Inspection Reports for Pruitthealth – Lilburn

A follow-up survey was conducted to verify correction of previously cited deficiencies.

The follow-up survey noted that all previously cited tags have been corrected.

An annual licensure survey was conducted at Pruitthealth Lilburn from May 12, 2025 through May 15, 2025 to assess compliance with regulatory requirements.

The facility failed to follow the care plan related to allergy restrictions for one resident, potentially causing an adverse allergic reaction, and failed to update the care plan for another resident to accurately reflect code status, risking care misalignment with end-of-life wishes. Two deficiencies were cited impacting 2 of 63 sampled residents.

A standard survey was conducted from May 12 to May 15, 2025, including investigation of multiple complaint intake numbers related to the facility's compliance with Medicare/Medicaid regulations.

The survey revealed multiple deficiencies including failure to maintain clean air filters, failure to document behavior monitoring for residents on psychotropic medications, failure to follow care plans related to allergy restrictions and code status, failure to administer medications as ordered, failure to adhere to food preferences and allergy restrictions, and failure to perform hand hygiene and sanitize shared medical equipment during medication pass.

Multiple complaint intake numbers were investigated. Several complaints were found unsubstantiated, some substantiated without deficiencies, and two substantiated with deficiencies related to the facility's noncompliance.

The visit was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.90(a) and NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.

The facility was found not in substantial compliance due to deficiencies including non-working emergency lighting on an exit sign in one smoke compartment and failure of doors (kitchen door and resident room door 158) to close properly in two smoke compartments.

The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LILBURN, indicating a regulatory inspection was completed.

The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.

A health revisit survey was conducted to verify correction of deficiencies cited during the January 18, 2024, Recertification survey.

All deficiencies cited as a result of the January 18, 2024, Recertification survey were found to be corrected.

A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, including a Life Safety Code (LSC) revisit.

All previously cited survey tags and LSC deficiencies were found to have been corrected during the follow-up survey.

The inspection was conducted as a State Licensure survey from January 16 through January 18, 2024, to determine compliance with the State Long Term Care Requirements.

The facility was cited for deficiencies including failure to follow infection control measures in storing nebulizer equipment for one resident and failure to offer flu and pneumonia vaccines to another resident. Interviews and record reviews confirmed these lapses in care and documentation.

A standard survey was conducted at Pruitthealth-Lilburn from January 16, 2024, through January 18, 2024, to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found not in compliance with several Medicare/Medicaid regulations including failure to refer a resident for Level II PASRR evaluation, failure to assist a resident in accessing vision services, improper infection control with nebulizer equipment, failure to offer influenza and pneumococcal vaccines to a resident, and failure to ensure required annual in-service training for nurse aides.

The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including fire safety systems and emergency power systems, at Pruitthealth - Lilburn.

The facility was found not in substantial compliance with emergency preparedness requirements and life safety codes. Deficiencies included lack of documentation for annual emergency preparedness updates, fire alarm system trouble, loaded sprinkler head, resident doors not latching properly, and missing records for the four-hour load bank test on the emergency generator.

A revisit survey was conducted to verify correction of deficiencies cited in the prior complaint survey dated 9/18/2023, and to investigate Complaint Intake Number GA00240340.

All deficiencies cited in the 9/18/2023 complaint survey were found to be corrected. The complaint investigation was substantiated but found without deficiency.

Complaint Intake Number GA00240340 was investigated and substantiated without deficiency.

A revisit survey was conducted on 11/22/2023 to investigate Complaint Intake Number GA00240340 in conjunction with the revisit survey.

All deficiencies cited as a result of the 9/18/2023 Complaint Survey were found to be corrected. The complaint investigation found GA00240340 substantiated without deficiency.

Complaint Intake Number GA00240340 was investigated and found substantiated without deficiency.

The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.

The report contains initial comments but does not provide specific details on deficiencies or findings.

The inspection was conducted as an Abbreviated Survey to verify the removal of Immediate Jeopardy (IJ) identified during a prior Abbreviated/Partial Extended Survey conducted from 9/11/2023 through 9/18/2023. The IJ related to failure to prevent and investigate sexual and physical abuse incidents and other compliance issues.

The facility was found to have failed to prevent sexual and physical abuse by resident R10 against multiple residents and failed to thoroughly investigate and implement interventions for these incidents. Immediate Jeopardy was removed on 9/16/2023 after corrective actions including staff reeducation, resident interviews, behavior management, and enhanced oversight were implemented. The facility remained out of compliance at a lower scope and severity while continuing management oversight and Plan of Correction development.

The visit was complaint-related due to allegations of sexual and physical abuse by resident R10 and others. The Immediate Jeopardy was substantiated and related to failure to prevent abuse and failure to thoroughly investigate and report incidents. The facility was informed of the IJ on 9/13/2023. An acceptable IJ removal plan was received on 9/20/2023 and validated by the State Survey Agency with removal of IJ on 9/16/2023.

A State Licensure survey was conducted from 9/11/2023 through 9/18/2023 to determine compliance with State Long Term Care Requirements.

The facility was cited for failure to timely notify a resident's representative of a fall with injury and hospitalization, failure to maintain infection control during incontinent care for two residents, and failure to implement audiology orders for one resident.

An Abbreviated/Partial Extended Survey was conducted from 9/11/2023 to 9/18/2023 to investigate multiple complaints alleging abuse and neglect at the facility.

The facility was found to have immediate jeopardy related to failure to prevent and investigate sexual and physical abuse incidents involving multiple residents. Additional deficiencies included failure to notify family timely of changes, failure to develop care plans for wandering residents, inadequate supervision leading to elopements, failure to implement audiology orders, and poor infection control during incontinence care.

The investigation was initiated due to multiple complaints alleging sexual and physical abuse by resident R10 and others. Some complaints were substantiated with findings of abuse and neglect, while others were unsubstantiated. Immediate Jeopardy was identified related to failure to prevent and investigate abuse.

A State Licensure survey was conducted from 9/11/2023 through 9/18/2023 to determine compliance with State Long Term Care Requirements.

The facility was found deficient in timely notification of a resident's representative after a fall with injury and hospitalization, failure to implement audiology orders for a resident, and failure to maintain proper infection control during incontinence care for two residents.

An abbreviated survey was conducted to investigate complaint #GA0022766.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA0022766 was investigated and found to be unsubstantiated with no deficiencies cited.

The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

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 483.90(a) and NFPA 101 2012 edition.

A state licensure survey was conducted from March 29, 2022 through April 1, 2022 to assess compliance with state licensure requirements for the facility.

The facility was cited for failing to provide written notification of hospital transfer to a resident, their representative, and the Ombudsman; and for improper storage and labeling of blood glucometer testing strips on medication carts across all hallways.

A standard survey was conducted by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health at Pruitt Health - Lilburn from March 29, 2022 through April 1, 2022, including investigations of multiple complaint cases.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide written transfer notifications, failure to provide bed hold notices, failure to post nurse staffing information daily, and improper labeling and storage of blood glucose test strips.

The survey included investigations of multiple complaint cases (GA00214001, GA00215311, GA00218452, GA00221948, GA0221967, and GA00222166) in conjunction with the standard survey.

A COVID-19 Focused Infection Control Survey and an Abbreviated/Partial Extended Survey were conducted to investigate multiple complaint allegations.

The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The complaints investigated were not substantiated, and no regulatory violations were cited.

Complaints identified by investigation numbers GA00205251, GA00205260, GA00206847, GA00208146, GA00208572, GA00208578, and GA00211287 were investigated and found not substantiated.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00209539.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00209539 was investigated and found to be unsubstantiated with no deficiencies cited.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.

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, implementing recommended practices to prepare for COVID-19.

An unannounced complaint survey was conducted on 1/21/2020 - 1/22/2020 by a Registered Nurse Surveyor.

There were no deficiencies cited during the complaint survey.

Unannounced complaint survey conducted; no deficiencies cited.

A complaint survey was conducted to investigate multiple complaints identified by their complaint numbers.

The survey determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.

The investigation covered complaints #GA00199728, GA00198942, GA00198705, GA00199562, GA00197383, GA00195862, GA00201607, GA00201539, GA00200468, GA00199971, and GA00199888. No deficiencies were found.

A complaint survey was conducted on 2/27/19 to investigate complaint GA00194770 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint GA00194770 was investigated and found to have no deficiencies.

A revisit survey was conducted on 2/12/19 for the Recertification Survey from 12/10/18 to 12/13/18.

The revisit survey revealed that all previously cited deficiencies were found to be corrected.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted during the follow-up survey.

An unannounced visit was made to the facility on 1/9/19-1/10/19 to investigate Complaint Intake Number GA 00193541.

The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.

Investigation of Complaint Intake Number GA 00193541; facility found in substantial compliance.

The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.

The facility was found not in substantial compliance due to failure to maintain multiple emergency lights outside exit discharge areas and one inside hallway A, and failure to maintain the outside exit door at A hall which would not self-close and latch properly, potentially placing residents and staff at risk during evacuation or fire.

An unannounced complaint survey was conducted on 8.11.18 by a Registered Nurse Surveyor.

There were no deficiencies cited during the complaint survey.

Unannounced complaint survey conducted; no deficiencies cited.

An unannounced Complaint Survey was conducted to investigate complaint # GA 00186019.

The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483 for Long Term Care Facilities.

Investigation of complaint # GA 00186019; facility found in substantial compliance.

An abbreviated/partial extended survey was conducted to investigate complaint GA00183963.

The complaint was investigated and found to be unsubstantiated.

Complaint GA00183963 was investigated and determined to be unsubstantiated.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The follow-up survey noted that all previously cited deficiencies had been corrected.

This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LILBURN, related to regulatory compliance following an inspection.

The document does not provide specific details of deficiencies or findings; it primarily serves as a plan of correction form with initial comments.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.

The facility was found not in substantial compliance with several Life Safety Code requirements including improper testing of exit and emergency lighting, maintenance issues with fire sprinkler systems, fire extinguishers, corridor doors, rated walls, electrical systems, fire drills, smoking regulations, generator maintenance, and oxygen cylinder storage.

Complaint Survey conducted to investigate complaint #GA00176882 to determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey.

Investigation of complaint #GA00176882 found no deficiencies; complaint was not substantiated.

The inspection was conducted as a Complaint Survey to investigate complaint #GA00173511 and determine compliance with Federal and State Long Term Care regulations.

No deficiencies were cited during the complaint survey at Pruitt Health Lilburn.

Complaint #GA00173511 was investigated and found to have no deficiencies cited.

A Health Revisit Survey in conjunction with an Abbreviated Survey was conducted to investigate complaint GA00172768 from March 24, 2017 through March 27, 2017.

The complaint was substantiated but no regulatory deficiency was cited. All previous deficiencies cited during a Health Revisit Survey and Abbreviated Survey of February 2, 2017, had been corrected.

Complaint GA00172768 was substantiated but no regulatory deficiency was cited.

A health revisit survey was conducted in conjunction with an abbreviated survey to investigate Complaint GA00172768 and to determine if deficiencies cited during a prior health revisit survey and complaint investigations were corrected.

Complaint GA00172768 was substantiated, but no regulatory violations were cited. The facility was found to be in substantial compliance.

Complaint GA00172768 was substantiated.

A Health Revisit Survey in conjunction with an Abbreviated Survey was conducted to investigate complaint GA00172768 from March 24, 2017 through March 27, 2017.

The complaint was substantiated but no regulatory deficiency was cited. All previous deficiencies cited during a Health Revisit Survey and Abbreviated Survey of February 2, 2017, had been corrected.

Complaint GA00172768 was substantiated but no regulatory deficiency was cited.

An abbreviated survey was conducted to investigate complaint GA00172325.

The complaint was not substantiated and no deficiencies were cited.

Complaint GA00172325 was investigated and found not substantiated.

An abbreviated survey was conducted from 1/30/17 through 2/2/17 to investigate complaint numbers GA00166862, GA00169868, and GA00170001. This survey was conducted in conjunction with a health revisit survey.

The facility was found to not be in substantial compliance with Medicare/Medicaid regulations at 42 CFR 483 Subpart B requirements for Long Term Care Facilities. Deficiencies were identified related to investigation and reporting of allegations of abuse, neglect, exploitation, or mistreatment, and failure to meet professional standards in comprehensive care plans.

The survey was conducted to investigate complaints GA00166862, GA00169868, and GA00170001. Deficiencies resulted from the investigation of complaints GA00169868 and GA00170001.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited deficiencies had been corrected.

The visit was a Life Safety Code Revisit conducted to determine if previously cited deficiencies from the Life Safety Code Survey of 10/25/17 had been corrected.

The facility failed to maintain fire safety features including corridor doors that did not resist fire for at least 20 minutes, improperly maintained rated walls with unprotected penetrations, fire sprinkler system not properly maintained and protected from freezing, and failure to maintain emergency generator inspections and testing.