Inspection Reports for Pruitthealth – Monroe
4796 HIGHWAY 42 NORTH, GA, 31029
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Mar 5, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA0000251496 and GA00254032.
Findings
Both complaints GA0000251496 and GA00254032 were substantiated, but no regulatory violations were cited during the survey.
Complaint Details
Complaints GA0000251496 and GA00254032 were substantiated with no regulatory violations cited.
Report Facts
Complaint numbers investigated: 2
Inspection Report
Deficiencies: 0
Jul 2, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 65
Deficiencies: 0
Jul 2, 2024
Visit Reason
A revisit survey was conducted at Pruitt Health-Monroe beginning on July 1, 2024, and ending on July 2, 2024, to verify correction of deficiencies cited in the May 5, 2024 survey.
Findings
All deficiencies cited as a result of the May 5, 2024 survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 20, 2024
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 by the surveyor.
Inspection Report
Annual Inspection
Deficiencies: 3
May 5, 2024
Visit Reason
A State Licensure survey was conducted at Pruitt Health Monroe from May 3, 2024, through May 5, 2024, to assess compliance with state health regulations and identify any deficiencies.
Findings
The facility was cited for deficiencies including failure to follow care plans for three residents related to nutrition, oxygen therapy, and hand splint refusal; improper maintenance of the walk-in freezer causing ice build-up on food storage shelves and products; and failure to ensure dishware was air dried before use, risking cross contamination.
Deficiencies (3)
| Description |
|---|
| Failed to create a nutrition care plan for Resident 14, failed to follow physician's oxygen order for Resident 24, and failed to add refusal of hand splint in care plan for Resident 30. |
| Failed to properly maintain the walk-in freezer to prevent ice build-up on food storage shelves and food products, potentially affecting 62 of 63 residents receiving an oral diet. |
| Failed to ensure dishware was air dried before usage to prevent potential cross contamination and bacteria contamination, potentially affecting 62 of 63 residents receiving an oral diet. |
Report Facts
Residents sampled: 26
Residents affected by freezer ice build-up: 62
Residents affected by dishware drying issue: 62
Ice mound dimensions: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Confirmed ice build-up in walk-in freezer and drying practices for dishware |
| Director of Health Services | Director of Health Services | Confirmed care plan deficiencies and staff noncompliance with oxygen order and hand splint care plan |
| Dietary Cook CC | Dietary Cook | Observed drying dishware with paper towel instead of air drying |
Inspection Report
Routine
Census: 63
Deficiencies: 7
May 5, 2024
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483 for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including inaccurate MDS assessments, failure to follow care plans, medication errors, improper oxygen administration, food sanitation issues, and maintenance problems with the walk-in freezer.
Severity Breakdown
D: 5
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to accurately code an annual Minimum Data Set (MDS) assessment for PASRR Level II for one resident. | D |
| Failed to follow care plans for nutrition, oxygen therapy, and hand splint application for three residents. | D |
| Failed to follow Occupational Therapy Restorative Nursing Program recommendations for orthotic application for two residents. | D |
| Failed to ensure oxygen was administered according to physician orders for one resident. | D |
| Medication error rate exceeded 5% with two errors in 27 opportunities involving crushing a 'Do Not Crush' medication and improper insulin pen priming. | D |
| Failed to ensure dishware was air dried after sanitizing, instead dried with paper towels, risking cross contamination. | F |
| Failed to properly maintain walk-in freezer to prevent ice build-up on food storage shelves and food products. | F |
Report Facts
Residents sampled: 26
Medication error rate: 7.41
Resident census: 63
Oxygen liter flow: 2
Oxygen liter flow observed: 3
Oxygen liter flow observed: 4
Blood sugar: 411
Ice mound height: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Crushed a 'Do Not Crush' medication and failed to prime insulin pen properly |
| Director of Health Services | Confirmed deficiencies in care plan adherence, oxygen administration, and medication errors | |
| Dietary Cook CC | Observed drying dishware with paper towels instead of air drying | |
| Dietary Manager | Confirmed ice build-up in walk-in freezer and drying practices | |
| LPN BB | Licensed Practical Nurse | Observed administering insulin without priming pen |
Inspection Report
Life Safety
Census: 63
Capacity: 83
Deficiencies: 5
May 4, 2024
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including sprinkler system maintenance, corridor door functionality, smoke barrier integrity, and fire safety measures.
Findings
The facility was found not in substantial compliance with emergency preparedness and life safety code requirements. Deficiencies included failure to update the Emergency Preparedness plan annually, missing escutcheon plates in multiple areas, patient doors failing to latch, unauthorized foam used to seal penetrations in fire walls, and smoke doors failing to close and seal properly.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Emergency Preparedness plan was not updated and reviewed annually. | SS=D |
| Escutcheon plates were missing in Hallway D 1, Patient room B 8, and closet room A 4. | SS=D |
| Patient door B 4 failed to latch when tested. | SS=D |
| Unauthorized foam used to seal penetrations in fire walls throughout Hallways A, B, and C. | SS=D |
| Smoke Door D Hallway failed to close when tested. | SS=D |
Report Facts
Census: 63
Total Capacity: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Apr 12, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints including GA00243954, GA00244790, GA00245012, GA00245029, GA00245103, GA00245235, and GA00245823.
Findings
Complaint GA00243954 was substantiated but no regulatory violations were cited. The other complaints were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaint GA00243954 was substantiated with no regulatory violations cited. Complaints GA00244790, GA00245012, GA00245029, GA00245103, GA00245235, and GA00245823 were unsubstantiated with no regulatory violations cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 8, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - MONROE, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 8, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited in the November 13, 2023, Complaint Survey.
Findings
All deficiencies cited as a result of the November 13, 2023, Complaint Survey were found to be corrected.
Complaint Details
This visit was a follow-up to a complaint survey conducted on November 13, 2023. All cited deficiencies were corrected.
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 13, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth-Monroe from November 1, 2023 through November 13, 2023 to assess compliance with state health regulations.
Findings
The facility was cited for failing to timely address significant weight loss in one resident and for inadequate wound assessment and documentation for the same resident. Interviews and record reviews confirmed delays in intervention and documentation.
Deficiencies (2)
| Description |
|---|
| Failed to ensure resident with significant weight loss was addressed in a timely manner for one of three sample residents (R2). |
| Failed to ensure wound assessments were completed weekly and failed to accurately document skin assessments for one of three sampled residents (R2). |
Report Facts
Weight loss percentage: 13.76
Dates of weight measurements: 2
Dates of skin observation reports: 2
Date wound management report completed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN BB | Registered Nurse | Took over weight program in July/August 2023 and notified Physician of resident's weight loss |
| RD | Registered Dietician | Reviewed weights monthly and addressed weight loss in September 2023 |
| Director of Nursing | Director of Nursing | Confirmed weight loss was not addressed timely and discussed weight loss in weekly meetings |
| LPN AA | Licensed Practical Nurse | Notified by CNA about open area on resident R2 and notified Skin Integrity Coordinator but did not dress area or notify Physician/family |
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 2
Nov 13, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate Complaint Intake Numbers GA00233759, GA00237658, and GA00238036. Two complaints were unsubstantiated, and one complaint (GA00238036) was substantiated with deficiencies.
Findings
The facility failed to ensure weekly wound assessments and accurate skin documentation for one resident (R2), and failed to address significant weight loss in a timely manner for the same resident. Interviews and record reviews confirmed delays in wound management and weight loss interventions.
Complaint Details
Complaint Intake Numbers GA00233759 and GA00237658 were unsubstantiated. Complaint Intake Number GA00238036 was substantiated with deficiencies related to wound care and nutrition/hydration status.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure wound assessments were completed weekly and accurately documented for one resident (R2). | Level D |
| Failed to ensure resident with significant weight loss was addressed in a timely manner for one resident (R2). | Level D |
Report Facts
Facility census: 147
Weight loss percentage: 13.76
Weight loss timeframe: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Notified about open area on resident R2 and failed to dress wound or notify physician/family |
| BB | Registered Nurse (RN) | Took over weight program and notified physician about resident R2's weight loss |
| Director of Nursing (DON) | Interviewed regarding wound and weight loss management; started education on 8/4/2023 | |
| Registered Dietician (RD) | Interviewed about weight loss monitoring and intervention timing |
Inspection Report
Deficiencies: 0
Dec 13, 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
Plan of Correction
Deficiencies: 0
Dec 13, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PruittHealth - Monroe, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings within the provided page.
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 0
Dec 13, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/04/2022 Complaint Survey.
Findings
All deficiencies cited as a result of the 10/04/2022 Complaint Survey were found to be corrected.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 10/04/2022; all cited deficiencies were corrected.
Report Facts
Census: 52
Inspection Report
Re-Inspection
Census: 52
Deficiencies: 0
Dec 13, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/23/2022 Recertification Survey.
Findings
All deficiencies cited as a result of the 10/23/2022 Recertification Survey were found to be corrected.
Inspection Report
Life Safety
Census: 49
Capacity: 83
Deficiencies: 0
Oct 26, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey 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 Life Safety Code 2012 edition.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 5
Oct 23, 2022
Visit Reason
A standard annual survey was conducted at Pruitthealth-Monroe from 10/21/22 through 10/23/22 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide required Medicare notices to residents, unsecured medication carts, improper preparation of pureed food, inadequate food safety practices including undated and expired food items, improper thawing of food, and incomplete personal food policy regarding safe reheating procedures.
Severity Breakdown
D: 3
E: 1
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two residents discharged from Medicare Part A services. | D |
| Medication carts were found unlocked and unattended during medication administration, failing to secure medications properly. | D |
| Pureed Salisbury steak was not prepared according to recipe, risking inadequate nutrient content. | D |
| Opened food items in walk-in refrigerator were not dated; expired food items were not discarded; food was improperly thawed without running water. | F |
| Facility policy on residents' personal food did not include procedures for safe consumption or reheating to prevent foodborne illness. | E |
Report Facts
Resident census: 51
Residents receiving pureed diet: 10
Residents receiving oral diet: 49
Medication carts observed unlocked: 1
Inspection Report
Original Licensing
Census: 49
Capacity: 51
Deficiencies: 3
Oct 21, 2022
Visit Reason
A Licensure Survey was conducted from 10/21/22 through 10/23/22 to assess compliance with physical plant standards and food safety regulations.
Findings
The facility failed to ensure opened food items in the walk-in refrigerator were dated, failed to discard food items past the 'Best If Use By' date, and failed to properly thaw food items to prevent foodborne illness, potentially affecting 49 of 51 residents receiving an oral diet.
Deficiencies (3)
| Description |
|---|
| Opened food items in the walk-in refrigerator were not dated. |
| Food items were not discarded after the 'Best If Use By' date. |
| Food items were not properly thawed to prevent foodborne illness. |
Report Facts
Residents affected: 49
Total residents: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Confirmed food safety deficiencies and expectations for labeling and thawing food | |
| Sister facility Dietary Manager | Confirmed food safety deficiencies regarding labeling of opened food items |
Inspection Report
Renewal
Deficiencies: 1
Oct 4, 2022
Visit Reason
A Licensure Survey was conducted from 9/6/22 through 10/4/22 to assess compliance with licensure requirements for the facility.
Findings
The facility failed to ensure two residents received showers as scheduled according to their care plans, indicating deficiencies in nursing care related to hygiene.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure two residents were given showers as scheduled according to their care plans. |
Report Facts
Residents in sample: 10
Resident A admission date: Jul 7, 2022
Resident B admission date: Mar 15, 2019
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 3
Oct 4, 2022
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints received by the facility, including GA00221417, GA00222202, GA00222906, GA00215023, GA00226576, and GA00227005.
Findings
The investigation found that four complaints were unsubstantiated with no deficiencies cited, while two complaints were substantiated with deficiencies related to resident care and documentation. Immediate Jeopardy was identified related to resident falls and care planning, and deficiencies were also found in ADL care and CPR documentation.
Complaint Details
Complaints GA00221417, GA00222202, GA00222906, and GA00226576 were unsubstantiated with no deficiencies cited. Complaints GA00215023 and GA00227005 were substantiated with cited deficiencies including Immediate Jeopardy related to resident falls and care planning.
Severity Breakdown
J: 2
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure resident was properly positioned in bed to prevent falls, resulting in a fall with injury and death (Immediate Jeopardy). | J |
| Failure to provide scheduled showers to two residents as required. | D |
| Failure to have valid Do Not Resuscitate (DNR) orders with required physician signatures for two residents. | D |
Report Facts
Resident census: 52
Number of complaints investigated: 6
Number of residents in sample: 10
Dates of showers missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Reported resident fall on 5/20/21. |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Reported resident shower schedule for Resident A. |
| Certified Nursing Assistant CC | Certified Nursing Assistant | Reported resident shower schedule for Resident B. |
| Administrator | Facility Administrator | Informed of Immediate Jeopardy and interviewed regarding DNR/POLST issues. |
| Social Services Director | Social Services Director | Interviewed regarding responsibility for DNR/POLST form completion. |
Inspection Report
Re-Inspection
Census: 57
Deficiencies: 0
Feb 11, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 28, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 55
Deficiencies: 4
Dec 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found not in compliance with infection control regulations, failing to ensure proper disinfectant use, availability of supplies in high-risk areas, and adherence to staff screening procedures, potentially exposing 32 of 55 residents to infection.
Deficiencies (4)
| Description |
|---|
| Housekeeping used a floor cleaner without disinfecting qualities in the COVID-19 positive resident area instead of the required disinfectant. |
| No alcohol-based hand rub was available on the PPE cart in the COVID-19 level one area. |
| Ten of 29 staff on duty were not screened or signed in according to facility policy upon entry. |
| Facility policy lacked reference to taking staff temperature as part of COVID-19 symptom monitoring. |
Report Facts
Residents positive for COVID-19: 23
Residents potentially exposed: 32
Total census: 55
Staff not screened: 10
Staff on duty: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HSK BB | Housekeeper | Used incorrect floor cleaner and responsible for supplying PPE carts |
| HSKS | Housekeeping Supervisor | Provided information on proper disinfectant use |
| CNA BB | Certified Nursing Assistant | Provided information on staff screening and shift records |
| Administrator | Provided employee daily list and information on facility access and resident COVID-19 status |
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 0
Dec 8, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility.
Findings
Most complaints were unsubstantiated, with one complaint substantiated but resulting in no deficiencies.
Complaint Details
Complaints #GA00208750, #GA00208105, #GA00205497, #GA00205132, #GA00204939, #GA00204057, and #GA00203293 were unsubstantiated. Complaint #GA00207952 was substantiated with no deficiencies.
Report Facts
Complaints investigated: 8
Inspection Report
Routine
Census: 60
Deficiencies: 0
Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.83 and 42 CFR 483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 66
Deficiencies: 0
Aug 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Report Facts
Total census: 66
Inspection Report
Routine
Census: 72
Deficiencies: 0
Jul 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on July 16-17, 2020.
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 to prepare for COVID-19.
Report Facts
Census: 72
Inspection Report
Follow-Up
Deficiencies: 0
Nov 27, 2019
Visit Reason
A revisit survey was conducted to follow up on a previous complaint survey from 11/25/19 through 11/27/19 to verify correction of deficiencies.
Findings
All deficiencies identified in the prior complaint survey were corrected, and the facility was found to be in substantial compliance as of 10/31/19.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 11/25/19 through 11/27/19.
Inspection Report
Re-Inspection
Census: 72
Deficiencies: 0
Nov 27, 2019
Visit Reason
A revisit survey was conducted from 11/25/19 through 11/27/19 to verify correction of deficiencies cited during the Standard Survey from 10/6/19 to 10/10/19.
Findings
All deficiencies cited in the prior Standard Survey were found to be corrected. The facility was in substantial compliance as of October 31, 2019.
Inspection Report
Life Safety
Census: 71
Capacity: 83
Deficiencies: 0
Oct 15, 2019
Visit Reason
The visit was conducted to perform a Life Safety Code Survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in compliance with the Life Safety Code requirements for participation in Medicare/Medicaid and the Emergency Preparedness plan met the requirements set forth in Appendix Z.
Report Facts
Certified beds: 83
Census: 71
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
Oct 10, 2019
Visit Reason
A standard survey was conducted at Pruitthealth Monroe from October 7, 2019 to October 10, 2019 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to perform consistent weekly skin assessments and wound documentation for residents with pressure ulcers, failure to monitor nutrition and hydration status adequately including weight monitoring and dietary preferences, and failure to properly analyze and act upon infection control data and antibiotic stewardship.
Severity Breakdown
SS= D: 2
SS= E: 1
SS= F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to consistently perform weekly skin assessments and document wound assessments for residents with pressure ulcers. | SS= D |
| Failure to provide adequate nutrition and hydration monitoring, including failure to assess dietary likes/dislikes on admission, inconsistent meal intake monitoring, failure to record weights and recognize significant weight loss, failure to implement dietician recommendations, and failure to follow physician orders for diet modifications. | SS= D |
| Failure to establish an effective infection prevention and control program including lack of analysis of infection data and follow-up actions to address infection trends. | SS= F |
| Failure to implement an effective antibiotic stewardship program including lack of periodic review of antibiotic prescribing practices and documentation of follow-up measures. | SS= E |
Report Facts
Resident census: 70
Resident weight loss: 7.8
Resident weight loss percentage: 4.67
Resident weight loss percentage: 13.95
Missed skin assessments: 13
Missed skin assessments: 11
Number of residents: 3
Number of months: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Skin Integrity Coordinator | RN Skin Integrity Coordinator | Interviewed regarding skin assessments and wound care for residents #28 and #36 |
| Director of Health Services | DHS | Interviewed regarding skin assessments, nutrition monitoring, infection control, and antibiotic stewardship |
| Registered Nurse Infection Control Nurse | RN Infection Control Nurse | Interviewed regarding infection control program and antibiotic stewardship |
| Dietary Manager | DM | Interviewed regarding dietary assessments, meal intake monitoring, and dietician recommendations |
| Administrator | Facility Administrator | Interviewed regarding infection control and antibiotic stewardship program oversight |
Inspection Report
Routine
Deficiencies: 1
Oct 10, 2019
Visit Reason
The inspection was conducted to evaluate compliance with nursing care requirements, specifically focusing on the performance and documentation of weekly skin and wound assessments for residents at risk of pressure ulcers.
Findings
The facility failed to consistently perform weekly skin assessments and document wound assessments for two residents with facility-acquired pressure ulcers, resulting in missed assessments and delayed wound monitoring. Interviews and record reviews confirmed multiple missed weekly skin assessments and wound evaluations for residents #28 and #36.
Deficiencies (1)
| Description |
|---|
| Failure to consistently perform weekly skin assessments and document wound assessments for residents with pressure ulcers. |
Report Facts
Missed weekly skin assessments: 13
Weight loss percentage: 11.06
Wound measurements: 2.2
Wound measurements: 2.5
Wound measurements: 2.1
Wound measurements: 2
Albumin level: 3.4
Wound measurements: 3.5
Wound measurements: 1.5
Wound measurements: 2.2
Wound measurements: 1
Wound measurements: 1
Wound measurements: 0.8
Wound measurements: 4
Wound measurements: 2
Wound depth: 0.2
Wound measurements: 2
Wound measurements: 2.5
Wound measurements: 2.5
Wound measurements: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Skin Integrity Coordinator (SIC) | Interviewed regarding wound care and skin assessments for residents #28 and #36 | |
| Director of Health Services (DHS) | Interviewed regarding responsibility for ensuring weekly skin assessments were done | |
| Attending Physician for resident #28 | Provided medical history and risk assessment for pressure ulcers | |
| Attending Physician for resident #36 | Provided medical history and risk assessment for pressure ulcers |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 8, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00197798.
Findings
The complaint was investigated and found to be unsubstantiated.
Complaint Details
Complaint number GA00197798 was investigated and determined to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 29, 2018
Visit Reason
A revisit was conducted on 8/29/18 for the recertification survey originally conducted on 6/28/18.
Findings
The revisit revealed that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 74
Capacity: 83
Deficiencies: 0
Jul 2, 2018
Visit Reason
The visit was conducted as a Life Safety Code Survey 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 substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards.
Report Facts
Certified beds: 83
Census: 74
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Feb 7, 2018
Visit Reason
An unannounced complaint survey was conducted to investigate complaint # GA 00184851 at Pruitt Health Monroe.
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.
Complaint Details
Investigation of complaint # GA 00184851 found the facility in substantial compliance with applicable regulations.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 6, 2017
Visit Reason
A follow-up to the Recertification survey of July 13, 2017 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of August 27, 2017.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 5, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 73
Capacity: 83
Deficiencies: 5
Jul 10, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain emergency lighting, fire sprinkler system maintenance, corridor doors resisting smoke passage, smoke barrier walls fire resistance, and proper maintenance of electrical wiring and equipment.
Severity Breakdown
D: 2
E: 2
F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain emergency lighting of the means of egress including exit discharge to a public way, placing 10 residents at risk. | D |
| Facility failed to maintain the fire sprinkler system as required, including overdue 5-year internal testing and corroded sprinkler head in boiler room, placing 73 residents at risk. | D |
| Facility failed to maintain corridor doors to resist the passage of smoke; specific doors had gaps greater than 0.5 inch, placing 3 residents at risk. | E |
| Facility failed to maintain smoke barrier walls with required fire resistance rating of at least one-half hour; unsealed and improperly sealed penetrations found, placing 40 residents at risk. | F |
| Facility failed to properly maintain electrical wiring and equipment, including unsecured electrical multi-taps, uncovered voids in electrical panel, and uncovered junction box with improper wiring, affecting 25 residents. | E |
Report Facts
Residents at risk: 10
Residents at risk: 73
Residents at risk: 3
Residents at risk: 40
Residents at risk: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Confirmed findings during tour and staff interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 18, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA 00170249 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted at PH-Monroe.
Complaint Details
Complaint #GA 00170249 was investigated and found to have no deficiencies.
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