Inspection Reports for
Pruitthealth – Lilburn
788 INDIAN TRAIL ROAD, LILBURN, GA, 30047
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Georgia average
Georgia average: 4.9 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
180% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
The follow-up survey noted that all previously cited tags have been corrected.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 2
Date: May 15, 2025
Visit Reason
An annual licensure survey was conducted at Pruitthealth Lilburn from May 12, 2025 through May 15, 2025 to assess compliance with regulatory requirements.
Findings
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.
Deficiencies (2)
Failure to follow care plan related to allergy restrictions concerning chocolate for resident R56, risking an adverse allergic reaction.
Failure to update the care plan for resident R30 to accurately reflect the resident's code status, potentially causing care not aligned with end-of-life wishes.
Report Facts
Sampled residents: 63
Residents impacted: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Registered Nurse (RN) | Named in interview regarding failure to follow allergy care plan for resident R56 |
| EE | Certified Nursing Assistant (CNA) | Named in interview regarding meal tray delivery and allergy verification for resident R56 |
| FF | Dietary Aide (DA) | Named in interview regarding tray line procedures and possible error in meal tray for resident R56 |
| GG | Dietary Aide (DA) | Named in interview and observation regarding meal tray verification and chocolate cake placement for resident R56 |
| HH | Dietary Aide (DA) | Named in interview regarding responsibility for adding tray items and verifying tray slips |
| II | Dietary Aide (DA) | Named in interview regarding serving beverages and desserts on tray line |
| DKM | Dietary Kitchen Manager | Named in interview explaining tray preparation and allergy verification process |
| BB | Licensed Practical Nurse (LPN) | Named in interview regarding verification of resident code status and care plan update for resident R30 |
| Social Work Director | Social Work Director | Named in interview regarding code status discussions and care plan update failure for resident R30 |
| Administrator | Administrator | Named in interview emphasizing importance of following care plans to prevent medical issues |
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 7
Date: May 15, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters in one room, increasing infection risk.
Failed to document behavior monitoring for two residents on psychotropic medication use.
Failed to follow care plan related to allergy restrictions concerning chocolate for one resident.
Failed to update care plan to accurately reflect resident's code status, risking care not aligned with end-of-life wishes.
Failed to administer medications as per physician's orders for two residents, including missed doses of antiviral and IV antibiotics.
Failed to adhere to documented food preferences and allergy-related restrictions concerning chocolate and disliked foods for one resident.
Failed to perform hand hygiene and sanitize shared medical equipment while providing care during medication pass for four residents.
Report Facts
Residents sampled: 63
Facility census: 124
Missed medication doses: 3
Missed medication doses: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse (LPN) | Named in relation to failure to document behavior monitoring |
| DD | Registered Nurse (RN) | Named in relation to failure to adhere to allergy-related food restrictions |
| EE | Certified Nursing Assistant (CNA) | Named in relation to failure to adhere to allergy-related food restrictions |
| GG | Dietary Aide | Named in relation to failure to adhere to allergy-related food restrictions |
| AA | Registered Nurse (RN) | Named in relation to failure to perform hand hygiene and sanitize equipment during medication pass |
| BB | Licensed Practical Nurse (LPN) | Named in relation to care plan code status update |
Inspection Report
Routine
Census: 86
Deficiencies: 6
Date: May 15, 2025
Visit Reason
Routine inspection of Pruitthealth - Lilburn nursing home to assess compliance with health, safety, medication, care planning, dietary, and infection control regulations.
Findings
The facility was found deficient in maintaining clean air filters, documenting behavior monitoring for psychotropic medication use, following care plans related to allergies and code status, adhering to dietary restrictions and preferences, and performing proper hand hygiene and equipment sanitation during medication passes.
Deficiencies (6)
F 0584: The facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters in one room, increasing infection risk.
F 0605: The facility failed to document behavior monitoring for two residents on psychotropic medications as ordered, risking inadequate oversight.
F 0656: The facility failed to follow a resident's allergy-related care plan by serving chocolate cake to a resident allergic to chocolate.
F 0657: The facility failed to update a resident's care plan to reflect accurate code status, risking care inconsistent with end-of-life wishes.
F 0806: The facility failed to provide meals consistent with documented resident allergies and preferences, including serving disliked and allergenic foods.
F 0880: The facility failed to perform hand hygiene and sanitize shared medical equipment properly during medication passes, increasing infection risk.
Report Facts
Residents affected: 63
Facility census: 86
Rooms in B Hall: 18
Behavior monitoring missing days: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Named in infection control and hand hygiene deficiency during medication pass |
| LPN JJ | Licensed Practical Nurse | Named in behavior monitoring documentation deficiency |
| RN DD | Registered Nurse | Named in dietary allergy and tray verification deficiency |
| CNA EE | Certified Nursing Assistant | Named in dietary allergy and tray verification deficiency |
| Dietary Aide FF | Dietary Aide | Named in dietary tray preparation and allergy protocol deficiency |
| Dietary Aide GG | Dietary Aide | Named in dietary tray preparation and allergy protocol deficiency |
| Dietary Aide HH | Dietary Aide | Named in dietary tray preparation and allergy protocol deficiency |
| Dietary Aide II | Dietary Aide | Named in dietary tray preparation and allergy protocol deficiency |
| Dietary Kitchen Manager | Dietary Kitchen Manager | Named in dietary allergy and tray verification deficiency |
| Maintenance Director | Maintenance Director | Named in air filter cleaning deficiency |
| Administrator | Facility Administrator | Named in multiple deficiencies including air filter, dietary, and behavior monitoring |
| Social Work Director | Social Work Director | Named in care plan update deficiency |
| Director of Health Services | Director of Health Services | Named in behavior monitoring and infection control deficiencies |
| Infection Control Nurse | Infection Control Nurse | Named in infection control deficiency |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: May 15, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain clean air filters, incomplete behavior monitoring documentation for psychotropic medication use, failure to follow allergy-related dietary restrictions, inaccurate care plan updates, missed medication administrations, and inadequate infection prevention practices such as hand hygiene and equipment sanitization.
Deficiencies (7)
F 0584: The facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters in one room, increasing infection risk.
F 0605: The facility failed to document behavior monitoring for two residents on psychotropic medications as ordered, risking inadequate oversight.
F 0656: The facility failed to follow allergy-related care plan restrictions for one resident by serving chocolate, risking an allergic reaction.
F 0657: The facility failed to update a resident's care plan to reflect accurate code status, risking care inconsistent with resident wishes.
F 0684: The facility failed to administer medications as ordered for two residents, including missed doses of shingles treatment and delayed IV antibiotics.
F 0806: The facility failed to provide meals consistent with documented resident allergies and preferences, including serving chocolate to an allergic resident and incorrect meals.
F 0880: The facility failed to perform hand hygiene and sanitize shared medical equipment properly during medication passes, increasing infection transmission risk.
Report Facts
Residents sampled: 63
Facility census: 86
Medication doses missed: 3
Medication doses scheduled: 50
Medication delay hours: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Observed failing to perform hand hygiene and sanitize equipment during medication pass |
| LPN JJ | Licensed Practical Nurse | Interviewed regarding behavior monitoring documentation responsibilities |
| RN DD | Registered Nurse | Interviewed regarding dietary allergy protocols and meal tray verification |
| DA FF | Dietary Aide | Interviewed regarding tray line procedures and meal preparation |
| DA GG | Dietary Aide | Interviewed regarding tray ticket verification and meal preparation |
| DA HH | Dietary Aide | Interviewed regarding meal tray setup responsibilities |
| DA II | Dietary Aide | Interviewed regarding tray line duties and meal verification |
| DKM | Dietary Kitchen Manager | Interviewed regarding dietary staff training and meal tray procedures |
| LPN BB | Licensed Practical Nurse | Interviewed regarding care plan and code status verification |
| Social Work Director | Social Work Director | Interviewed regarding care plan updates and code status documentation |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding hand hygiene and equipment cleaning expectations |
| Director of Health Services | Director of Health Services | Interviewed regarding medication administration and infection control expectations |
Inspection Report
Life Safety
Census: 122
Capacity: 152
Deficiencies: 3
Date: May 13, 2025
Visit Reason
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.
Findings
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.
Deficiencies (3)
Exit sign located in the B hall did not have working emergency lighting.
Facility failed to have a properly closing kitchen door.
Resident room door 158 did not close without a gap in the door frame.
Report Facts
Census: 122
Total Capacity: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting and door deficiencies during facility tour |
Inspection Report
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LILBURN, indicating a regulatory inspection was completed.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 112
Deficiencies: 0
Date: Mar 5, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the January 18, 2024, Recertification survey.
Findings
All deficiencies cited as a result of the January 18, 2024, Recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies, including a Life Safety Code (LSC) revisit.
Findings
All previously cited survey tags and LSC deficiencies were found to have been corrected during the follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 18, 2024
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failure to follow infection control measures during storage of nebulizer equipment for one resident.
Failure to offer flu and pneumonia vaccines to one resident.
Report Facts
Resident count reviewed for vaccines: 5
BIMS score: 15
Physician order dosage: 2.5
Physician order volume: 3
Resident admission date: Aug 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Certified Nursing Assistant | Interviewed regarding storage of oxygen tubing/nebulizer set ups |
| DD | Registered Nurse | Interviewed regarding storage of nebulizer tubing and mask |
| FF | Licensed Practical Nurse | Verified nebulizer mask storage and planned to obtain new supplies |
| Director of Health Services | Interviewed about nebulizer care process and vaccination documentation | |
| Director of Health Care | Interviewed about vaccination offering and Infection Preventionist staffing |
Inspection Report
Routine
Census: 107
Deficiencies: 5
Date: Jan 18, 2024
Visit Reason
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.
Findings
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.
Deficiencies (5)
Failed to refer a Level II PASRR for one resident with serious mental illness.
Failed to assist one resident in gaining access to vision services by making an appointment and arranging transportation.
Failed to follow infection control measures during storage of nebulizer equipment for one resident.
Failed to offer influenza and pneumococcal vaccines to one resident.
Failed to ensure seven out of 37 CNAs completed required 12 hours of annual in-service training.
Report Facts
Residents sampled: 43
Residents reviewed for flu and pneumonia vaccine: 5
Certified Nursing Assistants (CNA): 37
CNAs deficient in training: 7
Resident census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker AA | Social Worker | Interviewed regarding PASRR Level II referral and ophthalmology appointment scheduling |
| Admissions Director | Admissions Director | Interviewed regarding PASRR Level I application process |
| Administrator | Administrator | Interviewed regarding PASRR policy and ophthalmology appointment scheduling |
| Assistant Director of Health Services | Assistant Director of Health Services | Interviewed regarding ophthalmology consult orders and appointment scheduling |
| Director of Health Services | Director of Health Services | Interviewed regarding infection control and vaccination procedures |
| Certified Nursing Assistant EE | Certified Nursing Assistant | Interviewed regarding proper storage of nebulizer equipment |
| Registered Nurse DD | Registered Nurse | Interviewed regarding proper storage of nebulizer equipment |
| Licensed Practical Nurse FF | Licensed Practical Nurse | Interviewed regarding nebulizer equipment storage and replacement |
| Clinical Competency Coordinator | Clinical Competency Coordinator | Interviewed regarding CNA in-service training compliance and documentation |
| CNA II | Certified Nursing Assistant | Interviewed regarding failure to meet 12-hour education requirement |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening and resident review (PASRR), access to specialty services such as vision care, infection prevention and control, and staff training requirements.
Findings
The facility failed to submit a required Level II PASRR for one resident with serious mental illness, did not assist one resident in gaining access to vision services by scheduling appointments and arranging transportation, failed to follow infection control measures for nebulizer equipment storage for one resident, and did not ensure seven out of 37 Certified Nursing Assistants completed the required 12 hours of annual in-service training.
Deficiencies (4)
F 0644: The facility failed to refer one resident with serious mental illness for a Level II PASRR evaluation, potentially delaying specialized care.
F 0685: The facility failed to assist one resident in gaining access to vision services by making an appointment and arranging transportation.
F 0880: The facility failed to follow infection control procedures by storing nebulizer equipment uncovered and unbagged for one resident receiving nebulized medications.
F 0947: The facility failed to ensure seven out of 37 Certified Nursing Assistants completed the required 12 hours of annual in-service training.
Report Facts
Residents sampled: 43
Certified Nursing Assistants deficient: 7
CNA in-service hours completed: 7.65
CNA in-service hours completed: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker AA | Social Worker | Interviewed regarding PASRR Level II submission and ophthalmology consult scheduling |
| Admissions Director | Admissions Director | Interviewed regarding PASRR Level I and II application process |
| Administrator | Administrator | Interviewed regarding PASRR policy and referral scheduling issues |
| Certified Nursing Assistant EE | Certified Nursing Assistant | Interviewed regarding proper storage of nebulizer equipment |
| Registered Nurse DD | Registered Nurse | Interviewed regarding proper storage of nebulizer equipment |
| Licensed Practical Nurse FF | Licensed Practical Nurse | Interviewed regarding observed improper nebulizer equipment storage |
| Clinical Competency Coordinator | Clinical Competency Coordinator | Interviewed regarding CNA in-service training compliance and documentation |
| Director of Health Services | Director of Health Services | Interviewed regarding CNA education expectations and nebulizer care process |
| CNA II | Certified Nursing Assistant | Interviewed regarding failure to meet 12-hour education requirement |
Inspection Report
Life Safety
Census: 109
Capacity: 152
Deficiencies: 5
Date: Jan 16, 2024
Visit Reason
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.
Findings
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.
Deficiencies (5)
No completed documentation available providing a specific annual update and signed attendance sheet for the Emergency Preparedness Program.
Fire alarm panel had a trouble light illuminated indicating the 'street pit valve is open', affecting one of three smoke compartments.
Sprinkler system was not maintained in optimum readiness; a sprinkler head in the laundry area was found loaded.
Resident room doors to rooms 160 and 132 would not latch to secure the door closed, failing to resist passage of smoke.
Facility failed to provide documentation for the required four-hour load bank test on the emergency generator.
Report Facts
Census: 109
Total Capacity: 152
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness documentation, fire alarm trouble, sprinkler system issues, door latching problems, and missing generator test records |
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Date: Nov 22, 2023
Visit Reason
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.
Complaint Details
Complaint Intake Number GA00240340 was investigated and substantiated without deficiency.
Findings
All deficiencies cited in the 9/18/2023 complaint survey were found to be corrected. The complaint investigation was substantiated but found without deficiency.
Report Facts
Facility census: 106
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 0
Date: Nov 22, 2023
Visit Reason
A revisit survey was conducted on 11/22/2023 to investigate Complaint Intake Number GA00240340 in conjunction with the revisit survey.
Complaint Details
Complaint Intake Number GA00240340 was investigated and found substantiated without deficiency.
Findings
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.
Inspection Report
Deficiencies: 0
Date: Nov 22, 2023
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 details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 9
Date: Sep 28, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (9)
Failure to prevent sexual abuse by resident R10 against multiple residents including R9, R14, and R25.
Failure to prevent physical abuse incidents among residents including R15, R11, R19, R20, R16, R17, and R18.
Failure to thoroughly investigate and report incidents of sexual and physical abuse in a timely manner.
Failure to notify resident representative timely of a fall with injury and hospitalization for resident R9.
Failure to develop care plans addressing wandering and elopement risks for residents R9 and R10.
Failure to implement audiology orders for resident R7 as ordered by the physician.
Failure to provide adequate supervision to prevent elopements for residents R9 and R10.
Failure to maintain infection control during incontinence care for residents R29 and R31.
Failure of facility administration to effectively oversee an abuse prevention program and maintain an abuse-free environment.
Report Facts
Resident census: 114
Residents interviewed: 116
Staff in-serviced: 78
Residents on behavior management: 21
Residents with BIMS score 11 or above: 44
Residents with BIMS score 10 or below: 72
Resident elopement risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Witnessed and reported sexual abuse incident involving R9 and R10 |
| LPN EE | Licensed Practical Nurse | Witnessed and reported sexual abuse incident involving R9 and R10 |
| Administrator | Facility Administrator | Abuse Coordinator; failed to substantiate abuse incidents; involved in IJ removal plan and staff education |
| Social Services Director | Social Services Director | Aware of abuse incidents but failed to act timely |
| Director of Nursing | Director of Nursing | Confirmed failure to develop care plans and supervise residents adequately |
| Clinical Competency Coordinator | Conducted staff reeducation on abuse and neglect | |
| Senior Nurse Consultant | Provided in-service education to Administrator and staff; involved in QAPI meetings |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Sep 18, 2023
Visit Reason
The inspection was conducted due to complaints and allegations regarding failure to notify family of resident injury, abuse incidents including sexual and physical abuse, inadequate investigation of abuse, failure to develop care plans for wandering and elopement, inadequate supervision leading to elopements, failure to implement audiology orders, and improper incontinent care.
Complaint Details
The investigation was complaint-driven, focusing on allegations of failure to notify family of injury, sexual and physical abuse incidents, inadequate investigations, failure to develop care plans for wandering and elopement, inadequate supervision leading to elopements, failure to implement physician orders, and improper incontinent care. Immediate jeopardy was identified related to abuse prevention and investigation failures.
Findings
The facility failed to timely notify family of a resident's fall and hospitalization, failed to prevent and investigate multiple incidents of sexual and physical abuse involving several residents, failed to develop and implement care plans for wandering and elopement, failed to provide adequate supervision to prevent elopements, failed to follow up on audiology orders, and failed to maintain proper infection control during incontinent care. The Administrator failed to effectively oversee an abuse prevention program, resulting in immediate jeopardy to resident health and safety.
Deficiencies (8)
F580: The facility failed to notify the resident's representative timely of a fall with injury and hospitalization for one resident.
F600: The facility failed to ensure residents were free from sexual and physical abuse, with multiple incidents involving several residents and one perpetrator.
F610: The facility failed to thoroughly report and investigate incidents of sexual and physical abuse for multiple residents, and failed to implement corrective actions.
F656: The facility failed to develop care plans addressing wandering and elopement behavior for two residents until after elopements occurred.
F684: The facility failed to ensure audiology orders were implemented as ordered by the physician for one resident.
F689: The facility failed to provide adequate supervision to prevent elopements for two residents who eloped multiple times, including one found in a nearby neighborhood.
F690: The facility failed to maintain infection control during incontinent care for two residents, including improper cleansing technique and failure to wash hands between care.
F835: The facility administration failed to effectively oversee an abuse prevention program, resulting in failure to maintain an abuse-free environment and immediate jeopardy to resident health and safety.
Report Facts
Facility census: 113
Resident sample size: 35
Elopement risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed and reported sexual abuse incident involving residents R9 and R10 |
| LPN EE | Licensed Practical Nurse | Observed and reported sexual abuse incident involving residents R9 and R10 |
| LPN FF | Licensed Practical Nurse | Wrote progress note regarding resident R10 elopement and failure to notify family of fall |
| Administrator | Facility Administrator | Failed to substantiate abuse incidents and oversee abuse prevention program |
| Director of Nursing | Director of Nursing | Confirmed failure to develop care plans and follow up on physician orders |
| Social Services Director | Social Services Director | Aware of sexual abuse incident but failed to act timely |
| Infection Preventionist | Infection Preventionist | Confirmed failure to provide proper incontinent care |
| Regional Nurse Consultant NN | Regional Nurse Consultant | Unaware of many abuse incidents and advised Administrator to report |
| Certified Nursing Assistant HH | Certified Nursing Assistant | Observed improper incontinent care for resident R31 |
| Certified Nursing Assistant II | Certified Nursing Assistant | Observed improper incontinent care for resident R29 |
| Maintenance Assistant | Maintenance Assistant | Reported resident R10 eloped and was found in neighborhood |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 18, 2023
Visit Reason
A State Licensure survey was conducted from 9/11/2023 through 9/18/2023 to determine compliance with State Long Term Care Requirements.
Findings
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.
Deficiencies (3)
Failure to notify the resident's representative timely of a fall with injury and hospitalization for one resident.
Failure to maintain infection control during incontinence care for two residents.
Failure to ensure audiology orders were implemented as ordered by the physician for one resident.
Report Facts
Residents sampled: 35
Residents reviewed for change in condition: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Licensed Practical Nurse | Wrote progress note and did not contact family after resident fall |
| HH | Certified Nursing Assistant | Failed to provide proper incontinent care to resident R31 |
| II | Certified Nursing Assistant | Failed to provide proper incontinent care to resident R29 and failed to wash hands |
| PP | Unit Manager | Reported staff used back to front technique during incontinent care |
| Director of Nursing | Stated charge nurse should update orders and acknowledged failure to follow up on audiology orders | |
| Nurse Practitioner | Stated staff should notify her of outside appointment orders | |
| Admissions Coordinator | Stated staff can look for resident representative contact in medical record if not on face sheet | |
| Administrator | Stated family should be notified of any change in condition and staff failed to check entire medical record | |
| Infection Preventionist | Revealed facility failed to provide safe incontinent care per policy |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 8
Date: Sep 18, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failure to prevent sexual abuse by resident R10 against multiple residents and failure to investigate and intervene appropriately.
Failure to prevent physical abuse among residents and failure to investigate and intervene appropriately.
Failure to notify resident representative timely of a fall with injury and hospitalization for one resident.
Failure to develop care plans addressing wandering and elopement risks for residents R9 and R10.
Failure to implement audiology orders for resident R7 as ordered by the physician.
Failure to ensure adequate supervision to prevent elopements for residents R9 and R10.
Failure to maintain infection control during incontinence care for residents R29 and R31.
Failure of facility administration to effectively oversee an abuse prevention program and maintain an abuse-free environment.
Report Facts
Resident census: 113
Complaints investigated: 26
Residents involved in sexual abuse: 4
Residents involved in physical abuse: 8
Elopement risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed and reported sexual abuse incident involving R9 and R10 |
| LPN EE | Licensed Practical Nurse | Observed and reported sexual abuse incident involving R9 and R10 |
| LPN FF | Licensed Practical Nurse | Wrote progress note on R10 elopement and reported incident |
| CNA JJ | Certified Nursing Assistant | Aware of R9's elopements and door malfunction |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy and failed to substantiate abuse incidents |
| Social Services Director | SSD | Aware of sexual abuse incident involving R10 and R25 but failed to act |
| Director of Nursing | DON | Confirmed lack of care plans for wandering residents R9 and R10 |
| Regional Nurse Consultant | RNC | Unaware of many abuse incidents and advised Administrator to report |
| Infection Preventionist | Reported failure to provide safe incontinent care |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 11, 2023
Visit Reason
A State Licensure survey was conducted from 9/11/2023 through 9/18/2023 to determine compliance with State Long Term Care Requirements.
Findings
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.
Deficiencies (3)
Failure to notify the resident's representative timely of a fall with injury and hospitalization for one resident.
Failure to ensure audiology orders were implemented as ordered by the physician for one resident.
Failure to maintain infection control during incontinence care for two residents.
Report Facts
Residents reviewed for change in condition: 3
Sampled residents: 35
BIMS score: 4
BIMS score: 15
Dates of survey: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Licensed Practical Nurse | Wrote the 4/29/2023 progress note and failed to contact resident's family. |
| DON | Director of Nursing | Stated charge nurse should update orders and acknowledged failure to follow up on audiology orders. |
| NP | Nurse Practitioner | Stated staff should notify her of outside appointments and orders. |
| CNA HH | Certified Nursing Assistant | Failed to provide proper incontinent care to resident R31. |
| CNA II | Certified Nursing Assistant | Failed to provide proper incontinent care to resident R29 and failed to wash hands between care. |
| Infection Preventionist | Reported facility failed to provide safe incontinent care per policy. | |
| Unit Manager PP | Unit Manager | Reported staff used incorrect back to front technique during incontinent care. |
| Admissions Coordinator | Stated staff can look elsewhere in medical record for contact information if not on face sheet. | |
| Administrator | Stated family should be notified regarding any change in condition and staff failed to check entire medical record. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 13, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA0022766.
Complaint Details
Complaint #GA0022766 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
Deficiencies: 0
Date: Jun 23, 2022
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 details on deficiencies or findings.
Inspection Report
Life Safety
Census: 94
Capacity: 152
Deficiencies: 0
Date: Apr 8, 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 483.90(a) and NFPA 101 2012 edition.
Report Facts
Census: 94
Certified Beds: 152
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 4
Date: Apr 1, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide timely written notification of resident transfers to hospital and bed hold notices, failure to post daily nurse staffing information, and improper labeling and storage of blood glucometer testing strips.
Complaint Details
The investigation was complaint-driven, focusing on notification failures related to hospital transfers and bed hold notices, staffing information posting, and medication storage practices. The complaints were substantiated with findings of minimal to potential minimal harm.
Findings
The facility failed to provide written notification to residents, their representatives, and the Ombudsman regarding hospital transfers and bed hold notices for one resident. Staffing information was not posted daily for two days during the survey. Additionally, blood glucometer testing strips on medication carts were not labeled or dated as required.
Deficiencies (4)
F 0623: The facility failed to provide timely written notification to the resident, resident representative, and Ombudsman before transfer or discharge for one resident transferred to the hospital.
F 0625: The facility failed to provide a written bed hold notice within 24 hours of hospital transfer for one resident.
F 0732: The facility failed to post nurse staffing information daily and accessible to residents and visitors for two days during the survey.
F 0761: The facility failed to ensure blood glucometer testing strips were labeled and stored properly on four medication carts as per manufacturer's recommendations.
Report Facts
Census: 100
Days staffing information not posted: 2
Medication carts with unlabeled glucometer strips: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Observed using unlabeled blood glucose test strips for resident #13 |
| Registered Nurse Supervisor | Interviewed regarding notification and glucometer strip labeling failures | |
| Social Services Director | Interviewed regarding notification failures for hospital transfers and bed hold notices | |
| Human Resources Coordinator | Responsible for posting nurse staffing information but failed to post on two days | |
| Administrator | Interviewed about staffing information posting policies and practices | |
| Pharmacist | Supervised medications and biologicals; expected labeling of glucometer strips |
Inspection Report
Annual Inspection
Census: 100
Deficiencies: 2
Date: Apr 1, 2022
Visit Reason
A state licensure survey was conducted from March 29, 2022 through April 1, 2022 to assess compliance with state licensure requirements for the facility.
Findings
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.
Deficiencies (2)
Failure to provide written notification of transfer to resident, resident representative, and Ombudsman for one of two residents reviewed for hospital transfers.
Failure to properly store and label four containers of blood glucometer testing strips on four medication carts across four hallways.
Report Facts
Census: 100
Number of medication carts with unlabeled glucometer strips: 4
Residents reviewed for hospital transfers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed glucometer check and noted unlabeled blood glucose test strips |
| Registered Nurse Supervisor | Registered Nurse Nursing Supervisor | Interviewed regarding hospital transfer notification and glucometer strip labeling |
| Social Services Director | Social Services Director | Interviewed regarding notification to Ombudsman of hospital transfers |
| Pharmacist | Supervised medications and biologicals; stated expectation for labeling glucometer strips |
Inspection Report
Routine
Census: 100
Deficiencies: 4
Date: Apr 1, 2022
Visit Reason
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.
Complaint Details
The survey included investigations of multiple complaint cases (GA00214001, GA00215311, GA00218452, GA00221948, GA0221967, and GA00222166) in conjunction with the standard survey.
Findings
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.
Deficiencies (4)
Failure to ensure that the resident, resident representative, and Ombudsman were provided written notification of transfer for one resident sent to the hospital.
Failure to provide written bed hold notice to one resident within 24 hours of hospital transfer.
Failure to post nurse staffing information daily and make it accessible to residents and visitors for two days during the survey.
Failure to ensure proper labeling and dating of blood glucose test strips on medication carts, contrary to manufacturer's recommendations.
Report Facts
Resident census: 100
Deficiency count: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Performed glucometer check and noted unlabeled blood glucose test strips. |
| Registered Nurse Supervisor | Interviewed regarding transfer notification and blood glucose test strip labeling. | |
| Social Services Director | Interviewed regarding lack of written notification to Ombudsman and bed hold notices. | |
| Human Resources Coordinator | Responsible for posting nurse staffing information but failed to post on two days. | |
| Pharmacist | Supervised medications and biologicals, expected labeling of blood glucose test strips. | |
| Administrator | Interviewed regarding nurse staffing posting policy and importance. |
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and an Abbreviated/Partial Extended Survey were conducted to investigate multiple complaint allegations.
Complaint Details
Complaints identified by investigation numbers GA00205251, GA00205260, GA00206847, GA00208146, GA00208572, GA00208578, and GA00211287 were investigated and found not substantiated.
Findings
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.
Report Facts
Total census: 95
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 9, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00209539.
Complaint Details
Complaint #GA00209539 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
Routine
Census: 94
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
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, implementing recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
An unannounced complaint survey was conducted on 1/21/2020 - 1/22/2020 by a Registered Nurse Surveyor.
Complaint Details
Unannounced complaint survey conducted; no deficiencies cited.
Findings
There were no deficiencies cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 22, 2020
Visit Reason
A complaint survey was conducted to investigate multiple complaints identified by their complaint numbers.
Complaint Details
The investigation covered complaints #GA00199728, GA00198942, GA00198705, GA00199562, GA00197383, GA00195862, GA00201607, GA00201539, GA00200468, GA00199971, and GA00199888. No deficiencies were found.
Findings
The survey determined compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 27, 2019
Visit Reason
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.
Complaint Details
Complaint GA00194770 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 130
Deficiencies: 0
Date: Feb 12, 2019
Visit Reason
A revisit survey was conducted on 2/12/19 for the Recertification Survey from 12/10/18 to 12/13/18.
Findings
The revisit survey revealed that all previously cited deficiencies were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 25, 2019
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 0
Date: Jan 10, 2019
Visit Reason
An unannounced visit was made to the facility on 1/9/19-1/10/19 to investigate Complaint Intake Number GA 00193541.
Complaint Details
Investigation of Complaint Intake Number GA 00193541; facility found in substantial compliance.
Findings
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.
Inspection Report
Life Safety
Census: 131
Capacity: 152
Deficiencies: 2
Date: Dec 11, 2018
Visit Reason
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.
Findings
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.
Deficiencies (2)
Facility failed to maintain multiple emergency lights outside of the exit discharge areas and one emergency light at A hall.
Facility failed to maintain the outside exit door at A hall; the door would not self-close and latch properly.
Report Facts
Residents at risk: 60
Staff at risk: 20
Residents at risk: 20
Staff at risk: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings during the tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 11, 2018
Visit Reason
An unannounced complaint survey was conducted on 8.11.18 by a Registered Nurse Surveyor.
Complaint Details
Unannounced complaint survey conducted; no deficiencies cited.
Findings
There were no deficiencies cited during the complaint survey.
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 0
Date: Mar 7, 2018
Visit Reason
An unannounced Complaint Survey was conducted to investigate complaint # GA 00186019.
Complaint Details
Investigation of complaint # GA 00186019; facility found in substantial compliance.
Findings
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.
Report Facts
Resident census: 135
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 11, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00183963.
Complaint Details
Complaint GA00183963 was investigated and determined to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 10, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 5, 2018
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - LILBURN, related to regulatory compliance following an inspection.
Findings
The document does not provide specific details of deficiencies or findings; it primarily serves as a plan of correction form with initial comments.
Inspection Report
Life Safety
Census: 134
Capacity: 152
Deficiencies: 11
Date: Nov 13, 2017
Visit Reason
Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with 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.
Deficiencies (11)
Facility failed to properly test exit and exit directional signs monthly and annually.
Facility failed to properly test emergency lighting monthly and annually.
Fire sprinkler head in kitchen dry storage room was painted, indicating improper maintenance.
Fire extinguisher in smoking area mounted too high, not properly maintained.
Sleeping room doors in rooms 141 and 180 do not create a smoke resistant seal.
Unprotected and improperly protected penetrations and no top of wall assembly in corridor rated walls.
Exposed electrical wires and connections at base of light pole near smoking area.
Fire drills were not conducted quarterly as required; missing drills in late 2016 and early 2017.
Smoking area lacked required ashtrays and noncombustible containers with self-closing lids.
Facility failed to properly maintain generator load testing; missing monthly load runs and insufficient duration of tests.
Oxygen cylinders were not properly stored; empty and full cylinders stored together and one cylinder unsecured.
Report Facts
Census: 134
Total Capacity: 152
Missing monthly generator load tests: 4
Insufficient generator load test duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Interviewed and confirmed multiple findings during inspection |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 15, 2017
Visit Reason
Complaint Survey conducted to investigate complaint #GA00176882 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Investigation of complaint #GA00176882 found no deficiencies; complaint was not substantiated.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 25, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaint #GA00173511 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00173511 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health Lilburn.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2017
Visit Reason
A Health Revisit Survey in conjunction with an Abbreviated Survey was conducted to investigate complaint GA00172768 from March 24, 2017 through March 27, 2017.
Complaint Details
Complaint GA00172768 was substantiated but no regulatory deficiency was cited.
Findings
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.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 27, 2017
Visit Reason
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 Details
Complaint GA00172768 was substantiated.
Findings
Complaint GA00172768 was substantiated, but no regulatory violations were cited. The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 27, 2017
Visit Reason
A Health Revisit Survey in conjunction with an Abbreviated Survey was conducted to investigate complaint GA00172768 from March 24, 2017 through March 27, 2017.
Complaint Details
Complaint GA00172768 was substantiated but no regulatory deficiency was cited.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 14, 2017
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00172325.
Complaint Details
Complaint GA00172325 was investigated and found not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 2, 2017
Visit Reason
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.
Complaint Details
The survey was conducted to investigate complaints GA00166862, GA00169868, and GA00170001. Deficiencies resulted from the investigation of complaints GA00169868 and GA00170001.
Findings
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.
Deficiencies (2)
Failure to investigate and report allegations of abuse, neglect, exploitation, or mistreatment in accordance with regulatory requirements.
Services provided or arranged by the facility, as outlined by the comprehensive care plan, did not meet professional standards of quality.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 9, 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.
Inspection Report
Life Safety
Deficiencies: 5
Date: Dec 16, 2016
Visit Reason
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.
Findings
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.
Deficiencies (5)
Doors protecting corridor openings failed to resist fire for at least 20 minutes and had impediments to closing.
Facility failed to properly maintain smoke barrier walls with unprotected and improperly protected penetrations above ceilings and walls not sealed to roof deck.
Hazard area walls not properly maintained; non-rated expansion foam found at top of D Hall Storage wall.
Fire sprinkler system not properly maintained; areas containing sprinkler piping not protected from freezing.
Emergency generator not maintained properly; monthly 30-minute under load run not conducted for several months and weekly inspection forms incomplete.
Report Facts
Residents at risk: 94
Inspection duration: 20
Monthly generator test duration: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and record review |
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