Inspection Reports for Pruitthealth – Lanier
2451 PEACHTREE INDUSTRIAL BLVD, BUFORD, GA, 30518
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, identified deficiencies that were subsequently corrected by the end of that survey period. Earlier inspections showed recurring issues with call lights not being kept within residents’ reach, improper preparation of pureed foods, inadequate provision of activities of daily living such as nail care, and unsafe water temperatures in resident rooms. Complaint investigations were mostly unsubstantiated, although some complaints were substantiated without resulting in citations; no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior complaint investigations included a substantiated case involving delayed notification of a resident fall that caused harm, and another substantiated deficiency related to missed dialysis transportation impacting resident care. The facility’s recent correction of cited deficiencies suggests some improvement, though similar types of issues have appeared repeatedly over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
86 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LANIER, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Follow-Up
Census: 86
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A health revisit survey was conducted from June 23, 2025, through June 25, 2025, at Pruitthealth-Lanier to verify correction of deficiencies cited in the Recertification in conjunction with a Complaint Investigation survey concluded on May 9, 2025.
Complaint Details
The revisit survey was conducted following a Complaint Investigation survey concluded on May 9, 2025.
Findings
All deficiencies cited as a result of the Recertification and Complaint Investigation survey were found to be corrected.
Report Facts
Facility census: 86
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 9, 2025
Visit Reason
The inspection was a State Licensure survey conducted from May 6, 2025 through May 9, 2025, to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including improper preparation of pureed foods by dietary staff, failure to keep call lights within reach for residents, inadequate provision of Activities of Daily Living such as nail care, and unsafe water temperatures in resident rooms exceeding the recommended maximum.
Deficiencies (4)
Dietary staff failed to follow recipes for preparing pureed food items, compromising nutritive value and flavor for eight of 88 residents receiving a pureed diet.
Failure to keep call lights within reach for two residents (R31 and R37) while in bed.
Failure to provide Activities of Daily Living (ADLs) including nail care for one resident (R5), increasing risk for infections.
Water temperatures in 16 out of 48 resident rooms exceeded 110°F, posing a burn hazard.
Report Facts
Residents receiving pureed diet affected: 8
Residents sampled for call light issue: 2
Residents sampled for ADL failure: 1
Resident rooms with water temperature above 110°F: 16
Total resident rooms checked for water temperature: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Cook MM | Dietary Cook | Observed adding unmeasured water to pureed rice and baked ham, contrary to facility policy. |
| Dietary Manager | Dietary Manager | Confirmed Dietary Cook MM should not use water in puree preparation and stated re-education would occur. |
| Certified Nursing Assistant NN | Certified Nursing Assistant | Stated residents should always have call lights within reach while in bed. |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Confirmed long toenails of resident R5 but admitted not reporting due to being busy and forgetting. |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Acknowledged not reporting resident R5's toenail condition to charge nurse and intended to speak to podiatrist. |
| Regional Nurse Consultant | Regional Nurse Consultant | Emphasized importance of timely referrals for podiatry care and maintaining water temperatures within safe range. |
| Interim Administrator | Interim Administrator | Confirmed staff expectations for notifying social services about residents needing toenail care and maintaining water temperatures. |
| Maintenance Director | Maintenance Director | Conducted water temperature checks, acknowledged elevated temperatures, and contacted plumber for assistance. |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 8
Date: May 9, 2025
Visit Reason
A recertification survey was conducted at Pruitthealth-Lanier from May 6, 2025 through May 9, 2025, including investigation of two complaint intake numbers which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00254720 and GA00254917 were investigated and found unsubstantiated.
Findings
The survey revealed multiple deficiencies including failure to keep call lights within reach for residents, delayed transmission and inaccuracies in Minimum Data Set (MDS) assessments, failure to provide nail care, failure to follow behavior monitoring orders, unsafe water temperatures in resident rooms, improper preparation of pureed foods, and missing privacy curtains compromising resident privacy.
Deficiencies (8)
Failed to ensure call light was within reach for two residents.
Failed to transmit MDS discharge assessment within 14 days for one resident.
Failed to accurately code use of wander/elopement alarm in MDS assessment for one resident.
Failed to provide nail care for one resident, risking infections and discomfort.
Failed to follow physician orders for behavior monitoring for one resident.
Failed to maintain water temperatures within safe range (100°F to 110°F) in 16 resident rooms, exposing residents to burn risk.
Failed to ensure dietary staff followed recipes for preparing pureed foods, including improper use of water to thin purees.
Failed to replace missing privacy curtain in one resident room, compromising visual privacy.
Report Facts
Residents present: 88
Sampled residents: 45
Rooms with unsafe water temperatures: 16
Days with missing behavior monitoring documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NN | Certified Nursing Assistant (CNA) | Interviewed regarding call light accessibility and behavior monitoring |
| KK | Clinical Reimbursement Consultant | Interviewed regarding MDS discharge assessment transmission |
| BB | Certified Nursing Assistant (CNA) | Interviewed regarding nail care deficiency |
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding nail care and resident behavior |
| MD | Maintenance Director | Interviewed and observed regarding water temperature deficiencies |
| MM | Dietary Cook | Observed and interviewed regarding improper puree food preparation |
| LL | Licensed Practical Nurse (LPN) | Interviewed regarding missing privacy curtain |
| Housekeeping Supervisor | Interviewed regarding missing privacy curtain |
Inspection Report
Life Safety
Census: 86
Capacity: 117
Deficiencies: 0
Date: May 6, 2025
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 Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility.
Complaint Details
Complaints GA00254433 and GA00253360 were substantiated; complaints GA00253651, GA00249561, and GA00248042 were unsubstantiated.
Findings
Complaints GA00254433 and GA00253360 were substantiated, while complaints GA00253651, GA00249561, and GA00248042 were unsubstantiated. No deficiencies were cited related to any of the complaints.
Report Facts
Complaints investigated: 5
Inspection Report
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LANIER, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 82
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited as a result of a prior Complaint Investigation and a Focused COVID-19 Survey concluded on June 19, 2024.
Complaint Details
The revisit survey was conducted following a Complaint Investigation; all cited deficiencies were corrected.
Findings
All deficiencies cited in the previous Complaint Investigation and Focused COVID-19 Survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Jun 19, 2024
Visit Reason
The inspection was a State Licensure survey conducted from June 17, 2024 through June 19, 2024 to determine compliance with State Long Term Care Requirements.
Findings
The facility was found deficient in infection control practices related to Enhanced Barrier Precautions for one resident, and failed to maintain a clean and homelike environment in 12 of 49 resident rooms, potentially placing residents at risk for infection and diminished quality of life.
Deficiencies (2)
Failure to follow infection control practices during direct contact care for one resident on Enhanced Barrier Precautions, including not wearing gowns during incontinent care and G-tube medication administration.
Failure to maintain a clean and homelike environment in 12 of 49 resident rooms, including issues such as broken window screens, damaged bathroom doors, dirt and debris, missing flooring, and non-functioning lights.
Report Facts
Number of residents with infection control deficiency: 1
Number of resident rooms with environmental deficiencies: 12
Resident census: 49
Feeding tube calorie intake: 51
Feeding tube volume: 501
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN HH | Registered Nurse | Named in infection control deficiency for not wearing gown during G-tube medication administration |
| CNA PP | Certified Nursing Assistant | Named in infection control deficiency for not wearing gown and improper incontinence care technique |
| Director of Health Services | Interviewed regarding infection control practices | |
| CNA RR | Certified Nursing Assistant | Interviewed regarding proper incontinence care technique |
| Housekeeper OO | Housekeeper | Interviewed about housekeeping responsibilities and resources |
Inspection Report
Abbreviated Survey
Census: 78
Deficiencies: 3
Date: Jun 19, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations and concerns at PRUITTHEALTH - LANIER.
Complaint Details
The survey investigated multiple complaint allegations identified by various GA complaint numbers. Some complaints were unsubstantiated, some substantiated with no deficiencies, and others substantiated with deficiencies.
Findings
The survey found deficiencies related to maintaining a clean and homelike environment in 12 resident rooms, delays and procedural errors in medication administration for two residents, and failure to follow infection control practices during care and medication administration for one resident on Enhanced Barrier Precautions.
Deficiencies (3)
Facility failed to maintain a clean and homelike environment in 12 of 49 resident rooms, including issues such as broken window screens, trash on floors, peeling paint, and damaged bathroom doors.
Facility failed to administer medications in a timely manner for Resident 6 and failed to follow proper enteral medication administration procedures for Resident 9.
Facility failed to follow infection control practices during direct contact care and medication administration for Resident 9 on Enhanced Barrier Precautions, including not wearing gowns and improper incontinence care technique.
Report Facts
Resident rooms with environment issues: 12
Residents reviewed for medication administration: 7
Residents on Enhanced Barrier Precautions: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager GG | Interviewed regarding medication order processing and pharmacy delivery | |
| Director of Health Services | Interviewed regarding medication administration policies and infection control practices | |
| Registered Nurse NN | RN | Observed and interviewed regarding enteral medication administration for Resident 9 |
| Registered Nurse HH | RN | Observed and interviewed regarding gown use during G-tube medication administration |
| Certified Nursing Assistant PP | CNA | Observed providing incontinence care without proper infection control measures |
| Certified Nursing Assistant RR | CNA | Interviewed regarding proper incontinence care technique |
| Housekeeper OO | Housekeeper | Interviewed regarding housekeeping responsibilities and resources |
Inspection Report
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LANIER, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided document.
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
A revisit was conducted at Pruitthealth Lanier on 7/5/2023 to verify correction of deficiencies cited during the recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 6/20/2023.
Report Facts
Facility census: 70
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 1
Date: May 25, 2023
Visit Reason
A revisit survey was conducted from 5/23/2023 through 5/25/2023 to investigate multiple complaint intake numbers and to verify correction of deficiencies cited in the 3/30/2023 Recertification and Complaint Survey.
Complaint Details
Complaint Intake Numbers GA00235170, GA00235070, GA00235424, and GA00234872 were investigated. GA00235070, GA00235424, and GA00234872 were unsubstantiated. GA00235170 was substantiated with deficiency cited.
Findings
All deficiencies cited in the 3/30/2023 Recertification and Complaint Survey were found to be corrected. Three complaint intake numbers were unsubstantiated, while one complaint intake number was substantiated with a deficiency cited.
Deficiencies (1)
Deficiency cited related to complaint intake number GA00235170
Report Facts
Complaint Intake Numbers investigated: 4
Facility census: 62
Inspection Report
Renewal
Deficiencies: 0
Date: May 25, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from 5/23/2023 through 5/25/2023 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted from 5/23/2023 through 5/25/2023.
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 1
Date: May 25, 2023
Visit Reason
A revisit survey was conducted from 5/23/2023 through 5/25/2023, including investigation of multiple complaint intake numbers. The visit was to verify correction of previous deficiencies and investigate complaints related to dialysis transportation services.
Complaint Details
Complaint Intake Numbers GA00235170, GA00235070, GA00235424, and GA00234872 were investigated. GA00235070, GA00235424, and GA00234872 were unsubstantiated. GA00235170 was substantiated with deficiency cited.
Findings
The facility failed to ensure consistent transportation services for one resident requiring dialysis, resulting in multiple missed dialysis appointments and subsequent hospitalization due to systemic swelling/edema. The facility has a van and designated drivers but transportation issues persisted, impacting resident care.
Deficiencies (1)
Failed to ensure that transportation services were consistently provided for one resident requiring dialysis.
Report Facts
Missed dialysis appointments: 6
Dialysis frequency: 3
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Licensed Practical Nurse (LPN) | Interviewed regarding transportation setup and missed dialysis appointments. |
| HH | Registered Nurse (RN) | Interviewed about transportation process and requirements for resident transport. |
| II | Human Resources (HR) | Interviewed about communication with dialysis center and transportation concerns. |
| Assistant Maintenance Director | Interviewed about van driving duties and transportation availability. | |
| Administrator | Interviewed about facility van use and driver scheduling for weekend appointments. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 11, 2023
Visit Reason
A Life Safety Code (LSC) revisit was conducted to verify correction of previously cited LSC deficiencies.
Findings
The revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 7
Date: Mar 30, 2023
Visit Reason
A recertification survey was conducted from March 28 through March 30, 2023, including investigation of multiple complaint intake numbers in conjunction with the standard survey.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard recertification survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to assess resident for self-administration of medications, failure to provide showers per resident preference, failure to apply ordered splints, failure to change oxygen tubing as ordered, failure to secure medication carts, failure to maintain kitchen cleanliness, and unsafe handrails with sharp edges.
Deficiencies (7)
Failed to assess resident #16 for ability to self-administer medications prior to leaving medications at bedside without physician order or assessment.
Failed to provide showers according to resident #55's preferences, including lack of nail care and shaving.
Failed to ensure splint was applied to resident #29's left hand as ordered by physician.
Failed to ensure oxygen tubing was changed according to physician's order for resident #215.
Failed to ensure medication cart on 200 Hall was locked and medications secured when unattended.
Failed to ensure main kitchen was kept clean and sanitary, including routine cleaning of hood vent and kitchen floor.
Failed to maintain ten hollow plastic handrails on 200 and 300 Halls, which had cracked, jagged, and sharp edges posing safety risk.
Report Facts
Resident census: 66
Resident count assessed for self-administration: 39
Medication count on cart: 7
Number of hollow plastic handrails unsafe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Unaware of residents self-administering medications and requirements for medication storage |
| DD | Certified Nurse's Assistant (CNA) | Described bath/shower scheduling and documentation practices |
| EE | Licensed Practical Nurse (LPN) | Described CNA responsibilities for showers and documentation |
| FF | Senior Nurse Consultant (SNC) Registered Nurse (RN) | Confirmed residents should receive baths/showers as desired |
| CC | Registered Nurse (RN) | Responsible for medication cart found unlocked with medications unsecured |
| Director of Health Services | Provided expectations for medication storage, bathing, and self-administration policies | |
| Regional Nurse Consultant | Discussed restorative nursing program issues and documentation | |
| Director of Maintenance | Confirmed unsafe handrails and applied tape to hazardous areas | |
| Dietary Manager | Confirmed kitchen cleanliness deficiencies and cleaning schedule absence | |
| Administrator | Stated expectation for dietary staff to maintain clean kitchen environment |
Inspection Report
Life Safety
Census: 63
Capacity: 117
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code 2012 edition standards.
Findings
The facility was found not in substantial compliance due to failure to seal above ceiling penetrations at smoke compartments in the 200 and 300 Hallways, potentially placing 30 residents at risk of smoke spreading between compartments.
Deficiencies (1)
Failed to seal above ceiling penetrations at Smoke Compartments at 200 and 300 Hallways.
Report Facts
Residents at risk: 30
Census: 63
Certified Beds: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of unsealed ceiling penetrations during facility tour |
Inspection Report
Routine
Census: 39
Deficiencies: 5
Date: Mar 30, 2023
Visit Reason
The inspection was a State Licensure survey conducted from March 28, 2023 through March 30, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including failure to provide showers according to resident preferences, unsecured medication carts, failure to assess resident ability to self-administer medications, unsafe physical plant conditions such as cracked and jagged handrails, and inadequate cleaning and sanitation of the main kitchen.
Deficiencies (5)
Failure to ensure one resident (R#55) was provided showers according to his preferences.
Medication cart on the 200 Hall was unlocked and medications were unsecured when unattended.
Failure to assess one resident (R#16) for ability to self-administer medications prior to leaving medications at bedside.
Failure to maintain ten hollow plastic handrails safely on the 200 and 300 halls; rails had cracked, jagged, and sharp edges.
Failure to ensure the main kitchen was kept clean and sanitary, including inadequate routine cleaning of the hood vent and kitchen floor.
Report Facts
Residents present: 39
Medication tablets on cart: 7
Handrails unsafe: 10
TUMS count: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse | Responsible for medication cart found unlocked and unattended |
| DHS | Director of Health Services | Provided expectations on baths/showers, medication cart security, and medication self-administration |
| CNA DD | Certified Nurse's Assistant | Interviewed regarding shower/bath schedules and documentation |
| LPN EE | Licensed Practical Nurse | Interviewed about shower/bath schedules and documentation |
| SNC RN FF | Senior Nurse Consultant Registered Nurse | Interviewed regarding resident bathing preferences and observations |
| LPN AA | Licensed Practical Nurse | Interviewed about resident self-administration of medications and medication storage |
| Director of Maintenance | Interviewed regarding unsafe handrails and maintenance work orders | |
| Dietary Manager | Interviewed regarding kitchen cleaning and sanitation expectations | |
| Administrator | Interviewed regarding kitchen cleanliness expectations |
Inspection Report
Deficiencies: 0
Date: Nov 23, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - LANIER, 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: 59
Deficiencies: 0
Date: Nov 23, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 10/01/2021 Recertification Survey and to investigate Complaint Intake Number GA00218744.
Complaint Details
Complaint Intake Number GA00218744 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.
Report Facts
Facility census: 59
Inspection Report
Abbreviated Survey
Census: 59
Deficiencies: 0
Date: Nov 22, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00218744.
Complaint Details
Complaint #GA00218744 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Census: 60
Capacity: 117
Deficiencies: 0
Date: Oct 6, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.
Findings
The facility was found to be in compliance with the requirements set forth in 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found compliant with 42 CFR & 483.73.
Report Facts
Certified Beds: 117
Census: 60
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 1, 2021
Visit Reason
A licensure survey was conducted from 9/28/21 through 10/1/21 to assess compliance with regulatory requirements for the facility.
Findings
The facility failed to implement the comprehensive care plan related to ongoing communication and collaboration with the dialysis facility for one resident requiring dialysis, specifically regarding completion and transmission of dialysis communication sheets.
Deficiencies (1)
Failure to implement the comprehensive care plan related to ongoing communication and collaboration with the dialysis facility for Resident #47.
Report Facts
Dates of dialysis communication sheets located: 3
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Consultant JJ | Nurse Consultant | Interviewed regarding nursing staff responsibility for dialysis communication sheets |
| Registered Nurse DD | Registered Nurse | Confirmed sending dialysis communication sheet on 9/30/21 |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 3
Date: Oct 1, 2021
Visit Reason
A Recertification Survey and Complaint/Abbreviated Survey was conducted on behalf of the Georgia Department of Community Health from 9/28/21 through 10/1/21, including substantiated complaint investigations with no citation.
Complaint Details
Complaint Investigations GA00213382 and GA00217319 were substantiated with no citation.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to implement comprehensive care plans and dialysis care communication for one resident, and food safety violations including improper labeling, storage, and discarding of food items.
Deficiencies (3)
Failed to implement the comprehensive care plan related to ongoing communication and collaboration with the dialysis facility for one resident.
Failed to maintain ongoing assessment and oversight of the resident before and after dialysis treatments and communication with the dialysis facility for one resident.
Failed to ensure proper food safety practices including labeling opened items, discarding food by use-by date, refrigerating items after opening, and discarding prepared snacks timely, potentially affecting 60 residents.
Report Facts
Resident census: 62
Dialysis frequency: 3
Deficiency count: 3
Sandwiches dated: 4
Sandwiches dated: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Consultant JJ | Nurse Consultant | Interviewed regarding dialysis communication sheets and staff education |
| Registered Nurse DD | Registered Nurse | Confirmed sending dialysis communication sheet on 9/30/21 |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Interviewed regarding food labeling and storage practices |
Inspection Report
Deficiencies: 0
Date: Mar 23, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 0
Date: Mar 23, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey conducted on January 29, 2021.
Complaint Details
The revisit survey was conducted following a complaint survey on January 29, 2021; all prior deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint numbers from March 8, 2021 through March 11, 2021.
Complaint Details
Complaints GA00206826, GA00207447, GA00207581, GA00209183, GA00210373, GA00211694 were investigated. Five complaints were unsubstantiated with no deficiencies cited. One complaint was substantiated with no regulatory violations.
Findings
Complaints GA00206826, GA00207447, GA00209183, GA00210373, GA00211694 were unsubstantiated with no deficiencies cited. Complaint GA00207581 was substantiated with no regulatory violations. The facility was found to be in compliance with infection control regulations and implemented recommended COVID-19 practices.
Report Facts
Complaint numbers investigated: 6
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 29, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to promptly notify the responsible party and physician of a resident's fall.
Complaint Details
The complaint investigation concluded that the facility did not notify the responsible party or physician of a fall on 4/4/2020 for resident #4, resulting in delayed treatment and injury. The facility nurse responsible was terminated for failure to complete a fall report and notify appropriate parties. The incident was reported to the State Survey Agency on 4/8/2020.
Findings
The facility failed to notify the responsible party and physician of a fall for one resident, resulting in a three-day delay in treatment and actual harm including a right femur/hip fracture requiring hospitalization and surgery. The investigation revealed deficiencies in fall reporting and communication protocols.
Deficiencies (1)
Failure to notify the Responsible Party and the Physician of a fall for one of nine residents resulting in a delay in treatment of three days and actual harm.
Report Facts
Resident count related to deficiency: 1
Delay in treatment: 3
Dates of fall and related events: Fall occurred on 2020-04-04; hospitalization on 2020-04-07; surgery on 2020-04-08
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse (LPN) | Answered family call on day of fall, did not fully assess resident's injury or notify physician |
| AA | Registered Nurse (RN) | Primary nurse on day of fall, assessed resident, gave pain medication, failed to document fall or notify physician timely |
| BB | Director of Health Service (DHS), former | Reported that RN AA failed to notify and document fall; RN AA was terminated |
| LL | Registered Nurse (RN) | Obtained STAT order for X-ray following resident complaints of pain |
| OO | Nurse Practitioner (NP) | Ordered hospital transfer after diagnosis of right hip fracture |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 3
Date: Jan 29, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 1/25/2021 to 1/29/2021 to investigate multiple complaints regarding the facility, including allegations of failure to notify responsible parties and physicians of a resident fall resulting in injury.
Complaint Details
The investigation was initiated due to multiple complaints (GA00203437, GA00205239, GA00205527, GA00206105, GA00206223). Complaints GA00205527 was unsubstantiated; GA00206105, GA00203437, and GA00206223 were substantiated with no deficiencies cited. GA00205239 was substantiated with deficiencies cited related to failure to notify and assess a resident fall resulting in actual harm.
Findings
The facility failed to notify the responsible party and physician of a resident fall on 4/4/2020, resulting in a delay in treatment of three days for a right femur/hip fracture. The resident was found on the floor, assisted back to bed without documented assessment or timely reporting. The nurse responsible was terminated for failure to complete the occurrence report. Deficiencies were cited related to notification of changes, provision of services meeting professional standards, and accident prevention.
Deficiencies (3)
Failure to notify the responsible party and physician of a resident fall resulting in delayed treatment of a right femur/hip fracture.
Failure to provide services meeting professional standards including proper assessment and notification following a resident fall.
Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents.
Report Facts
Complaint numbers investigated: 5
Resident census: 61
Fall risk score: 17
Pain severity score: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Primary nurse on 4/4/2020 who failed to document and notify about resident fall; terminated for failure to complete occurrence report |
| LPN JJ | Licensed Practical Nurse | Answered family call on 4/4/2020, assessed resident but did not fully evaluate or notify physician |
| RN BB | Director of Health Services (former) | Received delayed notification of fall, reported incident to State Survey Agency |
| Nurse Practitioner OO | Nurse Practitioner | Ordered X-ray and hospital transfer for resident after fall |
| LPN NN | Licensed Practical Nurse | Notified NP of resident pain and obtained X-ray order |
| RN LL | Registered Nurse | Obtained STAT X-ray order after resident continued to complain of pain |
| CNA MM | Certified Nursing Assistant | Found resident on floor on 4/4/2020 and reported to nurse |
| CNA KK | Certified Nursing Assistant | Assisted CNA MM with resident care and reported resident pain |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208783.
Complaint Details
Complaint # GA00208783 was substantiated without regulatory violations.
Findings
The complaint was substantiated but no regulatory violations were found during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 9, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate four complaints identified by numbers GA00198865, GA00199830, GA00200179, and GA00204286.
Complaint Details
Complaint #GA00198865 was substantiated; complaints #GA00199830, GA00200179, and GA00204286 were unsubstantiated.
Findings
Three complaints (GA00199830, GA00200179, and GA00204286) were unsubstantiated with no regulatory violations cited. One complaint (GA00198865) was substantiated but no regulatory violations were cited.
Inspection Report
Routine
Census: 64
Deficiencies: 0
Date: Jul 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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
Census: 78
Deficiencies: 0
Date: Jul 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at PruittHealth-Lanier on July 6, 2020.
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.
Inspection Report
Abbreviated Survey
Census: 89
Deficiencies: 0
Date: Aug 1, 2019
Visit Reason
An abbreviated survey was conducted to investigate multiple complaint allegations identified by codes GA00196809, GA00196786, GA00197142, GA00196317, and GA00198071.
Complaint Details
The survey investigated five complaints; one was substantiated with no deficiencies, and the others were unsubstantiated but deficiencies were noted.
Findings
One complaint (GA00198071) was substantiated with no deficiencies found, while all other complaints were unsubstantiated but deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2019
Visit Reason
A complaint survey was conducted on 3/27/19 to investigate complaint GA00195327 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00195327 was investigated and no deficiencies were found, indicating compliance with applicable requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PruittHealth - Lanier, related to regulatory compliance following an inspection.
Findings
The document contains no detailed deficiencies or findings; it primarily serves as a form for reporting deficiencies and the provider's plan of correction.
Inspection Report
Routine
Census: 87
Deficiencies: 2
Date: Oct 11, 2018
Visit Reason
A standard survey was conducted at Pruitthealth - Lanier from 10/8/18 through 10/11/18 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to keep a resident's call light within reach and failure to develop and provide a baseline care plan within 48 hours for a newly admitted resident.
Deficiencies (2)
Resident #31's call light was not placed within her reach when she was in bed, potentially delaying response to her needs.
Resident #194 did not have a baseline care plan developed within 48 hours of admission, and neither the resident nor family were provided a written summary of the baseline care plan.
Report Facts
Resident census: 87
Number of sampled residents: 27
Number of newly admitted sampled residents: 3
Days from admission to survey completion: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Named in relation to resident #194's care and medication administration |
| BB | Registered Nurse (RN) Nurse Navigator | Responsible for setting up and conducting baseline care plan meetings |
| Director of Nursing (DON) | Verified call light placement issue and baseline care plan deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 11, 2018
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with medical, dental, and nursing care regulations at PRUITTHEALTH - LANIER.
Findings
The facility failed to ensure that a resident's call light was kept within reach as required by the care plan, resulting in the resident being unable to alert staff for assistance on multiple occasions. The Director of Nursing confirmed the call light was not accessible and no policy for call light placement was provided at the time of the survey.
Deficiencies (1)
Resident #31's call light was not kept within her reach as required by her care plan, preventing her from alerting staff for assistance.
Report Facts
Date of survey completion: Oct 11, 2018
Resident ID: 31
Oxygen flow rate: 2
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Verified call light was not within resident's reach and assisted in repositioning it |
Inspection Report
Life Safety
Census: 87
Capacity: 117
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements, including emergency preparedness and fire safety standards.
Report Facts
Census: 87
Certified Beds: 117
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 13, 2018
Visit Reason
A complaint survey was conducted on 2018-09-11 and 2018-09-12 to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA00189215, GA00189413, GA00190488, and GA00191211 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The investigation determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 4, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00188520 and GA00188772 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint investigation for complaints #GA00188520 and GA00188772; no deficiencies found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 10, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186417 and GA00187326 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint survey conducted for complaints #GA00186417 and GA00187326; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 26, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186780 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186780 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2018
Visit Reason
A complaint survey was conducted on 3/5/18 to investigate complaint GA00185495 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00185495 was investigated and no deficiency was found.
Findings
No deficiency was cited during the complaint investigation survey.
Inspection Report
Follow-Up
Census: 97
Deficiencies: 0
Date: Feb 16, 2018
Visit Reason
A revisit to the Complaint survey of 12/7/17 was conducted to verify correction of previous deficiencies.
Complaint Details
This was a follow-up visit to a complaint survey conducted on 12/7/17 to verify correction of deficiencies.
Findings
All deficiencies identified in the prior complaint survey were corrected as of 1/27/18, and the facility was in substantial compliance as of the Federal Monitoring visit on 12/13/18.
Report Facts
Census: 97
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 16, 2018
Visit Reason
A revisit to the Federal Monitoring survey of 12/13/17 was conducted to verify correction of previously cited deficiencies.
Findings
All deficiencies cited in the prior survey were corrected, and the facility was found to be in substantial compliance as of 2/8/18.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 9, 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 deficiencies had been corrected during this follow-up visit.
Inspection Report
Life Safety
Census: 90
Capacity: 117
Deficiencies: 2
Date: Dec 18, 2017
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted by CMS following a state survey to assess compliance with Medicare/Medicaid participation requirements related to Life Safety from Fire and related NFPA codes.
Findings
The facility was found not in substantial compliance due to deficiencies in the maintenance of the automatic sprinkler system and the smoke barrier fire resistance. Specifically, a metal HVAC duct obstructed a sprinkler's spray pattern, and a smoke barrier wall near rooms 203/204 had unsealed penetrations around wires.
Deficiencies (2)
A metal HVAC duct in the mechanical room obstructed discharge and spray pattern development of one sprinkler.
Smoke barrier wall near rooms 203/204 had unsealed or improperly sealed penetrations with a 1 1/2" hole not firestopped.
Report Facts
Census: 90
Total Capacity: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present when sprinkler deficiency was identified | |
| Maintenance Director | Present when sprinkler and smoke barrier deficiencies were identified |
Inspection Report
Monitoring
Census: 92
Deficiencies: 6
Date: Dec 13, 2017
Visit Reason
A Federal Monitoring survey was conducted to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B, Requirements for Long Term Care facilities.
Findings
The facility was found not in substantial compliance due to multiple deficiencies including failure to provide a bed accommodating a resident's height, failure to ensure privacy during care, failure to conduct a significant change assessment, inadequate pressure ulcer treatment documentation, food safety violations, and lack of full visual privacy in resident rooms.
Deficiencies (6)
Failed to provide a resident with a bed that accommodated his height.
Failed to ensure privacy curtains were closed during incontinent care.
Failed to conduct a Significant Change Assessment related to cognitive status, incontinence, and ambulation.
Failed to assess and document a sacral open area that progressed to a Stage 3 Pressure Ulcer, including measurements and characteristics over a two week period.
Failed to ensure dry cereals were labeled with expiration dates, scoop stored sanitarily, Tilapia sealed, and expired milk removed.
Failed to ensure rooms had privacy curtains providing total visual privacy for residents in five rooms.
Report Facts
Census: 92
Resident sample size: 14
Resident sample size: 11
Resident sample size: 3
Pressure ulcer size: 13
Pressure ulcer size: 5.5
Expired milk cartons: 6
Rooms lacking full privacy curtains: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Acknowledged not closing privacy curtain and not noticing bed length issue | |
| Certified Nursing Assistant #2 | Repositioned Resident #10 in bed | |
| Administrator | Interviewed regarding bed length and privacy curtain issues | |
| MDS Nurse #1 | Interviewed about significant change assessment | |
| MDS Nurse #2 | Referenced by MDS Nurse #1 for assessment review | |
| MDS Nurse #3 | Confirmed significant change assessment should have been conducted | |
| Director of Health Services (DHS) | Interviewed about wound care and assessment documentation | |
| Dietary Manager (DM) | Interviewed about food labeling and storage practices | |
| Dietary Consultant (DC) | Confirmed food labeling and expired milk issues | |
| Nursing Home Administrator (NHA) | Interviewed about missing privacy curtains in resident rooms |
Inspection Report
Life Safety
Census: 94
Capacity: 117
Deficiencies: 0
Date: Nov 16, 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 for participation in Medicare/Medicaid.
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 0
Date: Nov 2, 2017
Visit Reason
A Standard Survey was conducted at Pruitt Health Lanier Buford, Georgia from October 30th 2017 to November 2, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The Standard Survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 26, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00177391 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00177391 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jul 21, 2017
Visit Reason
A revisit survey was conducted to investigate the plan of correction (POC) of complaint #GA00174634 with entrance and conclusion on 7/21/2017.
Complaint Details
The revisit survey was conducted to investigate the plan of correction for complaint #GA00174634.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations. Licensed nurses were educated and monitored on administering tube feedings and hydration per physician orders, with ongoing quality assurance measures in place.
Deficiencies (2)
Comprehensive care plans did not meet professional standards of quality related to residents with gastric tubes.
Insufficient fluid intake to maintain proper hydration was initially identified but addressed through education and monitoring.
Report Facts
Date of resident discharge: Apr 28, 2017
Target date for hydration plan: Aug 26, 2017
QAPI meeting dates: Jun 30, 2017
Next QAPI meeting date: Jul 26, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aminatu Aifuwa | RN | Nurse on duty who verbalized receiving inservice contents. |
| Nadyne Jean | LPN | Nurse on duty who verbalized receiving inservice contents. |
| Jummai Akinrinmade | RN | Nurse on duty who verbalized receiving inservice contents. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: May 11, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00174634 with entrance on 5/5/17 and concluded on 5/11/17 regarding failure to provide enteral feeding and water flushes to a resident with a gastric feeding tube.
Complaint Details
Complaint #GA00174634 was substantiated. Actual harm was identified when a resident admitted with a gastric feeding tube was transferred to the hospital for severe dehydration, altered mental status, and urinary tract infection due to missed enteral feeding and water flushes. Multiple missing signatures on Medication Administration Records were noted. Staff interviews confirmed missed treatments and inadequate documentation.
Findings
The facility failed to maintain professional nursing standards by not ensuring that enteral feeding and water flushes were given as ordered to one resident, resulting in severe dehydration, altered mental status, urinary tract infection, and hospitalization. Multiple missing documentation and missed treatments were confirmed by staff interviews and record reviews.
Deficiencies (2)
Failure to meet professional nursing standards by not ensuring enteral feeding and water flushes were given as ordered to a resident with a gastric feeding tube.
Failure to provide sufficient fluid intake to maintain proper hydration and health for the resident.
Report Facts
Census: 92
Missed feeding doses: 8
Missed water flushes (20 ml): 11
Missed water flushes (200 ml): 11
IV fluids given in hospital: 3
Elevated white blood cell count: 19.1
Elevated blood glucose: 317
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Confirmed missing signatures on MAR and inability to confirm administration of feeding and water flushes |
| RN AA | Registered Nurse Supervisor | Assisted in resident assessment on 4/28/17 and confirmed irregular heart rate |
| LPN CC | Licensed Practical Nurse | Aware of resident's sweating but did not document or consider it a problem |
| Nurse Practitioner EE | Nurse Practitioner | Saw resident on 4/27/17 and stated nutritional orders are based on Registered Dietitian recommendations |
| CNA DD | Certified Nursing Assistant | Reported resident sweating profusely requiring gown changes every two hours |
| Director of Nursing | Director of Nursing | Acknowledged multiple missing signatures on MAR and lack of monitoring |
| Administrator | Facility Administrator | Participated in interviews regarding resident care and documentation issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 7, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00173552 at PruittHealth - Lanier.
Complaint Details
Investigation of complaint GA00173552; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 6, 2017
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 visit.
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