Inspection Reports for Pruitthealth – Marietta
70 SAINE DRIVE SW, MARIETTA, GA, 30008
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 11, 2025 found no deficiencies, with all previously cited issues corrected during follow-up surveys earlier that month. Prior inspections showed a pattern of deficiencies related mainly to resident care planning, medication administration, staffing levels, and maintaining sanitary and safe environmental conditions, including oxygen equipment and PPE use. Complaint investigations were mostly unsubstantiated, though some complaints were substantiated without resulting in cited deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed earlier deficiencies effectively, showing improvement in compliance over time.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
98 residents
Based on a March 2025 inspection.
Census over time
Inspection Report
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - MARIETTA, indicating a regulatory inspection was conducted.
Findings
No specific deficiencies or findings are detailed in the provided report content.
Inspection Report
Re-Inspection
Census: 98
Deficiencies: 0
Date: Mar 11, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/28/2025 Recertification Survey.
Findings
All deficiencies cited in the prior Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 4, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 3
Date: Jan 16, 2025
Visit Reason
An annual licensure survey was conducted at Pruitthealth Marietta from January 14, 2025 through January 16, 2025 to assess compliance with healthcare regulations.
Findings
The facility was cited for deficiencies including failure to develop an adequate care plan for a resident resulting in actual harm, and failure to maintain sanitary conditions related to oxygen equipment and use of appropriate personal protective equipment for residents on Enhanced Barrier Precautions.
Deficiencies (3)
Failure to develop a care plan for one resident related to amount of assistance needed during transfer, resulting in bruising to the resident's left eye.
Failure to maintain sanitary conditions for oxygen equipment for one resident, with nasal cannula tubing touching the floor.
Failure to use appropriate personal protective equipment for a resident on Enhanced Barrier Precautions during care.
Report Facts
Residents sampled: 49
Residents sampled: 50
Date of injury: Nov 5, 2024
BIMS score: 99
BIMS score: 14
Oxygen order: 2
Date of oxygen order: Nov 18, 2024
Date of care plan review: Jan 16, 2025
Date of admission: Jun 16, 2015
Date of admission: Dec 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Certified Nursing Assistant | Named in the finding related to resident injury during transfer |
| LL | Licensed Practical Nurse | Observed not using PPE during care of resident R3 on Enhanced Barrier Precautions |
Inspection Report
Annual Inspection
Census: 106
Deficiencies: 5
Date: Jan 16, 2025
Visit Reason
A recertification survey was conducted from January 14 through January 16, 2025, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations.
Complaint Details
Complaint Intake Numbers GA00245459, GA00248635, GA00249444, GA00252823, and GA00252808 were investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to develop appropriate care plans, improper medication administration, inadequate staffing during mechanical lifts causing resident injury, failure to maintain sanitary conditions for oxygen equipment and PPE use, and environmental safety hazards such as dust buildup and structural issues.
Deficiencies (5)
Failure to develop a care plan for a resident related to amount of assistance needed during transfer, resulting in actual harm when resident was hit on the head by mechanical lift.
Failure to adhere to medication administration standards by crushing medications that should not be crushed and not measuring correct dosage of diclofenac ointment.
Failure to provide adequate staff to prevent injury during mechanical lift transfer, resulting in resident injury.
Failure to maintain sanitary conditions for oxygen equipment and failure to use appropriate PPE for a resident on Enhanced Barrier Precautions.
Failure to maintain a safe, functional, sanitary, and comfortable environment including wedged items in privacy curtain, dust buildup, loose PTAC units, peeling trim, and substances on floors and ceilings.
Report Facts
Resident census: 106
Residents sampled: 49
Residents observed: 7
Deficiency counts: 5
Medication dosage: 4
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Certified Nursing Assistant | Named in incident where resident was hit on the head by mechanical lift during transfer. |
| AA | Licensed Practical Nurse | Observed improperly crushing medications and not measuring diclofenac ointment correctly. |
| BB | Unit Manager | Interviewed regarding medication crushing and measuring practices. |
| CC | Unit Manager | Interviewed regarding medication crushing and measuring practices. |
| DD | Pharmacist | Interviewed about medication orders and crushing policies. |
| ADON | Assistant Director of Nursing | Provided in-service education on mechanical lifts and interviewed about incident. |
| LL | Licensed Practical Nurse | Observed not using PPE during care of resident on Enhanced Barrier Precautions. |
Inspection Report
Life Safety
Census: 106
Capacity: 119
Deficiencies: 3
Date: Jan 14, 2025
Visit Reason
A Life Safety Code Survey was 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 in sprinkler system maintenance, smoke resistance of corridor doors, and unobstructed access to electrical panels. These issues affected 1 of 8 smoke compartments and were confirmed by staff during the tour.
Deficiencies (3)
Fire sprinkler in the laundry was discovered as loaded, indicating failure to assure minimum readiness of the sprinkler system.
Corridor door to the central supply room could not resist smoke passage through the door handle, indicating failure to assure smoke resistance of doors.
Electrical panel box in the laundry was obstructed, indicating failure to assure clear unobstructed access to electrical locations.
Report Facts
Census: 106
Total Capacity: 119
Smoke Compartments Affected: 1
Total Smoke Compartments: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their codes, initiated on March 14, 2024 and concluded on April 3, 2024.
Complaint Details
Complaints GA00234096, GA00239311, GA00240668, GA00242213, GA00242474, GA00243125, GA00243513, and GA00245177 were investigated and found to be unsubstantiated.
Findings
All complaints investigated during the survey were found to be unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints #GA000232671, #GA000232674, #GA000232822, and #GA000233406 on behalf of the Georgia Department of Community Health.
Complaint Details
Complaints #GA000232674 and #GA000233406 were unsubstantiated. Complaints #GA000232822 and #GA000232671 were substantiated.
Findings
Complaints #GA000232674 and #GA000233406 were unsubstantiated, while complaints #GA000232822 and #GA000232671 were substantiated. No regulatory violations were cited.
Inspection Report
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - MARIETTA, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 7, 2022 Standard Survey.
Findings
All deficiencies cited as a result of the October 7, 2022 Standard Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
An Abbreviated Survey was conducted to investigate complaint numbers GA00228613 and GA00229737.
Complaint Details
The survey was complaint-related, investigating complaints GA00228613 and GA00229737, with no regulatory violations found.
Findings
No regulatory violations were cited during the abbreviated survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 15, 2022
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
Follow-Up
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags (both State and Federal) have been corrected.
Findings
The surveyor noted that all previously cited deficiencies have been corrected.
Inspection Report
Life Safety
Census: 91
Capacity: 119
Deficiencies: 1
Date: Nov 8, 2022
Visit Reason
An unannounced Emergency Preparedness survey and a Life Safety Code Federal Monitoring Survey were conducted following a state survey. The visit was to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in substantial compliance with emergency preparedness requirements but was not in substantial compliance with life safety code requirements, specifically related to door latching hardware on one door that required two simultaneous releasing operations to open.
Deficiencies (1)
The door from the second-floor janitor room required two simultaneous releasing operations to open, which does not meet the requirement that releasing mechanisms be installed between 34" and 48" above finished floor and not require simultaneous releasing operations.
Report Facts
Census: 91
Total Capacity: 119
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Present when the door latching deficiency was identified |
Inspection Report
Life Safety
Census: 89
Capacity: 119
Deficiencies: 2
Date: Oct 13, 2022
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to protect against electrical hazards in one of eight smoke compartments. Specifically, a cart was obstructing an electrical panel in the kitchen and an electrical light switch cover was missing, exposing users to potential electrical shock.
Deficiencies (2)
A cart/table was found obstructing the electrical panel in the kitchen.
An electrical light switch cover was missing, not protecting the user from electrical shock.
Report Facts
Smoke Compartments affected: 1
Certified beds: 119
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M confirmed findings at time of discovery |
Inspection Report
Routine
Census: 90
Deficiencies: 9
Date: Oct 7, 2022
Visit Reason
A standard survey was conducted at Pruitthealth - Marietta from October 3, 2022 through October 7, 2022, including investigation of multiple complaint intake numbers.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey, including allegations of sexual abuse and inadequate care.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to accommodate resident needs for shower beds, failure to prevent sexual abuse, failure to timely report abuse allegations, inaccurate PASARR screening, failure to provide care per professional standards including wound care and medication administration, improper use and documentation of bed rails, insufficient nursing staff, and failure to maintain accurate resident medical records.
Deficiencies (9)
Failure to accommodate needs of residents related to providing a functional shower bed on the second floor, resulting in residents not receiving showers as preferred.
Failure to prevent sexual abuse of one resident by another, including inadequate staff response and education.
Failure to report allegations of abuse timely and appropriately for two residents.
Failure to ensure accurate PASARR screening for one resident with mental health diagnoses.
Failure to provide wound care per physician's orders for one resident with pressure ulcers.
Failure to assess and obtain informed consent for bed/side rail use and failure to care plan their use for three residents.
Failure to have sufficient nursing staff to provide care for residents, including two residents reviewed for ADLs and one for wound care.
Failure to prohibit the Director of Nursing from serving as a charge nurse for multiple days when census was greater than 60 residents and no waiver was in effect.
Failure to maintain accurate medical records for two residents, including inaccurate documentation of warfarin administration and g-tube water flushes.
Report Facts
Resident census: 90
Residents desiring shower bed: 5
Residents sampled for shower bed need: 48
Days DON served as charge nurse: 8
Resident census: 94
Resident census: 46
Medication doses: 4
Medication doses: 2.5
Water flush volume: 150
Water flush volume: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Responsible for wound care and medication administration; admitted wound care was not done on 10/3/22 |
| Wound Care Nurse OO | Wound Care Nurse | Responsible for wound care; reassigned to staff nurse duties, unable to provide consistent wound care |
| Administrator AA | Administrator | Reported sexual abuse incident; acknowledged staffing shortages and DON working as staff nurse |
| DON BB | Director of Nursing | Scheduled as charge nurse multiple days; acknowledged staffing shortages |
| Senior Nurse Consultant WW | Senior Nurse Consultant | Acknowledged staffing shortages and wound care issues |
| HR XX | Human Resources Director | Provided staffing schedules and confirmed DON worked as charge nurse |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 2
Date: Oct 7, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from October 3, 2022 through October 7, 2022 to assess compliance with state regulations for nursing services, professional services, and overall facility staffing.
Findings
The facility was found deficient in having sufficient nursing staff to provide care to residents, including failure to provide adequate wound care and assistance with activities of daily living. Additionally, the facility failed to ensure proper administration and documentation of insulin medications for a resident. Staffing shortages were documented across multiple shifts and dates, with staff and administration acknowledging ongoing staffing challenges.
Deficiencies (2)
Insufficient nursing staff to provide care for residents, including inadequate wound care and assistance with activities of daily living.
Failure to ensure one resident received blood sugar monitoring and insulin medications as ordered, with multiple instances of undocumented medication administration.
Report Facts
Resident census: 92
Resident census: 93
Resident census: 94
Resident census: 46
Resident census: 50
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BB | Director of Nursing (DON)/Registered Nurse (RN) | Interviewed regarding staffing and wound care deficiencies |
| WW | Senior Nurse Consultant (NC) | Interviewed regarding staffing and wound care deficiencies |
| OO | Wound Care Nurse | Interviewed regarding wound care provision and staffing issues |
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding staffing shortages and medication administration |
| NN | Registered Nurse (RN) | Interviewed regarding wound care and medication administration |
| LL | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration documentation |
| Administrator | Interviewed regarding staffing and medication administration expectations |
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00217247.
Complaint Details
Complaint #GA00217247 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The complaint was unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00216174, #GA00213072, #GA00213845, and #GA00215819.
Complaint Details
Complaint #GA00216174 was substantiated with no deficiency cited. Complaints #GA00213072, #GA00213845, and #GA00215819 were unsubstantiated with no deficiency cited.
Findings
Complaint #GA00216174 was substantiated with no deficiency cited. Complaints #GA00213072, #GA00213845, and #GA00215819 were unsubstantiated with no deficiency cited.
Inspection Report
Abbreviated Survey
Census: 86
Deficiencies: 0
Date: Feb 23, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey. Multiple complaints were investigated during this survey.
Complaint Details
Complaints #GA00212158, #GA00211739, #GA00209343, and #GA00207479 were investigated and found to be unsubstantiated with no regulatory violations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS and CDC recommended practices for COVID-19. Complaints investigated were unsubstantiated with no regulatory violations.
Report Facts
Complaints investigated: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 21, 2020
Visit Reason
An Abbreviated/Partial Extended Survey investigating complaint #GA00208285 was conducted on October 21, 2020.
Complaint Details
Complaint #GA00208285 was investigated; complaint #GA00208825 was unsubstantiated with no regulatory violations cited.
Findings
Complaint #GA00208825 was unsubstantiated and no regulatory violations were cited.
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 0
Date: Aug 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess the facility's compliance with COVID-19 related regulations and preparedness.
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 CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 5, 2020
Visit Reason
The visit was an onsite Abbreviated/Partial Extended Survey initiated to investigate multiple complaints related to infection control and other allegations.
Complaint Details
The investigation included complaints #GA00205069, GA00204790, GA00203290, GA00203432, GA00203339, GA00203367, and GA00205609. Complaints #GA00205069, GA00204790, GA00203290, GA00203432, and GA00203367 were unsubstantiated. Complaint #GA00203339 was substantiated. No regulatory violations were cited.
Findings
The investigation found that several complaints were unsubstantiated, one complaint was substantiated, but no regulatory violations were cited.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the July 24, 2019 Annual Survey and to investigate multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA002050609, GA00203290, GA00204790, GA00203432, GA00203339, and GA00203367 were investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the July 24, 2019 Annual Survey were found to be corrected. The complaint investigations were unsubstantiated with no deficiencies identified.
Report Facts
Complaint Intake Numbers: 6
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Date: Aug 3, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the July 24, 2019 Annual Survey.
Findings
All deficiencies cited as a result of the July 24, 2019 Annual Survey were found to be corrected.
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 16 and June 17, 2020 by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health.
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
Routine
Deficiencies: 1
Date: Feb 26, 2020
Visit Reason
The inspection was conducted to assess compliance with nursing care standards, specifically focusing on the provision of appropriate indwelling urinary catheter care for residents.
Findings
The facility failed to provide appropriate indwelling urinary catheter care for one sampled resident (#3), as evidenced by inadequate catheter care practices observed during the inspection, including failure to wash the meatus and catheter tubing properly.
Deficiencies (1)
Failed to provide appropriate indwelling urinary catheter care for resident #3, including failure to wash the meatus of the penis and wipe down the catheter tubing.
Report Facts
Date of catheter change: Feb 8, 2020
BIMS score: 15
Date of last CNA training: 201912
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Observed providing inadequate catheter care to resident #3 |
| Nurse Consultant | Interviewed regarding catheter care training and competency checks |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Feb 26, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint numbers including GA00202822, which was substantiated with deficiencies.
Complaint Details
Complaint number GA00202822 was substantiated. The facility failed to report an allegation of abuse involving resident #1 within the required timeframe. The Administrator did not consider the incident as abuse and did not report it to the State agency.
Findings
The facility failed to report an allegation of abuse within the required timeframe for one resident and failed to provide appropriate indwelling urinary catheter care for another resident. The complaint was substantiated with deficiencies related to reporting alleged violations and catheter care.
Deficiencies (2)
Failed to report an allegation of abuse to the State Survey Agency within the required timeframe for one resident.
Failed to provide appropriate indwelling urinary catheter care, including failure to wash the meatus and catheter tubing properly.
Report Facts
Complaint numbers investigated: 6
Resident sample size: 4
Resident sample size: 3
Date of catheter change: Feb 8, 2020
BIMS score: 15
Date of survey completion: Feb 26, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in allegation of abuse by resident #1 |
| CNA BB | Certified Nursing Assistant | Observed providing inadequate catheter care to resident #3 |
| Administrator | Did not report the abuse allegation to the State agency | |
| Social Worker | Received complaint from resident #1 and reported incident to Administrator | |
| Nurse Consultant | Provided information about annual skill check-offs including catheter care |
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Date: Nov 19, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous 10/2/19 Revisit Survey.
Findings
All deficiencies cited in the previous revisit survey were found to be corrected during this visit.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 10, 2019
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.
Inspection Report
Routine
Census: 108
Deficiencies: 10
Date: Jul 24, 2019
Visit Reason
A standard survey was conducted at PruittHealth Marietta from July 21, 2019 through July 24, 2019, including investigation of complaint intake number GA00196597.
Complaint Details
Complaint intake number GA00196597 was investigated 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 quarterly financial statements for resident trust funds, failure to post survey results prominently, unsafe and unclean environment in multiple resident rooms and common areas, inadequate supervision for a resident who smokes, insufficient hydration for some residents, insufficient nursing staff to meet resident needs, failure to post daily nurse staffing data timely, kitchen staff not wearing proper hair protection, unsafe and unsanitary dish machine room conditions, improper disposal and storage of cooking oil and grease trap area, and privacy curtains that were missing, dirty, or too short.
Deficiencies (10)
Failed to provide quarterly financial statements for two cognitively intact residents with trust fund accounts.
Failed to post notice of availability of state survey results in prominent places accessible to residents and families.
Facility environment not maintained in a safe, clean, comfortable, and homelike manner in multiple resident rooms and common areas, including holes in ceilings, broken outlets, odors, and damaged furnishings.
Failed to provide supervised smoking for one resident who smokes, observed smoking unsupervised.
Failed to provide hydration (ice/water) at bedside for two residents.
Failed to provide sufficient nursing staff to meet resident care needs on two units, resulting in delayed care and resident dissatisfaction.
Failed to post nurse staffing information timely on one of four days observed.
Kitchen staff failed to wear proper hair and beard protection; dish machine room had broken floor tiles and pooled dirty water with food debris.
Failed to ensure sanitary handling of used cooking oil and grease trap area was inaccessible due to overgrown weeds and clutter.
Privacy curtains were missing, dirty, or too short in six beds on one unit, failing to assure full visual privacy.
Report Facts
Resident census: 108
Resident trust fund accounts: 93
Residents sampled: 55
Residents receiving oral diet: 103
Facility census: 106
Residents on 200 Hall: 55
Residents on 100 Hall: 51
CNAs scheduled on 200 Hall: 2
CNAs scheduled on 100 Hall: 2
Privacy curtains too short: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook MM | Cook | Observed working without proper beard net in kitchen |
| Kitchen Aide AA | Kitchen Aide | Confirmed floor drain not draining properly |
| Kitchen Aide BB | Kitchen Aide | Explained grease disposal and showed grease trap area |
| CNA NN | Certified Nursing Assistant | Responsible for daily scheduling of nurses and CNAs |
| CNA OO | Certified Nursing Assistant | Reported staffing discrepancies on 200 Hall evening shift |
| Maintenance Director | Maintenance Director | Discussed plumbing and grease trap issues |
| Housekeeping Aide DD | Housekeeping Aide | Inspects privacy curtains daily |
| Housekeeping Supervisor | Housekeeping Supervisor | Described expectations for privacy curtain maintenance |
| Administrator | Administrator | Discussed staffing and survey posting responsibilities |
| Regional Nurse Consultant | Regional Nurse Consultant | Discussed posting of survey results |
| Activity Director | Activity Director | Discussed resident education on survey results |
| Accounts payable/Financial Counselor | Financial Counselor | Responsible for resident trust fund accounts |
Inspection Report
Routine
Census: 106
Deficiencies: 6
Date: Jul 24, 2019
Visit Reason
Routine inspection to assess compliance with nursing service staffing requirements, safety standards, physical plant standards, and kitchen/food service regulations.
Findings
The facility was found to have insufficient nursing staff to meet resident care needs, with multiple resident and staff interviews confirming staffing shortages. Safety issues included maintenance deficiencies such as broken ceiling tiles, holes, and odors. Privacy curtains were missing or too short in several rooms. The kitchen had a non-draining floor drain causing water pooling and broken tiles, and kitchen staff did not fully comply with hair/beard covering policies. The grease trap area was overgrown with weeds and cluttered with old equipment, with no formal policies for grease trap or cooking oil disposal.
Deficiencies (6)
Insufficient nursing staff to provide required direct care hours, resulting in delayed resident assistance and unmet care needs.
Multiple physical plant safety hazards including broken ceiling tiles, holes, missing light fixtures, and strong odors in resident rooms and common areas.
Privacy curtains missing, too short, or dirty in multiple patient rooms, compromising resident privacy.
Kitchen floor drain not draining properly causing pooled water with food debris and broken floor tiles.
Kitchen staff non-compliance with hair and beard covering policies during food preparation.
Grease trap area overgrown with weeds and cluttered with broken equipment; lack of formal policies for grease trap and cooking oil disposal.
Report Facts
Residents onsite: 106
Residents on 200 Hall: 55
Residents on 100 Hall: 51
Minimum direct nursing care hours per patient: 2
BIMS score: 15
Number of CNAs scheduled on 200 Hall evening shift: 4
Depth of pooled water at kitchen floor drain: 5
Health inspection score: 98
Height of weeds in grease trap area: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA MM | Certified Nursing Assistant | Interviewed about staffing levels and shift coverage on 7/24/19 |
| CNA NN | Certified Nursing Assistant and Scheduler | Responsible for daily scheduling of nurses and CNAs since May 2019; interviewed about staffing |
| CNA OO | Certified Nursing Assistant | Interviewed about actual CNA coverage on 200 Hall 3-11 shift on 7/24/19 |
| Maintenance Director | Interviewed about maintenance issues including kitchen floor drain and grease trap area | |
| Cook MM | Kitchen Staff | Observed working without full beard covering during food preparation |
| Housekeeping Aide DD | Housekeeping Aide | Interviewed about privacy curtain cleaning and inspection |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about privacy curtain inspection expectations |
| Rehab Director | Rehab Director | Interviewed about equipment disposal and maintenance request process |
| Nurse Consultant LL | Nurse Consultant | Interviewed about kitchen staff attire policies |
| Kitchen Aide AA | Kitchen Aide | Interviewed about kitchen floor drain issue |
| Kitchen Aide BB | Kitchen Aide | Observed during kitchen tour and grease disposal explanation |
Inspection Report
Life Safety
Census: 106
Capacity: 119
Deficiencies: 5
Date: Jul 22, 2019
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with several fire safety requirements including emergency lighting documentation, ceiling finishes affecting sprinkler activation, fire alarm system readiness, smoke barrier door functionality, and electrical circuit identification. These deficiencies posed varying levels of risk to residents and staff.
Deficiencies (5)
Failure to maintain minimum documentation on Emergency Evacuation Devices, specifically incomplete emergency lighting monthly test records for August through December 2018.
Failure to assure ceiling finishes served their purpose to activate the fire sprinkler system due to broken, moved, and penetrated ceiling tiles in multiple locations.
Failure to maintain and assure constant readiness of fire protection equipment; a trouble signal on the Fire Alarm Control Panel indicated a communication fault preventing automatic alarm notification.
Failure to assure fire and smoke barrier doors close properly to resist passage of smoke; specifically, the 2nd floor dining hall fire door would not close completely.
Failure to maintain listings of all electrical circuits to identify circuits needing to be shut down; circuit panel in the sprinkler riser room lacked identification labels.
Report Facts
Residents at risk due to emergency evacuation documentation deficiency: 30
Residents at risk due to ceiling finish deficiency: 40
Residents at risk due to fire alarm system deficiency: 106
Residents at risk due to smoke barrier door deficiency: 40
Staff members at risk due to electrical circuit identification deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency lighting, ceiling finishes, fire alarm system, smoke barrier doors, and electrical circuit identification during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 30, 2019
Visit Reason
A complaint survey was conducted to investigate complaint GA00196017 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00196017 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: Feb 13, 2019
Visit Reason
A complaint survey was conducted to investigate complaints GA00194683 and 194434 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted in response to complaints GA00194683 and 194434; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 10, 2019
Visit Reason
A complaint survey was conducted from 2019-01-09 to 2019-01-10 to investigate complaints GA00192192, GA00191019, and GA00193323 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey was conducted to investigate complaints GA00192192, GA00191019, and GA00193323; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 12, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 19, 2018 Annual Survey.
Findings
All deficiencies cited as a result of the April 19, 2018 Annual Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 11, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up visit.
Inspection Report
Life Safety
Census: 108
Capacity: 119
Deficiencies: 3
Date: Apr 17, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including issues with electrical shock hazards, use of prohibited portable space heaters, and insufficient fire protection signage in the oxygen storage area.
Deficiencies (3)
Multi-Outlet Power strip found on the floor in the Kitchen Dietary Office and a void space in the electrical panel box in the kitchen, posing electrical shock risk.
Portable space heater in operation under the desk in the dietary office without documentation confirming heating element did not exceed 212 degrees Fahrenheit.
Oxygen Storage area lacked required signage stating 'CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING'.
Report Facts
Staff at risk: 6
Staff at risk: 4
Census: 108
Total Capacity: 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to electrical hazards, portable space heater, and oxygen storage signage during facility tour. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 21, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00186166 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00186166 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 28, 2017
Visit Reason
A follow-up to the Recertification survey of July 27, 2017 was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 10, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 27, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 112
Capacity: 119
Deficiencies: 5
Date: Jul 24, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and related NFPA standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including non-operational emergency lighting, fire sprinklers loaded in the laundry, unsealed smoke barrier penetrations, smoke barrier doors not closing properly, and electrical hazards due to unprotected multi-outlet power strips on the floor.
Deficiencies (5)
Emergency lighting units were not operative in test mode in the Kitchen and 2nd story Nurses Station.
Fire sprinklers were found loaded in the laundry, indicating failure to maintain fire protection systems in maximum operative condition.
A wall penetration at the roof/top of wall above double smoke doors near the Administrator's office was not sealed to resist smoke passage.
Two corridor/hallway smoke doors on the 2nd floor near A200 and C220 did not close to seal away smoke spread.
Multi-Outlet Power Strips (MOPS) were identified on the floor in Laundry, Environmental office, and staffing office, not protected from water flooding or wet exposure.
Report Facts
Residents at risk: 60
Residents at risk: 75
Staff at risk: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 13, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint numbers GA00164722, GA00159513, and GA00168208 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The survey was conducted in response to complaints GA00164722, GA00159513, and GA00168208. No deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey conducted on 05/06/2017 and 05/12/2017.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 23, 2017
Visit Reason
The abbreviated survey was conducted to investigate a complaint #GA 00171807 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00171807 was investigated and no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey conducted at Pruitthealth - Marietta.
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