with recurring urinary tract infections. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 57
Resident sample size: 26
Medication doses missed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper AA | Interviewed regarding cleaning procedures and responsibilities | |
| Environmental Services Director | Interviewed regarding deep cleaning schedules and procedures | |
| Maintenance Director | Interviewed regarding maintenance responsibilities including air conditioner vent cleaning and painting | |
| Administrator | Interviewed regarding replacement of privacy curtains and facility expectations | |
| Director of Nursing | DON | Interviewed regarding missing medication documentation |
| Registered Nurse AA | RN | Interviewed regarding missing medication documentation |
| Senior Nurse Consultant | SNC | Interviewed regarding MAR notation explanations |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 8, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00214326, #GA00215761, #GA00215826, and #GA00217168.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints #GA00214326, #GA00215761, #GA00215826, and #GA00217168 were investigated and found to be unsubstantiated with no regulatory violations cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 6, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00210657.
Findings
The complaint #GA00210657 was unsubstantiated following the survey.
Complaint Details
Complaint #GA00210657 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 2, 2020
Visit Reason
A Desk Review for the COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on October 1-2, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 14, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate infection control allegations related to multiple complaints received between March and August 2020.
Findings
The offsite desk review found no immediate jeopardy, abuse, or infection control concerns. Onsite investigations substantiated some complaints without regulatory violations and found others unsubstantiated with no violations.
Complaint Details
Complaints #GA00203720, GA00203937, GA00203966, GA00204500, and GA00206903 were substantiated without regulatory violations. Complaints #GA00203866, GA00204362, and GA00205821 were unsubstantiated with no regulatory violations identified.
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 3
Jun 19, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on June 17-19, 2020 to assess compliance with infection control regulations during the COVID-19 pandemic.
Findings
The facility was found not in substantial compliance with Medicare regulations due to failures in ensuring staff wore appropriate personal protective equipment (PPE), including eye protection, while caring for COVID-19 positive residents and inconsistencies between facility PPE policies and CDC guidelines for different care units.
Severity Breakdown
E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure facility and contract staff wore eye protection while in close contact with a COVID-19 positive resident. | E |
| Failure to ensure staff followed facility policy to wear PPE including gown, gloves, N95 mask, and eye protection on the Level I COVID-19 positive care unit. | E |
| Facility policy regarding PPE for the Level II unit was inconsistent with CDC guidelines, lacking required eye protection. | E |
Report Facts
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Observed not wearing required PPE including eye protection and gown on COVID-19 units |
| Registered Nurse #1 | RN | Observed not wearing eye protection while assisting resident transfer on COVID-19 unit; provided PPE guidance to CNA #1 |
| Registered Nurse #2 | RN | Present during observations; indicated being oriented and unaware of eye protection requirements |
| Infection Preventionist | Provided interview confirming PPE requirements and re-education of staff | |
| Administrator | Interviewed regarding facility policy inconsistencies with CDC guidance |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Nov 26, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint number GA00200424.
Findings
The complaint was found to be unsubstantiated following the investigation.
Complaint Details
Complaint number GA00200424 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 8, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 6/7/2019 recertification survey.
Findings
All deficiencies cited as a result of the 6/7/2019 recertification survey were found to be corrected.
Inspection Report
Routine
Census: 69
Deficiencies: 4
Jun 7, 2019
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 including failure to develop an elopement care plan for a resident at risk, failure to implement a diabetes mellitus care plan related to medication administration, failure to invite a resident to care plan meetings, and failure to adequately supervise and assess elopement risk for a resident.
Severity Breakdown
SS= D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop an elopement care plan for one resident at risk for elopement (R#45). | SS= D |
| Failure to implement diabetes mellitus care plan related to medications as ordered for one resident (R#59). | SS= D |
| Failure to provide evidence that one resident (R#30) was invited to attend care plan meetings. | SS= D |
| Failure to reassess for elopement risk after hospital readmission, after an actual elopement, and at least quarterly; failure to provide evidence of assessment before removing wanderguard bracelet; failure to consistently check placement and function of wanderguard bracelet for one resident (R#45). | SS= D |
Report Facts
Resident census: 69
Incorrect insulin doses: 15
Elopement risk score: 12
BIMS score: 11
BIMS score: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services (DHS) | Interviewed regarding elopement care plan, wanderguard use, and elopement risk assessments for resident R#45 | |
| Activity Director | Interviewed regarding resident invitations to care plan meetings | |
| Licensed Practical Nurse (LPN) MDS Coordinator DD | Interviewed regarding resident invitations and attendance at care plan meetings | |
| Registered Nurse (RN) MDS Coordinator AA | Interviewed regarding resident invitations and attendance at care plan meetings | |
| Social Services Director (SSD) | Interviewed regarding documentation of resident attendance at care plan meetings | |
| Maintenance Director | Interviewed regarding door locking and wanderguard system functionality |
Inspection Report
Routine
Census: 33
Deficiencies: 2
Jun 7, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care plans and medication administration for residents, including evaluation of elopement risk and diabetes mellitus care.
Findings
The facility failed to develop an elopement care plan for one resident at risk for elopement and failed to properly implement the diabetes mellitus care plan related to medication administration for another resident, with multiple incorrect insulin doses administered.
Deficiencies (2)
| Description |
|---|
| Failure to ensure an elopement care plan was developed for resident #45 at risk for elopement. |
| Failure to implement diabetes mellitus care plan related to medications as ordered for resident #59, including incorrect doses of sliding scale insulin administered multiple times. |
Report Facts
Residents in sample: 33
Incorrect insulin doses: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Director of Health Services | Interviewed regarding elopement care plan for resident #45 |
Inspection Report
Life Safety
Census: 69
Capacity: 72
Deficiencies: 0
Jun 5, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan met the standards set forth in Appendix Z.
Report Facts
Census: 69
Certified beds: 72
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 0
May 30, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 2, 2018 standard survey.
Findings
All deficiencies cited in the April 2, 2018 standard survey were found to be corrected during the May 30, 2018 revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
May 21, 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
Life Safety
Census: 68
Capacity: 72
Deficiencies: 6
Apr 3, 2018
Visit Reason
The inspection was conducted to review the facility's Emergency Preparedness Plan and to assess compliance with Life Safety Code requirements, including fire safety and emergency preparedness.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and multiple Life Safety Code standards. Deficiencies included an incomplete emergency preparedness plan, improperly maintained egress ramps, obstructed fire alarm pull station, sprinkler system maintenance issues, damaged corridor doors, and electrical system hazards.
Severity Breakdown
F: 1
E: 4
D: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan was not site specific and did not address all identified hazards. | F |
| Facility failed to properly maintain facility egress ramp; guardrails removed, no curb on left side, no landing at door. | E |
| Fire alarm pull station next to main entry obstructed by furniture. | D |
| Fire sprinkler system not properly maintained; hydraulic data plate not permanent, heads loaded in kitchen, corroded head in kitchen cooler, improper head spacing in showers. | E |
| Doors opening into corridors not properly maintained; soiled utility door and linen room door will not close and latch. | E |
| Electrical system hazards including exposed wiring, flexible power cord through wall, missing knockout in junction box, damaged outlet cover, and unprotected gas meter. | E |
Report Facts
Residents at risk: 68
Certified beds: 72
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 12, 2017
Visit Reason
An abbreviated survey was conducted on 8/11/2017 and 8/12/2017 to investigate complaint GA00178294.
Findings
It was determined that the facility was in compliance with Federal and State Long Term Care regulations 42 CFR, Part 483, Subpart B; no deficiencies were cited.
Complaint Details
Complaint GA00178294 was investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 4, 2017
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 deficiencies had been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 27, 2017
Visit Reason
A Revisit Survey was conducted to verify that all previously cited deficiencies had been corrected.
Findings
The revisit survey revealed that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 4
Jun 23, 2017
Visit Reason
A revisit survey was conducted to determine if the facility had achieved substantial compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failures in testing exit and emergency lighting monthly and annually, unprotected and improperly protected penetrations in smoke barriers and rated walls, and failure to perform monthly generator load testing as required.
Severity Breakdown
E: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Exit lights were not tested monthly for 30 seconds and annually for 90 minutes as required. | E |
| Emergency lights were not tested monthly for 30 seconds and annually for 90 minutes as required. | D |
| Unprotected and improperly protected penetrations in corridor smoke and utility room walls and rated ceilings were observed, including holes above ceiling in Boiler Room and use of non-rated fire foam in Electrical Room. | E |
| Generator monthly load run testing was not performed in May 2017 and June 2017 testing was incomplete. | E |
Report Facts
Duration of exit light testing: 30
Duration of exit light testing: 90
Duration of emergency light testing: 30
Duration of emergency light testing: 90
Generator load run frequency: 1
Generator load run duration: 30
Generator load run frequency per year: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and confirmed findings related to exit light testing, emergency light testing, smoke barrier penetrations, and generator testing |
Inspection Report
Life Safety
Census: 64
Capacity: 72
Deficiencies: 10
May 2, 2017
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 multiple Life Safety Code requirements including improper maintenance of exit and emergency lighting, fire alarm system deficiencies, sprinkler system issues, unsealed rated wall penetrations, electrical system hazards, heating device venting problems, and failure to maintain the emergency generator.
Severity Breakdown
E: 5
D: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Exit lighting not tested monthly for 30 seconds and annually for 90 minutes. | E |
| Emergency lighting not tested monthly for 30 seconds and annually for 90 minutes. | D |
| No smoke detector protecting fire alarm panel in Electrical room. | D |
| Fire sprinkler riser not properly protected from freezing. | E |
| Fire sprinkler system maintenance and testing not current; annual inspection last conducted 4/26/16; backflow valves not tested annually; low voltage wiring on sprinkler piping above ceiling. | E |
| Fire extinguishers not inspected within past 12 months; last inspection 4/26/16. | D |
| Unprotected and improperly protected penetrations in corridor smoke and utility room walls and rated ceilings; holes above ceiling in Boiler Room; use of non-rated fire foam in Electrical Room; rated wall not properly constructed above ceiling in Boiler Room. | E |
| Missing junction box covers and receptacle cover in Electrical Room; flexible cord buried in ground to power facility sign. | D |
| Vent to fuel fired furnace has come apart. | D |
| No monthly load runs of the emergency generator in the past 12 months. | E |
Report Facts
Census: 64
Total Capacity: 72
Deficiencies cited: 10
Last Annual Sprinkler Inspection Date: Apr 26, 2016
Last Fire Extinguisher Inspection Date: Apr 26, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and confirmed findings related to exit lighting, emergency lighting, fire alarm, sprinkler system, fire extinguishers, rated walls, electrical system, heating device, and generator maintenance. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 26, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00172791 and determine compliance with Federal and State Long Term Care regulations under 42 CFR, Part 483, Subpart B.
Findings
The document is a statement of deficiencies and plan of correction related to the complaint survey conducted at PH-Grandview. Specific findings or deficiencies are not detailed in the provided text.
Complaint Details
Complaint #GA00172791 was investigated during the survey; no substantiation status or further details are provided.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00165706, GA00161105, and GA0000171193 and to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health-Grandview-Athens.
Complaint Details
The visit was complaint-related, investigating three specific complaints, and no deficiencies were found.
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