Inspection Reports for Pruitthealth – Toccoa
633 FALLS ROAD, TOCCOA, GA, 30577
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 4, 2025, was a complaint investigation in which several complaints were substantiated, but no deficiencies were cited. Earlier inspections showed a pattern of deficiencies primarily related to medication management, infection control, dietary services, care plan adherence, and safety hazards, with some issues involving environmental cleanliness and call light functionality. Complaint investigations were mostly unsubstantiated, though substantiated complaints occasionally occurred without resulting deficiencies; a notable substantiated case in 2023 involved neglect related to call light response and delayed abuse reporting. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility has demonstrated some improvement over time, with recent surveys showing correction of prior deficiencies and no new citations in the latest complaint investigation.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
116 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Jun 4, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints received against the facility.
Complaint Details
Complaints GA00255183, GA00254808, GA00253763, and GA00253760 were substantiated. Complaints GA00255108 and GA00253822 were unsubstantiated. No deficiencies were cited for any complaints.
Findings
Complaints GA00255183, GA00254808, GA00253763, and GA00253760 were substantiated, while complaints GA00255108 and GA00253822 were unsubstantiated. No deficiencies were cited related to any of the complaints.
Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Date: Nov 26, 2024
Visit Reason
An Abbreviated Partial/Extended Survey was conducted to investigate complaints GA00250013 and GA00245056.
Complaint Details
Complaints GA00250013 and GA00245056 were investigated and found to be unsubstantiated.
Findings
No deficiencies were cited for the complaints investigated, and the complaints were found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 15, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - TOCCOA, 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 visible content.
Inspection Report
Re-Inspection
Census: 103
Deficiencies: 0
Date: May 15, 2024
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the 3/21/2024 Recertification Survey.
Findings
All deficiencies cited in the prior 3/21/2024 Recertification Survey were found to be corrected during this revisit survey.
Report Facts
Facility census: 103
Inspection Report
Routine
Census: 102
Deficiencies: 7
Date: Mar 21, 2024
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements.
Findings
The facility was found deficient in multiple areas including dietary service preparation, medication management and administration, infection control, care plan adherence for assistance with ADLs, safety hazards in resident rooms, physical plant standards related to food storage and sanitation, and call light functionality.
Deficiencies (7)
Failed to follow recipes to ensure puree foods were prepared properly affecting twelve residents on a puree diet.
Medication cart left unlocked unattended and failure to obtain physician orders for resident self-administration of medications.
Failure to perform proper infection control including hand hygiene and medication handling by staff.
Failure to follow care plan for assistance with showers and ADLs for one resident.
Unsafe condition due to a metal plate with sharp, jagged edges on bathroom door in one resident room.
Failure to maintain sanitary nourishment refrigerators, improper food storage, and failure to dispose of expired food items timely in two units.
Call light communication system nonfunctional in one resident room, preventing resident from calling for assistance.
Report Facts
Facility census: 102
Residents on puree diet: 12
Sample size: 46
Medication carts observed: 5
Medication carts left unlocked unattended: 1
Residents sampled for medication self-administration: 46
Residents with medication self-administration issues: 1
Staff observed for infection control: 6
Staff failing hand hygiene: 2
Staff observed for medication preparation: 4
Staff failing medication handling: 2
Residents sampled for care plan adherence: 46
Residents with care plan deficiencies: 1
Resident rooms inspected for safety: 14
Rooms with safety hazards: 1
Units inspected for nourishment refrigerator sanitation: 3
Units with nourishment refrigerator deficiencies: 2
Residents sampled for call light functionality: 46
Rooms with nonfunctional call light: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Licensed Practical Nurse | Left medication cart unattended and unlocked while administering medication. |
| DA II | Dietary Aide II | Failed to follow recipes and proper measurement procedures for pureed foods. |
| DM | Dietary Manager | Confirmed lack of recipes and proper procedures for pureed food preparation. |
| CMA/CNA DD | Certified Medication Aide/Certified Nursing Assistant | Left medications at bedside without physician order and failed proper medication handling. |
| CMA EE | Certified Medication Aide | Failed proper medication handling during medication pass. |
| LPN JJ | Licensed Practical Nurse | Failed to perform hand hygiene during meal tray pass. |
| LPN KK | Licensed Practical Nurse | Failed to perform hand hygiene during meal tray pass. |
| DHS | Director of Health Services | Provided multiple interviews confirming expectations and deficiencies. |
| RN HH | Registered Nurse | Responsible for cleaning nourishment refrigerator and confirmed expired food items. |
| CNA AA | Certified Nursing Assistant | Described shower scheduling and documentation process. |
| LPN BB | Licensed Practical Nurse | Confirmed shower offering expectations and documentation. |
| Administrator | Verified bathroom door hazard and maintenance reporting process. | |
| Maintenance Director | Verified unawareness of bathroom door hazard. |
Inspection Report
Routine
Census: 102
Deficiencies: 8
Date: Mar 21, 2024
Visit Reason
A standard survey was conducted from March 19, 2024 through March 21, 2024, including investigation of Complaint Intake Number GA00244527, which was unsubstantiated.
Complaint Details
Complaint Intake Number GA00244527 was investigated in conjunction with the standard survey and was found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including unsafe environment due to damaged bathroom door, failure to follow care plans for assistance with showers and ADLs, medication storage and administration issues, improper food preparation and storage, infection control lapses, and a nonfunctional resident call light system.
Deficiencies (8)
Unsafe bathroom door with a metal plate having sharp, jagged edges in Room 246.
Failure to follow care plan for assistance with showers and baths for resident R37.
Failure to provide necessary assistance with ADLs for resident R37.
Medication cart left unlocked unattended and failure to obtain physician orders for resident R55 to self-administer medications.
Failure to follow recipes and proper preparation methods for pureed foods affecting 12 residents.
Failure to maintain sanitary conditions and proper labeling/storage of food in resident nourishment refrigerators on Blue Unit and Memory Care Unit.
Failure to perform proper hand hygiene by staff during meal tray pass and medication administration; improper medication handling and preparation.
Resident call light system nonfunctional in Room 259A, preventing resident from calling for assistance.
Report Facts
Residents receiving pureed diet: 12
Sample size: 46
Medication carts: 5
Units with nourishment refrigerator issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN LL | Licensed Practical Nurse | Left medication cart unattended and unlocked during medication administration |
| CMA/CNA DD | Certified Medication Aide/Certified Nursing Assistant | Failed to properly prepare insulin and improperly handled medications during administration |
| CMA EE | Certified Medication Aide | Handled medication improperly by punching it into bare hand |
| LPN JJ | Licensed Practical Nurse | Failed to perform proper hand hygiene during meal tray pass |
| LPN KK | Licensed Practical Nurse | Failed to perform proper hand hygiene during meal tray pass |
| Director of Health Services | Provided expectations on care plan adherence, medication administration, hand hygiene, and call light system | |
| Dietary Aide II | Dietary Aide | Failed to follow recipes and proper preparation methods for pureed foods |
| Dietary Manager | Dietary Manager | Confirmed lack of recipes for pureed hamburger patties and expectation for recipe use |
| RN HH | Registered Nurse | Responsible for cleaning Memory Care Unit refrigerator and confirmed expired/unlabeled food items |
| LPN UM FF | Licensed Practical Nurse, Unit Manager | Confirmed unlabeled/undated food items in nourishment refrigerator |
Inspection Report
Life Safety
Census: 102
Capacity: 181
Deficiencies: 0
Date: Mar 20, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with regulatory requirements.
Report Facts
Census: 102
Total Capacity: 181
Inspection Report
Abbreviated Survey
Census: 110
Deficiencies: 0
Date: Jan 17, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations identified by codes GA00242119, GA00241617, GA00238892, GA00238830, GA00238599, and GA00238216.
Complaint Details
The survey investigated complaints GA00242119, GA00241617, GA00238892, GA00238830, GA00238599, and GA00238216. No deficiencies were found related to these complaints.
Findings
No deficiencies were cited related to the complaints investigated during this survey.
Inspection Report
Abbreviated Survey
Census: 113
Deficiencies: 0
Date: Dec 19, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00241936.
Complaint Details
Investigation of complaint #GA00241936; no deficiencies were found related to the complaint.
Findings
No deficiencies were cited related to complaint #GA00241936 during the survey.
Inspection Report
Abbreviated Survey
Census: 99
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00240111.
Complaint Details
Complaint #GA00240111 was substantiated with no deficiencies cited.
Findings
The complaint was substantiated but no deficiencies were cited during the survey.
Report Facts
Census: 99
Inspection Report
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection.
Findings
The report contains initial comments but does not provide specific findings or deficiencies.
Inspection Report
Re-Inspection
Census: 97
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the standard survey conducted on January 26, 2023.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during the revisit survey.
Inspection Report
Renewal
Census: 98
Deficiencies: 7
Date: Jan 26, 2023
Visit Reason
The inspection was a Licensure Survey conducted from January 24, 2023 through January 26, 2023 to assess compliance with licensure requirements and facility regulations.
Findings
The facility failed to provide required RN coverage for at least eight consecutive hours on two days, failed to secure medication and treatment carts properly, had missing controlled substance count signatures, failed to maintain effective infection control practices including PPE use and hand hygiene, improperly stored CPAP equipment, failed to conduct pre and post dialysis assessments and maintain communication with the dialysis center, and did not maintain a clean and homelike environment in multiple resident rooms with clogged sinks, dust buildup, and dirty air conditioner/heater units.
Deficiencies (7)
Failed to provide RN coverage for at least eight consecutive hours on 12/18/22 and 1/21/23.
Medication and treatment carts were left unlocked and unattended; narcotics counts were not documented at shift changes.
Missing nurse signatures verifying controlled substance counts on multiple dates.
Staff failed to don required PPE entering COVID-19 positive resident room and failed to perform hand hygiene during wound care.
CPAP mask for resident was improperly stored unbagged, uncovered, and exposed to environment.
Failed to conduct pre and post dialysis assessments and maintain ongoing communication with dialysis center for resident R#37.
Facility environment not maintained in a clean and homelike condition in 12 of 15 resident rooms on Blue Hall, including clogged sinks, dust buildup on vents and light fixtures, and dirty air conditioner/heater units.
Report Facts
Facility census: 98
Missing controlled substance count signatures: 30
Dialysis communication forms incomplete: 10
Dialysis days: 20
Resident rooms with environmental deficiencies: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Director of Health Services (DHS) | Confirmed lack of RN coverage and expectations for RN coverage and medication cart security |
| Administrator | Facility Administrator | Confirmed lack of RN coverage and expectations for RN coverage and medication cart security |
| Licensed Practical Nurse JJ | LPN | Responsible for treatment cart left unlocked and unattended |
| Licensed Practical Nurse HH | LPN | Observed medication carts left unlocked and verified CPAP mask storage issue |
| Certified Nursing Assistant AA | CNA | Observed entering COVID-19 positive room without proper PPE |
| Housekeeper BB | Housekeeper | Observed entering COVID-19 positive room without proper PPE and hand hygiene |
| Licensed Practical Nurse CC | LPN | Observed wound care without proper hand hygiene between glove changes |
| Unit Manager/Interim Director of Health Services | Unit Manager/Interim DHS | Described dialysis communication process and expectations |
| Dialysis center representative LL | Dialysis center representative | Described dialysis communication issues and process |
| Maintenance Director | Maintenance Director | Verified environmental concerns and described cleaning schedule |
| Housekeeping Supervisor | Housekeeping Supervisor | Verified environmental concerns and cleaning responsibilities |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 7
Date: Jan 26, 2023
Visit Reason
A recertification survey was conducted from January 24 through January 26, 2023, including investigation of multiple complaint intakes, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Complaint Details
The survey included investigation of complaint intake numbers GA00219548, GA00220424, GA00220547, GA00223891, and GA00228630. Findings included substantiated neglect related to call light response, delayed reporting of resident abuse, and infection control failures.
Findings
The facility was found not in substantial compliance with regulations, with deficiencies including failure to maintain a clean environment, neglect in responding to a resident's call light, delayed reporting of resident-to-resident abuse, incomplete dialysis assessments and communication, lack of required RN coverage, unsecured medication and treatment carts, failure to count narcotics properly, and infection control lapses including improper PPE use and wound care.
Deficiencies (7)
Facility failed to maintain a clean, comfortable, and homelike environment in 12 of 15 resident rooms on Blue Hall, including clogged sinks, dust buildup, and dirty air conditioner units.
Failed to ensure one resident was protected from neglect by not answering call light for over 50 minutes despite multiple staff passing by.
Failed to report resident-to-resident abuse within required timeframe; incident involving hitting with a pool noodle was reported late.
Failed to ensure pre and post dialysis assessments were conducted and maintain communication with dialysis center for one resident.
Failed to provide RN coverage for at least eight consecutive hours on two days (12/18/22 and 1/21/23).
Failed to ensure medication and treatment carts were locked and secured when unattended; failed to count narcotics and document counts at shift changes.
Failed to maintain effective infection control program: staff did not don required PPE entering COVID-19 positive resident room; failed to perform hand hygiene between glove changes during wound care; failed to properly store CPAP mask.
Report Facts
Resident census: 98
Dialysis days: 20
Missing dialysis communication forms: 10
Missing post-dialysis vital signs: 6
Days without RN coverage for 8 consecutive hours: 2
Missing narcotics count signatures: 30
Resident sample size: 37
Resident sample size: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN OO | Licensed Practical Nurse | Documented resident-to-resident altercation and assessment |
| Administrator | Reported resident abuse incident late; abuse coordinator; acknowledged lack of RN coverage | |
| LPN KK | Licensed Practical Nurse | Described dialysis communication form process |
| Unit Manager/Interim Director of Health Services | Unit Manager/Interim DHS | Reviewed dialysis communication forms and confirmed missing data |
| LPN HH | Licensed Practical Nurse | Observed leaving medication cart unlocked; described CPAP mask care |
| Director of Health Services | DHS | Confirmed lack of RN coverage; expectations for medication cart security and controlled substance counts; expectations for infection control |
| Infection Preventionist | IP | Provided infection control expectations and on-the-spot education |
| CNA AA | Certified Nursing Assistant | Entered COVID-19 positive resident room without full PPE |
| Housekeeper BB | Housekeeper | Entered COVID-19 positive resident room without PPE and did not sanitize hands |
| LPN CC | Licensed Practical Nurse | Observed performing wound care without hand hygiene between glove changes |
| CNA GG | Certified Nursing Assistant | Described CPAP mask care for resident |
Inspection Report
Life Safety
Census: 99
Capacity: 181
Deficiencies: 0
Date: Jan 25, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Emergency Preparedness Program requirements and Life Safety Code standards at the time of the survey.
Report Facts
Census: 99
Total Capacity: 181
Inspection Report
Re-Inspection
Census: 112
Deficiencies: 0
Date: Nov 3, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey conducted on September 2, 2021.
Complaint Details
The revisit survey was conducted following a complaint survey on September 2, 2021. All cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 2
Date: Sep 2, 2021
Visit Reason
A Complaint/Abbreviated Survey was conducted on behalf of the Georgia Department of Community Health from 8/31/21 through 9/2/21 to investigate multiple complaint investigations regarding alleged abuse and neglect at PruittHealth - Toccoa.
Complaint Details
Multiple complaint investigations were conducted; some were substantiated with citations (GA00216523 and GA00216506), others were substantiated with no citations or unsubstantiated. The abuse incident involving R#3 was substantiated and cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to protect a resident (R#3) from physical and verbal abuse by a Licensed Practical Nurse (LPN CC) on 6/15/21. The facility also failed to immediately report the abuse incident to the Administrator and other officials as required. The investigation concluded no abuse occurred, but the survey found otherwise and cited the facility.
Deficiencies (2)
Failure to protect a resident from verbal and physical abuse by a Licensed Practical Nurse.
Failure to immediately report alleged abuse to the Administrator and other officials as required by policy and regulation.
Report Facts
Complaint Investigations Substantiated and Cited: 2
Resident Census: 110
Dates of Complaint Survey: 8/31/21 through 9/2/21
Date of Abuse Incident: 6/15/21
Date of Resident Expiration: 7/21/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Named as perpetrator of physical and verbal abuse against Resident #3; placed on suspension and terminated. |
| CNA AA | Certified Nursing Assistant | Witnessed abuse incident, reported it to Assistant Director of Health Services; confirmed training on abuse recognition and reporting. |
| CNA DD | Certified Nursing Assistant | Heard about the incident from CNA AA, confirmed training on abuse recognition and reporting. |
| LPN GG | Licensed Practical Nurse | Worked the shift after the incident, took report from LPN CC, learned of incident after the fact. |
| ADHS BB | Assistant Director of Health Services | Received report of abuse incident from CNA AA. |
Inspection Report
Abbreviated Survey
Census: 121
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00212248.
Complaint Details
Complaint #GA00212248 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint #GA00212248 was unsubstantiated with no regulatory violations found during the survey.
Report Facts
Facility census: 121
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 19, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00208790.
Complaint Details
Complaint GA00208790 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint GA00208790 was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00204740 and GA00204278 at Pruitthealth Toccoa Nursing Home.
Complaint Details
Complaints #GA00204740 and GA00204278 were investigated and found to be unsubstantiated.
Findings
The complaints were found to be unsubstantiated and no regulatory violations were cited during the investigation.
Report Facts
Complaint numbers: 2
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the July 17, 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
Deficiencies: 0
Date: Aug 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was initiated on August 24, 2020 by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health (DCH). The survey was scheduled as a CMS Strike Team survey for the week and was determinated.
Findings
The document provides initial comments about the COVID-19 focused infection control survey initiation and scheduling. No specific findings or deficiencies are detailed in the provided page.
Inspection Report
Routine
Census: 128
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on August 4, 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 infection control. No deficiencies were cited as a result of this survey.
Inspection Report
Abbreviated Survey
Census: 148
Deficiencies: 1
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on July 16 and 17, 2020 to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control regulations due to failure to ensure a resident (Resident #4) wore a mask during transport outside the isolation unit, contrary to facility policy. The resident was transported in a shower chair without a mask in an area with other residents and staff present.
Deficiencies (1)
Failure to ensure Resident #4 wore a mask when transported outside the isolation unit, violating the facility's COVID-19 infection prevention and control policy.
Report Facts
Total census: 148
Positive COVID-19 test results: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in deficiency for failing to ensure Resident #4 wore a mask during transport |
| UM | Unit Manager | Observed and instructed CNA AA to have Resident #4 wear a mask |
| Director of Nursing | Director of Nursing | Confirmed CNA AA should have put a mask on Resident #4 during transport |
| Administrator | Administrator | Provided information about positive COVID-19 test results and facility policy |
Inspection Report
Routine
Census: 148
Deficiencies: 0
Date: Apr 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with emergency preparedness and infection control regulations 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, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 148
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 12, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00202407, GA00201172, and GA00200691.
Complaint Details
The complaints investigated were unsubstantiated.
Findings
The complaints were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Sep 18, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted in July 2019.
Findings
The revisit survey found that all previously cited deficiencies were corrected and the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 9, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The Emergency Preparedness plan for Pruitt Health - Toccoa was reviewed and found to be in substantial compliance with the requirements set forth in Appendix Z. All previously cited deficiencies have been corrected.
Inspection Report
Routine
Census: 68
Deficiencies: 6
Date: Jul 19, 2019
Visit Reason
Routine inspection to assess compliance with healthcare facility regulations including dietary services, infection control, nursing care, and other resident care standards.
Findings
The inspection identified multiple deficiencies including lack of a qualified dietitian providing required hours, failure to properly clean blood glucose monitoring equipment, failure to implement care plans for nail care, failure to follow physician orders regarding adaptive eating devices, failure to secure urinary catheters properly, and inadequate communication with dialysis providers.
Deficiencies (6)
Dietary service did not employ a qualified dietitian providing at least eight hours per month.
One of two nurses observed failed to clean blood glucose monitoring equipment between residents and did not follow proper hand hygiene.
Facility failed to implement care plan related to nail care for one totally-dependent resident.
Facility failed to follow physician's order to discontinue divided plate for one resident.
Facility failed to ensure urinary catheter was secured to the leg to prevent urethral traction for one resident.
Facility lacked effective communication and documentation with dialysis center for one resident receiving dialysis.
Report Facts
Residents reviewed for nail care: 68
Date of survey completed: Jul 19, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Named in infection control deficiency related to blood glucose monitoring |
| LPN GG | Licensed Practical Nurse, MDS Coordinator | Named in nail care and catheter securement deficiencies |
| DM | Dietary Manager | Named in dietary service deficiency |
| LPN II | Licensed Practical Nurse Treatment Nurse II | Named in catheter securement deficiency |
| CNA HH | Certified Nursing Assistant | Named in nail care and catheter securement deficiencies |
| CNA KK | Certified Nursing Assistant | Named in dialysis communication deficiency |
| LPN BB | Licensed Practical Nurse | Named in dialysis communication deficiency |
Inspection Report
Routine
Census: 147
Deficiencies: 8
Date: Jul 19, 2019
Visit Reason
A standard survey was conducted from 7/15/19 to 7/19/19, including investigation of multiple complaints, to assess compliance with Medicare/Medicaid regulations for Long Term Care Facilities.
Complaint Details
Complaint investigations #GA00197522, #GA00194057, #GA00192187, and #GA00194367 were included in the survey.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to obtain required physician signatures on DNR orders, failure to implement care plans for dependent residents, failure to follow physician orders for adaptive devices, failure to secure urinary catheters properly, failure to communicate with dialysis centers, lack of qualified dietary staff, and improper infection control practices related to blood glucose monitoring.
Deficiencies (8)
Failed to obtain a concurring physician's signature on DNR order forms for two residents without decision-making capacity.
Failed to implement care plan related to nail care for a totally-dependent resident with multiple sclerosis and contractures.
Failed to perform nail care for a totally-dependent resident with bilateral hand contractures.
Failed to follow physician's order to discontinue divided plate for one resident.
Failed to ensure urinary catheter was secured to the leg to prevent urethral traction for one resident.
Failed to communicate with dialysis center for one resident receiving dialysis.
Failed to employ a qualified dietary manager with required certification or degree.
Failed to ensure proper sanitization and hand hygiene during blood glucose monitoring for multiple residents; nurse observed not cleaning glucometer or sanitizing hands between residents.
Report Facts
Resident census: 147
Residents reviewed for advance directives: 41
Residents reviewed for nail care: 68
Residents reviewed for urinary catheter use: 3
Residents receiving blood glucose testing: 36
Deficiency observations: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Named in infection control deficiency related to improper blood glucose monitoring |
| LPN GG | Licensed Practical Nurse, MDS Coordinator | Named in nail care deficiency for resident #52 |
| CNA HH | Certified Nursing Assistant | Named in nail care deficiency for resident #52 |
| Dietary Manager | Dietary Manager | Named in dietary staffing deficiency; hired 9/22/18, completing certification in July 2019 |
| DHS CC | Director of Health Services | Named in infection control deficiency response |
| Administrator | Facility Administrator | Named in infection control deficiency response |
Inspection Report
Life Safety
Census: 147
Capacity: 181
Deficiencies: 4
Date: Jul 18, 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) standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to maintain the kitchen hood extinguishing system, fire alarm system batteries, fire sprinkler system maintenance, and improper storage of oxygen cylinders. These deficiencies could place residents and staff at risk in the event of a fire.
Deficiencies (4)
Failed to maintain kitchen hood extinguishing system over equipment; extinguisher nozzle was not over the deep fat fryer.
Failed to maintain the fire alarm system and its components; fire alarm batteries in panels lacked manufacturer date markings.
Failed to maintain fire sprinkler system and its components; storage stacked to ceiling level impeding sprinkler head spray patterns.
Failed to maintain oxygen cylinders in storage; empty and full cylinders stored together without signage.
Report Facts
Census: 147
Total Capacity: 181
Deficiencies cited: 4
Inspection date: Jul 18, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 11, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00191951, GA00191945, GA00191857, and GA00190800.
Complaint Details
The complaint investigation was not substantiated.
Findings
The complaint investigation was concluded and found to be not substantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 10, 2018
Visit Reason
A revisit survey was conducted from October 9, 2018 to October 11, 2018 to verify correction of deficiencies cited during the complaint investigation survey completed on July 16, 2018 to July 24, 2018.
Findings
All deficiencies cited during the prior complaint investigation survey were found to be corrected.
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 6
Date: Jul 24, 2018
Visit Reason
An Abbreviated Survey investigating complaint intake GA00189372 was initiated on July 16, 2018 and concluded on July 24, 2018. The complaint was substantiated and it was determined that the facility was not in substantial compliance with Medicare/Medicaid regulations related to scabies treatment and infection control.
Complaint Details
Complaint intake GA00189372 was substantiated related to scabies treatment and infection control deficiencies.
Findings
The facility failed to revise care plans and document treatment and follow-up assessments for residents treated for scabies. The facility failed to follow physician orders for scabies treatment, including timely administration and documentation of Permethrine 5% Cream. Infection control practices were inadequate, including lack of isolation signage, incomplete cleaning checklists, and failure to track and report infections and antibiotic use. The facility also failed to maintain an effective Quality Assurance program to address the scabies outbreak and infection control deficiencies.
Deficiencies (6)
Failure to revise care plans and document treatment and follow-up assessments for residents treated for scabies.
Failure to follow physician orders for scabies treatment including administration and documentation of Permethrine 5% Cream.
Failure to maintain complete and accurate resident medical records related to scabies treatment and follow-up.
Failure to maintain an effective Quality Assurance program to address scabies outbreak and infection control.
Failure to establish and maintain an effective infection prevention and control program including isolation signage, infection tracking, and outbreak reporting.
Failure to implement an antibiotic stewardship program including analysis of antibiotic use and follow-up.
Report Facts
Resident census: 156
Residents treated for scabies: 27
Residents treated for scabies: 11
Forms incomplete: 14
Forms blank: 11
Residents treated with Ivermectin: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Case Mix Director/LPN | Confirmed care plans were not updated for scabies treatment |
| FF | Registered Nurse/Unit Manager | Reported lack of documentation and follow-up for scabies treatment |
| HH | Skin Integrity Coordinator/LPN | Described rash assessments and scabies treatment follow-up |
| DHS | Director of Health Services | Confirmed failures in documentation, infection control, and QA program |
| ICN | Infection Control Nurse | Provided infection control data and described infection control practices |
| RN AA | Registered Nurse | Described isolation practices and scabies treatment |
| CMD GG | Case Mix Director | Discussed isolation care plans and infection control |
| CP LL | Consultant Pharmacist | Discussed medication regimen reviews and antibiotic stewardship |
| Administrator | Discussed QA program and scabies outbreak management | |
| Medical Director Dr. (Name) | Physician | Provided clinical assessment of scabies outbreak and treatment |
| HOSP ICN PP | Hospital Infection Control Preventionist | Reported hospital staff scabies cases linked to nursing facility residents |
Inspection Report
Routine
Deficiencies: 6
Date: Jul 16, 2018
Visit Reason
Routine inspection of PruittHealth - Toccoa nursing facility to assess infection control practices, treatment of scabies outbreaks, and compliance with medical record documentation requirements.
Findings
The facility failed to properly post isolation signage for residents on transmission-based precautions, inadequately tracked and documented infections and antibiotic use, and did not fully implement infection control policies. There was a significant scabies outbreak with inadequate treatment documentation, delayed medication administration, and incomplete care plans. The facility also failed to report the outbreak to public health authorities and did not maintain complete medical records for residents treated for scabies.
Deficiencies (6)
Failure to post signage or conspicuous posting on doors for residents on transmission-based precautions, violating infection control policies and resident rights.
Inadequate infection control tracking and reporting, including lack of line listings, monthly infection rates, and antibiotic follow-up documentation.
Failure to properly isolate and treat residents during a scabies outbreak, including incomplete contact identification, delayed and staggered treatment without documentation, and inadequate environmental cleaning.
Failure to document administration and follow-up of Permethrine 5% Cream treatment for scabies in residents' medical records and medication administration records.
Care plans were not updated to reflect scabies diagnosis, treatment, or follow-up assessments for affected residents.
Failure to report scabies outbreak to Department of Public Health as required.
Report Facts
Residents treated with Ivermectin: 19
Residents treated with Permethrine Cream: 27
Residents on isolation: 3
Residents treated for scabies in March 2018: 25
Staff treated prophylactically for scabies: 13
Staff with rash treated: 3
Forms incomplete: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Described isolation cart use and infection control practices |
| DHS | Director of Health Services | Provided information on infection control policies and scabies treatment |
| ICN | Infection Control Nurse | Provided infection control data and described scabies outbreak management |
| RN/UM FF | RN Unit Manager | Described isolation signage and scabies outbreak quarantine |
| CDM GG | Case Mix Director | Discussed isolation care plans and scabies treatment documentation |
| Dr. (Name) | Medical Director | Provided medical opinion on scabies outbreak and treatment |
| CNA BB | Certified Nursing Assistant | Reported resident skin assessments and rash observations |
| LPN II | Licensed Practical Nurse/Wound Nurse | Described scabies treatment and documentation practices |
| HOSP ICN PP | Hospital Infection Control Preventionist | Reported hospital staff scabies cases linked to nursing facility residents |
| SIC/LPN HH | Skin Integrity Coordinator/LPN | Assessed resident rashes and scabies testing |
| CNA JJ | Certified Nursing Assistant | Reported personal rash and family treatment for scabies |
| Housekeeper KK | Housekeeper | Described environmental cleaning during scabies outbreak |
| DES | Director of Environmental Services | Described deep cleaning procedures during scabies outbreak |
| DM | Dietary Manager | Described meal delivery procedures during scabies outbreak |
| ADM | Assistant Dietary Manager | Described meal delivery procedures during scabies outbreak |
| RN/UM FF | RN Unit Manager | Described quarantine and resident movement during scabies outbreak |
| Administrator | Facility Administrator | Provided information on facility closure and scabies protocol absence |
| DP MM | Dispensing Pharmacist | Described medication dispensing and refill procedures |
| APM NN | Assistant Pharmacy Manager | Provided pharmacy records and medication delivery details |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 14, 2018
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 survey tags have been corrected.
Inspection Report
Annual Inspection
Census: 154
Deficiencies: 0
Date: May 10, 2018
Visit Reason
A standard survey was conducted at PuittHealth - Toccoa from May 7, 2018 through May 10, 2018 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The standard survey revealed that the facility was in substantial compliance with the Healthcare Portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B.
Inspection Report
Life Safety
Census: 152
Capacity: 181
Deficiencies: 1
Date: May 7, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety requirements for participation in Medicare/Medicaid at Pruitt Health-Toccoa.
Findings
The facility was found not in substantial compliance due to the absence of a fire alarm strobe in the staff/public restroom by the main entrance, as confirmed by staff during the inspection.
Deficiencies (1)
Facility failed to have a fire alarm strobe in the staff/public restroom by the main entrance.
Report Facts
Census: 152
Total Capacity: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed absence of fire alarm strobe during facility tour |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 3, 2018
Visit Reason
An unannounced abbreviated survey was conducted on 4/3/18 by a Licensed Practical Nurse following an anonymous complaint.
Complaint Details
The complaint was anonymous; no substantiation status is provided.
Findings
The survey was completed on the same day with a phone call made to the Ombudsmen and a voicemail left. No specific deficiencies or findings are detailed in the report.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 11, 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
Follow-Up
Deficiencies: 0
Date: May 11, 2017
Visit Reason
A follow-up visit was conducted to the recertification survey to verify correction of previous deficiencies.
Findings
The deficiencies identified in the prior recertification survey were corrected at the time of the follow-up visit.
Inspection Report
Life Safety
Census: 155
Capacity: 181
Deficiencies: 4
Date: Mar 28, 2017
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 NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with sprinkler system maintenance, corridor door smoke resistance and latching, and improper sealing of smoke barriers with flammable foam. These deficiencies posed risks to staff and residents in the event of a fire.
Deficiencies (4)
Three sprinkler heads behind main dryer units were covered with debris causing delayed activation risk.
Patient room door for room 110 did not seal properly to resist smoke and did not latch correctly.
New penetrations through smoke and fire walls were sealed with highly flammable foam instead of UL listed fire caulk.
Corridor doors failed to meet smoke resistance and latching requirements.
Report Facts
Staff at risk: 6
Residents at risk: 3
Residents at risk: 115
Census: 155
Total licensed beds: 181
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to sprinkler heads, corridor door, and smoke barrier penetrations |
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