Inspection Reports for Pruitthealth – Ocilla
209 WEST HUDSON STREET, GA, 31774
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Severe
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
May 15, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00241635.
Findings
The complaint was unsubstantiated with no deficiencies identified during the investigation.
Complaint Details
Complaint number GA00241635 was investigated and found to be unsubstantiated with no deficiencies.
Report Facts
Facility census: 58
Inspection Report
Abbreviated Survey
Census: 67
Deficiencies: 0
Nov 1, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00231965, #GA00235481, #GA00237381, and #GA00237889.
Findings
The complaints investigated were unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaints #GA00231965, #GA00235481, #GA00237381, and #GA00237889 were unsubstantiated with no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report
Re-Inspection
Deficiencies: 0
Mar 14, 2023
Visit Reason
A Life Safety Code (LSC) revisit was conducted to verify correction of previously cited deficiencies.
Findings
The revisit found that all previously cited Life Safety Code deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Jan 26, 2023
Visit Reason
A standard survey was conducted at Pruitt Health - Ocilla from January 23, 2023, through January 26, 2023. In addition, Complaint Intake Number GA000227847 was investigated in conjunction with this standard survey.
Findings
The standard survey revealed that the facility was in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.
Complaint Details
Complaint Intake Number GA000227847 was investigated in conjunction with this standard survey.
Inspection Report
Life Safety
Census: 62
Capacity: 83
Deficiencies: 2
Jan 23, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with life safety code requirements, specifically regarding the kitchen hood exhaust termination and sprinkler system installation. The kitchen exhaust fan was improperly installed, posing fire risk, and resident room closets were not sprinkler protected.
Severity Breakdown
SS= D: 1
SS= F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Kitchen hood exhaust termination is installed incorrectly, causing grease laden vapors to blow back onto the combustible roof and lacking proper cleaning access and grease trap. | SS= D |
| Facility failed to ensure all portions are fully sprinkler protected; closets in resident rooms throughout the facility are not sprinkler protected. | SS= F |
Report Facts
Residents at risk: 30
Census: 62
Total licensed beds: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to kitchen exhaust fan and sprinkler protection during tour and observation |
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Apr 27, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00217670, GA00218245 and GA00223554 from April 25, 2022 through April 27, 2022.
Findings
The facility was found to be in compliance with 42 CFR §483.80 Infection Control regulations. The complaints were unsubstantiated.
Complaint Details
Complaints GA00217670, GA00218245 and GA00223554 were investigated and found to be unsubstantiated.
Report Facts
Total Census: 63
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 0
Aug 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Licensure Survey of 6/10/2021.
Findings
All deficiencies cited as a result of the Licensure Survey of 6/10/2021 were found to be corrected.
Inspection Report
Re-Inspection
Census: 53
Deficiencies: 0
Aug 9, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification Survey of 2021-06-10.
Findings
All deficiencies cited as a result of the Recertification Survey of 2021-06-10 were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 28, 2021
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 at the time of the follow-up survey.
Inspection Report
Renewal
Census: 55
Deficiencies: 2
Jun 10, 2021
Visit Reason
A licensure survey was conducted from June 7, 2021 through June 10, 2021, including investigation of two complaint intakes which were found to be unsubstantiated.
Findings
The facility was found not in substantial compliance due to ineffective infection control practices related to medication administration for two residents, including failure to clean a nasal spray applicator and improper cleaning of a glucometer.
Complaint Details
Complaint Intake Numbers GA00212893 and GA00213661 were investigated and found to be unsubstantiated.
Severity Breakdown
D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to clean the nasal applicator before and after administering fluticasone nasal spray to Resident #37. | D |
| Failure to clean the glucometer with approved germicidal wipes as required when checking fingerstick blood sugar for Resident #34. | D |
Report Facts
Residents present: 55
Fingerstick blood sugar checks per day: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering nasal spray without cleaning applicator |
| LPN BB | Licensed Practical Nurse | Observed cleaning glucometer improperly with alcohol swab |
| Director of Health Services | Director of Health Services | Interviewed regarding infection control expectations |
| Clinical Competency Coordinator | Clinical Competency Coordinator | Interviewed regarding glucometer cleaning expectations |
Inspection Report
Routine
Census: 55
Deficiencies: 2
Jun 10, 2021
Visit Reason
A standard survey was conducted from June 7, 2021 through June 10, 2021, including investigation of two complaint intake numbers which were found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to staffing qualifications for the Dietary Manager and infection prevention and control practices during medication administration.
Complaint Details
Complaint Intake Numbers GA00212893 and GA00213661 were investigated in conjunction with the standard survey and were found to be unsubstantiated.
Severity Breakdown
F: 1
D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| The facility failed to ensure that the Dietary Manager was certified or had a similar food service management certification or degree as required by regulations. | F |
| The facility failed to provide effective infection control practices related to medication administration, including improper cleaning of a nasal spray applicator and incorrect cleaning of a glucometer. | D |
Report Facts
Resident census: 55
Residents receiving oral diet: 51
Start date of Dietary Manager: May 17, 2021
Fingerstick blood sugar checks per day: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed administering nasal spray without cleaning applicator; acknowledged error in cleaning |
| LPN BB | Licensed Practical Nurse | Observed cleaning glucometer with alcohol swab instead of approved germicidal wipes |
| Director of Health Services | Expected licensed nursing staff to clean nasal applicators before and after medication administration | |
| Clinical Competency Coordinator | Stated expectation for licensed nursing staff to clean glucometers with approved germicidal wipes | |
| Administrator | Aware that current Dietary Manager was not in compliance with certification requirements | |
| Dietary Manager | Started May 2021; not certified or Serve Safe certified; planned to begin certification classes |
Inspection Report
Life Safety
Census: 55
Capacity: 83
Deficiencies: 1
Jun 9, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code.
Findings
The facility was found not in substantial compliance due to impeded egress corridors caused by unused linen bins, medical equipment, and carts left in the corridors, which obstructed the required minimum aisle width.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Egress corridors impeded by unused linen bins, medical equipment, and carts obstructing aisle width. | SS= D |
Report Facts
Census: 55
Total Capacity: 83
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 6, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00209881 and a COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The complaint #GA00209881 was unsubstantiated with no regulatory violations found. The facility was found to be in compliance with 42 CFR §483.73 and §483.80 related to emergency preparedness and infection control regulations, including CMS and CDC recommended practices for COVID-19.
Complaint Details
Complaint #GA00209881 was investigated and found to be unsubstantiated with no regulatory violations.
Inspection Report
Deficiencies: 0
Dec 22, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for the facility PRUITTHEALTH - OCILLA, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comments section but does not provide specific findings or deficiencies in the extracted text or image.
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 0
Dec 22, 2020
Visit Reason
A revisit survey was conducted to follow up on the complaint survey of 9/26/2020 and the abbreviated/partial extended survey of 10/5/2020 related to complaints GA00208203, GA00208568, and GA00208777.
Findings
All deficiencies cited as a result of the previous complaint surveys were found to be corrected, and the facility was found in substantial compliance as of 10/7/2020.
Complaint Details
The revisit survey was related to complaints GA00208203, GA00208568, and GA00208777. All deficiencies were corrected and the facility was found in substantial compliance.
Report Facts
Complaint identifiers: GA00208203, GA00208568, GA00208777
Inspection Report
Abbreviated Survey
Deficiencies: 0
Nov 3, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA#00209345 and GA#00209395.
Findings
The complaints GA#00209345 and GA#00209395 were unsubstantiated and no regulatory violations were cited.
Complaint Details
Complaints GA#00209345 and GA#00209395 were investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Oct 20, 2020
Visit Reason
An abbreviated partial extended survey was conducted to investigate complaint #GA00208958.
Findings
The complaint was substantiated but no regulatory violations were found during the investigation.
Complaint Details
Complaint #GA00208958 was substantiated with no regulatory violations.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Oct 5, 2020
Visit Reason
An Abbreviated/Partial Extended Survey, including a Focused COVID-19 Survey, was conducted from 9/16/2020 to 10/5/2020 to investigate complaints GA00208203, GA00208568, and GA00208777. Complaint GA00208203 was substantiated with deficiencies, GA00208568 was partially substantiated without deficiencies, and GA00208777 was unsubstantiated.
Findings
The facility was found to be out of compliance due to failure to implement cardiopulmonary resuscitation (CPR) interventions for two residents (R#1 and R#3) who were full code. Immediate Jeopardy was identified related to multiple regulatory requirements, including comprehensive care plans, quality of life, administration, and quality assurance. The Immediate Jeopardy was removed on 9/27/2020 after corrective actions including staff in-service and audits were completed.
Complaint Details
Complaints GA00208203, GA00208568, and GA00208777 were investigated. GA00208203 was substantiated with deficiencies related to failure to provide CPR and care plan compliance. GA00208568 was partially substantiated without deficiencies. GA00208777 was unsubstantiated.
Severity Breakdown
Scope and Severity (S/S) J: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to initiate CPR for Resident #1 despite full code status during respiratory distress and cardiac arrest. | Scope and Severity (S/S) J |
| Failure to initiate CPR for Resident #3 who was documented as full code despite a non-executed DNR POLST. | Scope and Severity (S/S) J |
Report Facts
Resident census: 58
Residents audited: 56
Licensed nurses in-serviced: 20
Date Immediate Jeopardy identified: Sep 25, 2020
Date Immediate Jeopardy removed: Sep 27, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse BB | LPN | Assessed Resident #1 and obtained orders for chest x-ray during change in condition. |
| Certified Nursing Assistant AA | CNA | Witnessed Resident #1 take last breath but did not initiate CPR. |
| Licensed Practical Nurse FF | LPN | Documented Resident #3's condition and confirmed she would have initiated CPR if not shown a DNR order. |
| Hospice RN #2 | RN | Present at bedside when Resident #3 died and showed LPN FF a DNR order. |
| Director of Health Services | DHS | Confirmed expectations that staff follow physician orders and initiate CPR for full code residents; provided in-service training. |
| LPN CC | LPN | Responsible for reviewing and revising care plans at MDS assessments. |
| Social Services | SS | Responsible for POLST completion and follow-up on advance directives. |
| Administrator | Stated expectations for staff to initiate CPR per care plans and physician orders. |
Inspection Report
Abbreviated Survey
Census: 58
Deficiencies: 4
Oct 5, 2020
Visit Reason
An Abbreviated/Partial Extended Survey, in conjunction with a Focused COVID-19 Survey, was initiated on 2020-09-16 and concluded on 2020-10-05. The survey investigated complaints GA00208203, GA00208568, and GA00208777.
Findings
The facility failed to provide CPR for two residents (R#1 and R#3) who were full code status, failed to have a properly executed POLST for R#3, and failed to ensure licensed nurses maintained current CPR certification. Immediate Jeopardy was identified related to comprehensive care plans, quality of life, administration, and quality assurance/performance improvement activities. The facility implemented corrective actions and removed the Immediate Jeopardy on 2020-09-27.
Complaint Details
Complaints GA00208203, GA00208568, and GA00208777 were investigated. GA00208203 was substantiated with deficiencies, GA00208568 was partially substantiated without deficiencies, and GA00208777 was unsubstantiated.
Severity Breakdown
J: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide CPR for two full code residents (R#1 and R#3) during change in condition and death. | J |
| Failure to have a properly executed POLST for R#3, lacking signature by Healthcare Agent and second physician. | J |
| Failure to ensure licensed nursing staff maintained current CPR certification. | J |
| Failure to implement effective quality assurance and performance improvement activities to address identified deficiencies. | J |
Report Facts
Resident census: 58
Deficiency counts: 4
Licensed nurses CPR certification audit: 21
Licensed nurses CPR certification expired: 3
Residents audited for code status: 56
Residents with DNR status: 17
Residents receiving advanced directive informational packet: 52
Mock code participants: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Nurse in charge during R#1's death who did not initiate CPR |
| LPN FF | Licensed Practical Nurse | Nurse in charge during R#3's change of condition who did not initiate CPR due to DNR order shown by Hospice RN |
| CNA AA | Certified Nursing Assistant | Witnessed R#1's last breath and did not initiate CPR |
| Hospice RN#2 | Hospice Nurse | At bedside when R#3 died, showed DNR order to LPN FF |
| Director of Health Services | Informed of Immediate Jeopardy, led corrective actions and education | |
| Administrator | Received education on roles and responsibilities, involved in QAPI | |
| Regional Nurse Consultant | Provided education to Administrator and staff, involved in QAPI | |
| Social Service Director | Conducted audits and education on advanced directives | |
| Area Vice President | Provides oversight and mentoring to Administrator |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 26, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA#00204953.
Findings
The complaint GA#00204953 was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint GA#00204953 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 64
Deficiencies: 0
Jul 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted at Pruitt Health Ocilla from 7/7/2020 through 7/8/2020 to assess compliance with federal COVID-19 related 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 CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Total census: 64
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00198399.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00198399 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 29, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00198399.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00198399 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 30, 2018
Visit Reason
The inspection was conducted to investigate complaints #GA00192855 and #GA00192892 to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was complaint-related, investigating two complaints (#GA00192855 and #GA00192892), and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 22, 2018
Visit Reason
A complaint survey was conducted on 11/22/2018 to investigate complaints #GA00190257 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint investigation survey.
Complaint Details
Complaint #GA00190257 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 18, 2018
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the standard survey on 2018-08-23.
Findings
All deficiencies cited as a result of the standard survey on 2018-08-23 were found to be corrected during the revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 9, 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 survey tags have been corrected.
Inspection Report
Life Safety
Census: 63
Capacity: 83
Deficiencies: 9
Aug 21, 2018
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with 42 CFR Subpart 483.70(a), Life Safety from Fire, and the related NFPA 101 Life Safety Code 2012 edition requirements.
Findings
The facility was found not in substantial compliance with Life Safety Code requirements, with multiple deficiencies including failure to maintain minimum headroom in means of egress, emergency lighting issues, kitchen hood exhaust duct maintenance, fire alarm system deficiencies, sprinkler system maintenance problems, corridor door smoke tightness, smoke barrier penetrations, and electrical system violations.
Severity Breakdown
D: 4
E: 1
F: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to maintain minimum 6' 8" headroom in means of egress due to a shelf installed in room #23. | D |
| Emergency lighting deficiencies including no emergency light at kitchen exit and non-working emergency light #10. | E |
| Kitchen hood exhaust duct has holes not welded liquid tight. | D |
| Failed to properly maintain facility smoke detectors located too close to air registers or grills. | F |
| Sprinkler piping supporting external loads such as HVAC ducts, wiring, conduit, and water piping in multiple areas. | F |
| Sprinkler heads obstructed by light fixtures in multiple rooms and offices. | D |
| Hall Pantry storage room door has an unapproved louver, failing to maintain smoke tightness. | F |
| Multiple penetrations in smoke/fire barriers not sealed with a listed fire stop system in various locations including Peach Hall, Dietary office, Magnolia Hall, and Oak Hall corridor. | F |
| Electrical system deficiencies including open junction boxes without coverplates, spliced wiring not in junction boxes, and missing light fixture covers in multiple locations. | F |
Report Facts
Census: 63
Total Capacity: 83
Number of sprinkler piping locations supporting external loads: 9
Number of sprinkler heads obstructed: 7
Number of smoke/fire barrier penetrations not sealed: 11
Number of electrical deficiencies: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 6, 2017
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as of the follow-up survey date.
Inspection Report
Routine
Census: 163
Deficiencies: 0
Sep 21, 2017
Visit Reason
A standard survey was conducted at Pruitt Ocilla from September 18, 2017 through September 21, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 66
Capacity: 83
Deficiencies: 10
Sep 19, 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 life safety code requirements, including issues with egress doors, self-closing doors, hazardous area enclosures, fire alarm system maintenance, corridor doors, smoke barriers, electrical system code compliance, and smoking area regulations.
Severity Breakdown
D: 6
E: 3
F: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Kitchen exit door has multiple unapproved locking devices. | D |
| Doors in hazardous rooms (Bio-hazard room and Food Pantry Dry Storage) are not closing and latching. | F |
| Landings, ramps, and stairs greater than 30 inches above grade lack approved guardrails and outside handrails are not continuously graspable. | D |
| Hazardous areas are not properly separated from the remainder of the facility; holes and unsealed penetrations noted in boiler room, electrical data room, and sprinkler mechanical room. | E |
| Fire alarm system not properly maintained; one horn/strobe light in activity room failed to function. | D |
| Corridor doors not closing and latching to maintain smoke tight door assembly (Men's Dayroom to corridor and Therapy unit door). | E |
| Smoke barriers not properly fire stopped with listed fire stop system; multiple unprotected penetrations and unsealed areas in various locations including unit 1, front hall, unit 2, and nurses desk area. | D |
| Smoke door in unit 1 by Room #10 not closing properly, maintaining a gap of less than 1/8 inch. | D |
| Electrical system code violations including missing light fixture covers, unsecured light fixture, unapproved multi-plug adapters, improperly mounted surge protectors, unlabeled circuit panels, missing weatherproof cover on exterior receptacle, and missing blanks in electrical panel box. | F |
| Smoking area lacks ashtrays of noncombustible materials and safe design. | D |
Report Facts
Certified beds: 83
Census: 66
Deficiencies cited: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during the tour and interviews. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2017
Visit Reason
The inspection was conducted as a Complaint Survey from 3/2/17 to 3/6/17 to investigate complaints #GA00170732 and #GA00172164 and to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was complaint-related, investigating two complaints (#GA00170732 and #GA00172164), and no deficiencies were found.
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