Inspection Report
Annual Inspection
Deficiencies: 0
Jun 12, 2025
Visit Reason
An annual licensure survey was conducted at Pruitthealth Virginia Park from June 10, 2025 to June 12, 2025.
Findings
There were no deficiencies cited during the annual licensure survey.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 3
Jun 12, 2025
Visit Reason
A standard survey was conducted from June 10 to June 12, 2025, including investigation of multiple complaint intakes, with one substantiated complaint resulting in deficiencies cited.
Findings
The facility was found noncompliant with Medicare/Medicaid regulations, with deficiencies including failure to assess a resident for self-administration of medication, failure to maintain clean air filters in PTAC units in three rooms, and failure to properly store a BiPAP machine mask, increasing risk of harm or infection.
Complaint Details
Complaint intake GA00254828 was substantiated with deficiencies cited; other complaint intakes were unsubstantiated.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to adequately assess one resident (R269) for self-administration of medication. | D |
| Failure to ensure PTAC unit air filters were free of dirt and debris in three rooms (306, 307, 308), potentially diminishing air quality. | D |
| Failure to properly store BiPAP mask for one resident (R54), increasing risk of respiratory infection. | D |
Report Facts
Residents present: 115
Residents assessed for medication self-administration: 31
Rooms with dirty PTAC filters: 3
Residents using BiPAP: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) AA | Confirmed resident R269 had not been assessed for self-administration of medication | |
| Licensed Practical Nurse (LPN) BB | Confirmed resident R269 had not been assessed for self-administration of medication and BiPAP mask was not properly stored | |
| Nurse Navigator | Confirmed resident R269 had not been assessed for self-administration of medication and BiPAP mask was not properly stored | |
| Director of Nursing (DON) | Stated medications should not be at residents' bedside unless assessed and approved for self-administration; stated there should be a bag to place the BiPAP mask | |
| Administrator | Confirmed PTAC units and filters were covered with debris and dirt | |
| Maintenance Director | Responsible for cleaning PTAC filters; confirmed observations of dirty filters | |
| Housekeeping Supervisor | Responsible for wiping down PTAC units; confirmed observations of dirty filters |
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 0
Aug 15, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints numbered GA00249130, GA00248761, GA00245791, GA00244226, GA00248146, and GA00243365.
Findings
All complaints investigated were found to be unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00249130, GA00248761, GA00245791, GA00244226, GA00248146, and GA00243365 were investigated and determined to be unsubstantiated.
Report Facts
Complaints investigated: 6
Inspection Report
Deficiencies: 0
Feb 15, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a healthcare facility inspection conducted at PruittHealth - Virginia Park.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 114
Deficiencies: 0
Feb 15, 2024
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the January 4, 2024 Recertification in conjunction with a Complaint survey.
Findings
All deficiencies cited as a result of the January 4, 2024 Recertification and Complaint survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Feb 14, 2024
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Census: 110
Deficiencies: 6
Jan 4, 2024
Visit Reason
A standard survey was conducted from January 2 through January 4, 2024, including investigation of multiple complaint intake numbers, all found unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to obtain physician orders for resident self-administration of medications, failure to document risks and physician notification for discharge against medical advice, failure to develop and revise care plans for residents with ADL deficits and self-administration needs, failure to provide passive range of motion exercises, and failure to follow infection prevention and control procedures related to COVID-19.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey and found unsubstantiated.
Severity Breakdown
SS= D: 5
SS= F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to assess and obtain a physician order for one resident to safely self-administer and store nebulizer treatments at bedside. | SS= D |
| Failed to document risks and benefits and notify physician at time of discharge against medical advice for one resident. | SS= D |
| Failed to ensure a care plan was developed for one resident with limitations in range of motion and ADL deficits. | SS= D |
| Failed to revise the comprehensive care plan as needed related to self-administration of nebulizer treatments for one resident following hospital stay. | SS= D |
| Failed to ensure one resident with limited range of motion received passive range of motion exercises as needed. | SS= D |
| Failed to follow droplet transmission-based precautions procedures prior to entering and exiting COVID positive resident rooms on one hall. | SS= F |
Report Facts
Residents sampled: 29
Resident census: 110
Discharge date: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| JJ | Licensed Practical Nurse (LPN) | Interviewed regarding self-administration medication procedures |
| FF | Respiratory Therapist (RT) | Interviewed regarding resident self-administering nebulizer treatments |
| DON | Director of Nursing | Interviewed regarding facility policies on self-administration of medications |
| Senior Nurse Consultant | Confirmed assessment regarding resident self-administration | |
| SSD | Social Service Director | Interviewed regarding AMA discharge follow-up and documentation |
| DHS | Director of Health Services | Interviewed regarding AMA discharge procedures and care plan expectations |
| LPN AA | Licensed Practical Nurse | Interviewed regarding resident care and range of motion exercises |
| RN MDS Director EE | Registered Nurse, MDS Director | Interviewed regarding care plan updates and responsibilities |
| CNA CC | Certified Nursing Assistant | Interviewed regarding resident care and range of motion exercises |
| RA DD | Restorative Aide | Interviewed regarding range of motion and splinting responsibilities |
| ADON | Assistant Director of Nursing and acting Infection Control Preventionist | Interviewed regarding infection control expectations and PPE use |
| Phlebotomist GG | Observed and interviewed regarding PPE use in COVID positive rooms | |
| LPN II | Licensed Practical Nurse | Observed regarding PPE use in COVID positive rooms |
Inspection Report
Life Safety
Census: 109
Capacity: 125
Deficiencies: 2
Jan 3, 2024
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance due to failure to secure ceiling tiles to prevent smoke passage and failure to provide a GFI plug near a water source in the Med Room on Hall 200. These issues were confirmed by staff during the inspection.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to secure ceiling tiles to prevent passage of smoke in the Med room on Hall 200. | SS= D |
| Facility failed to provide a GFI plug near a water source; an open J box and non-GFIA electrical outlet were noted in the Med Room on Hall 200. | SS= D |
Report Facts
Census: 109
Total Capacity: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of missing ceiling tile and electrical issues in Med Room |
Inspection Report
Routine
Deficiencies: 3
Jan 2, 2024
Visit Reason
The inspection was a State Licensure survey conducted from January 2, 2024 through January 4, 2024 to determine compliance with the State Long Term Care Requirements.
Findings
The facility was cited for multiple deficiencies including failure to follow droplet transmission-based precautions for COVID-19 positive residents, failure to obtain a physician order for a resident to self-administer nebulizer treatments, and failure to develop and implement a care plan and provide passive range of motion exercises for a resident with limited range of motion and ADL deficits.
Deficiencies (3)
| Description |
|---|
| Failure to follow droplet transmission-based precautions procedures prior to entering and exiting COVID positive resident rooms, including improper use of PPE by staff. |
| Failure to assess and obtain a physician order for a resident to safely self-administer and store nebulizer treatments at bedside. |
| Failure to develop a care plan for a resident with limited range of motion and ADL deficits and failure to provide passive range of motion exercises as needed. |
Report Facts
Residents sampled: 29
Resident ID: 75
Resident ID: 568
Date survey completed: Jan 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse II | LPN II | Observed not following droplet transmission-based precautions in COVID positive room 113. |
| Phlebotomist GG | Phlebotomist | Observed improper PPE use in COVID positive room 111 and admitted to discarding face shield improperly. |
| Certified Nursing Assistant HH | CNA | Observed not wearing gown and improper handling of dirty linens in COVID positive room 113. |
| Assistant Director of Nursing | ADON | Provided expectations for droplet precautions and PPE use. |
| Regional Vice President of Operations | Regional VP | Reviewed video footage and provided education on infection control practices. |
| Licensed Practical Nurse JJ | LPN | Interviewed regarding proper procedure for resident self-administration of medication. |
| Respiratory Therapist FF | RT | Confirmed resident self-administered nebulizer treatments without physician order. |
| Director of Nursing | DON | Confirmed no resident was authorized for self-administration of medications. |
| Senior Nurse Consultant | Senior Nurse Consultant | Verified assessment indicating resident would not self-administer medications. |
| Licensed Practical Nurse AA | LPN | Reported resident was not receiving range of motion exercises. |
| Registered Nurse MDS Director | RN MDS Director | Acknowledged lack of care plan for resident with contractures and ADL deficits. |
| Director of Health Services | DHS | Verified resident did not have care plans developed and noted communication breakdown. |
| Certified Nursing Assistant CC | CNA | Provided ADL care but did not perform range of motion exercises. |
| Therapy Manager | Therapy Manager | Reported resident discharged from skilled therapy to caregiver functional exercise program. |
| Restorative Aide DD | RA | Performed range of motion and splinting for residents; confirmed resident was not on functional ROM program. |
Inspection Report
Abbreviated Survey
Census: 112
Deficiencies: 0
Dec 21, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint number GA00241902.
Findings
No deficiencies were cited related to complaint GA00241902 during the survey.
Complaint Details
Complaint number GA00241902 was investigated and found to have no deficiencies cited.
Report Facts
Complaint number: GA00241902
Facility census: 112
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 18, 2022
Visit Reason
This 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 detailed findings or deficiencies.
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Aug 18, 2022
Visit Reason
A revisit was conducted at Pruitt Health-Virginia Park from 8/15/22 to 8/18/22 in conjunction with a complaint #GA00218826 to verify correction of deficiencies cited in the recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 8/3/22.
Complaint Details
The revisit was conducted in conjunction with complaint #GA00218826.
Report Facts
Facility census: 114
Inspection Report
Re-Inspection
Census: 114
Deficiencies: 0
Aug 15, 2022
Visit Reason
A revisit was conducted at Pruitt Health-Virginia Park from 8/15/22 to 8/18/22 in conjunction with a complaint #GA00218826 to verify correction of deficiencies cited in the prior recertification survey.
Findings
All deficiencies cited as a result of the recertification survey were found to be corrected as of 8/3/22.
Complaint Details
The revisit was conducted in conjunction with complaint #GA00218826.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 8, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Enforcement
Census: 112
Deficiencies: 9
Jun 27, 2022
Visit Reason
An abbreviated survey was conducted to verify the removal of Immediate Jeopardy (IJ) related to unsafe temperature levels in the facility that posed serious harm or death risk to residents.
Findings
The facility failed to maintain safe temperature levels between 71 to 81°F, with hallway temperatures reaching as high as 91°F and resident rooms up to 88°F. Portable air conditioners were installed but failed to adequately cool the facility. The facility also had deficiencies in medication self-administration orders, care plan accuracy, medication administration, respiratory care, and resident record accuracy. The facility implemented a corrective plan including additional portable AC units, temperature monitoring, hydration rounds, and HVAC system repairs. The Immediate Jeopardy was removed on 6/19/2022, but the facility remained out of compliance at a lower scope and severity.
Severity Breakdown
Level L: 2
Level D: 5
Level E: 1
Level F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility failed to maintain safe temperature range of 71 to 81°F, with temperatures reaching up to 91°F in resident rooms and hallways. | Level L |
| Facility failed to ensure one resident had a physician's order for self-administration of respiratory medications prior to self-administration. | Level D |
| Facility failed to maintain a safe, clean, comfortable, and homelike environment, including temperature control and maintenance issues in resident rooms. | Level F |
| Facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' status, including fall history and respiratory treatments. | Level D |
| Facility failed to develop and implement comprehensive care plans for residents related to oxygen administration and self-administration of medications. | Level E |
| Facility failed to ensure medications were administered as ordered for one resident. | Level D |
| Facility failed to ensure residents with tracheostomies received oxygen at the correct physician ordered concentration. | Level D |
| Facility failed to maintain complete and accurately documented medical records related to advance directives for three residents. | Level D |
| Facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies related to temperature control. | Level F |
Report Facts
Resident census: 112
Facility temperature: 91
Facility temperature: 89
Facility temperature: 88
Facility temperature: 84
Resident temperature: 100.6
Number of portable AC units: 10
Number of portable AC units: 8
Number of portable AC units: 10
Number of fans: 15
Temperature monitoring frequency: 2
Resident sample size: 41
Medication doses missed: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anthony Grant | Administrator | Named in relation to temperature issues and QAPI oversight |
| LPN HH | Licensed Practical Nurse | Named in medication self-administration deficiency |
| DHS | Director of Health Services | Named in multiple findings including temperature, medication, and care plan deficiencies |
| LPN AA | Licensed Practical Nurse | Named in oxygen administration and code status discrepancies |
| Corporate Nurse Consultant | Named in medication self-administration and code status discrepancies | |
| RT | Respiratory Therapist | Named in oxygen administration deficiency |
| RTD | Respiratory Therapy Director | Named in oxygen administration deficiency |
| LPN CC | Licensed Practical Nurse | Named in code status discrepancy |
| LPN BB | Licensed Practical Nurse | Named in code status discrepancy |
| Administrator | Named in QAPI education and oversight | |
| DON | Director of Nursing | Named in QAPI education and oversight |
Inspection Report
Renewal
Deficiencies: 2
Jun 16, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from June 12, 2022 through June 16, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to ensure one resident (R#96) had a physician's order for self-administration of respiratory medications and failed to develop or implement care plans related to oxygen administration for four residents (R#64, R#69, R#96, and R#100). Observations confirmed residents self-administering medications without proper physician orders or care plans.
Deficiencies (2)
| Description |
|---|
| Failure to ensure resident R#96 had a physician's order for self-administration of respiratory medications prior to nebulizer medications being kept at bedside and self-administered. |
| Failure to implement or develop care plans for four residents related to oxygen administration and self-administration of medications. |
Report Facts
Sampled residents: 41
Residents with care plan deficiencies: 4
Resident R#96 medications: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed resident R#96 self-administers medications without physician order |
| LPN II | Licensed Practical Nurse | Confirmed absence of physician order for resident R#96 to self-administer medications |
| Director of Health Services | Confirmed lack of physician order and care plan for resident R#96 self-administration | |
| Corporate Nurse Consultant | Confirmed absence of physician order and care plan for resident R#96 self-administration | |
| LPN DD | Licensed Practical Nurse | Assessed resident R#96 for inhalers but overlooked nebulizer self-administration assessment |
| Minimum Data Set Coordinator | Confirmed resident R#96 did not have a care plan for self-administration of medications |
Inspection Report
Routine
Census: 116
Deficiencies: 7
Jun 16, 2022
Visit Reason
A standard survey was conducted from 6/12/2022 through 6/16/2022, including investigation of multiple complaint intakes, to assess compliance with Medicare/Medicaid regulations and facility licensing requirements.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, including failure to maintain safe temperature levels between 71 to 81°F, resulting in immediate jeopardy. Additional deficiencies included failure to ensure proper self-administration medication orders, incomplete care plans for oxygen administration, medication administration errors, inaccurate medical records regarding code status, and ineffective QAPI processes to address systemic quality deficiencies.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. One complaint (GA00223638) was substantiated with citations; all others were unsubstantiated.
Severity Breakdown
Level L: 2
Level E: 1
Level D: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to maintain safe temperature range of 71 to 81°F for 116 residents over multiple days, with temperatures reaching as high as 91°F in resident rooms despite use of portable air conditioners. | Level L |
| One resident self-administered nebulizer medications without a physician's order for self-administration. | Level D |
| Facility failed to develop or implement care plans for oxygen administration for three residents with tracheostomies and failed to develop a care plan for self-administration of medication for one resident. | Level E |
| Medications were not administered as ordered for one resident, with multiple documented missed doses. | Level D |
| Facility failed to ensure correct oxygen flow rates were administered to three residents with tracheostomies, inconsistent with physician orders. | Level D |
| Medical records were incomplete and inaccurate regarding residents' code status, with discrepancies between physician orders and documented code status for three residents. | Level D |
| Facility failed to implement effective QAPI processes to address systemic quality deficiencies, specifically failure to maintain safe temperature levels despite identified issues and interventions. | Level L |
Report Facts
Resident census: 116
Facility temperature: 91
Portable air conditioners: 10
Missed medication doses: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Confirmed resident R#96 did not have a physician's order for self-administration of nebulizer medications |
| Director of Health Services | Director of Health Services (DHS) | Informed of immediate jeopardy and confirmed deficiencies related to care plans and oxygen administration |
| Corporate Nurse Consultant | Corporate Nurse Consultant | Confirmed absence of physician order and care plan for self-administration of medication for resident R#96 |
| LPN CC | Licensed Practical Nurse | Confirmed no documentation of medication refusals for resident R#323 |
| Respiratory Therapist | Respiratory Therapist (RT) | Confirmed incorrect oxygen flow rates for residents with tracheostomies |
| Administrator | Facility Administrator | Informed of immediate jeopardy and described HVAC issues and QAPI plan |
| Maintenance Director | Maintenance Director | Performed temperature checks and described HVAC system issues |
Inspection Report
Life Safety
Census: 116
Capacity: 128
Deficiencies: 4
Jun 14, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in hood suppression system coverage, sprinkler system maintenance, smoke barrier integrity, and electrical safety, affecting 1 of 3 smoke compartments.
Severity Breakdown
SS= D: 3
SS= E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Hood suppression system failed to assure operation as needed; two hood suppression red nozzle covers were not covering the nozzles, potentially allowing grease accumulation and obstructing fire extinguishing capability. | SS= D |
| Fire sprinkler system was not at optimum readiness; a loaded sprinkler head in a washing machine room may delay activation of the fire sprinkler system. | SS= D |
| Smoke barriers were penetrated and not sealed via wiring and a small section knocked loose above the ceiling on 400 hall near Room 411, failing to prevent passage of smoke. | SS= D |
| Electrical hazards present including open junction box with exposed wires above ceiling tiles at a smoke penetration, daisy-chained power strips in Room 410, power strips screwed to walls in multiple rooms, and a power strip on the floor in the laundry under the electrical panel. | SS= E |
Report Facts
Census: 116
Total Capacity: 128
Smoke Compartments affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Renewal
Deficiencies: 2
Jun 12, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from June 12, 2022 through June 16, 2022 to assess compliance with licensure requirements.
Findings
The facility failed to ensure one resident (R#96) had a physician's order for self-administration of respiratory medications, and failed to develop or implement care plans related to oxygen administration for four residents (R#64, R#69, R#96, and R#100). Observations confirmed residents self-administering medications without proper orders or care plans.
Deficiencies (2)
| Description |
|---|
| Failure to ensure resident R#96 had a physician's order for self-administration of respiratory medications prior to nebulizer medications being kept at bedside and self-administered. |
| Failure to implement or develop care plans for four residents related to oxygen administration and self-administration of medications. |
Report Facts
Sampled residents: 41
Residents with care plan deficiencies: 4
Resident R#96 nebulizer vials: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse (LPN) | Interviewed regarding resident R#96 self-administration of medications and confirmed lack of physician order |
| DD | Licensed Practical Nurse (LPN) | Assessed resident R#96 for inhalers and acknowledged oversight in assessing nebulizer treatment |
| Corporate Nurse Consultant | Reviewed medical records and confirmed absence of physician order and care plan for self-administration of medications for resident R#96 | |
| Director of Health Services (DHS) | Confirmed lack of physician order and care plans for resident R#96 and discussed expectations for staff compliance | |
| Minimum Data Set Coordinator (MDSC) | Reviewed care plan for resident R#96 and confirmed absence of care plan for self-administration of medications |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 1, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00221193.
Findings
The complaint #GA00221193 was substantiated with no regulatory violations cited.
Complaint Details
Complaint #GA00221193 was substantiated with no regulatory violations cited.
Inspection Report
Follow-Up
Deficiencies: 0
Dec 8, 2021
Visit Reason
A revisit was conducted on 12/08/21 to follow up on the Focused Infection Control and Complaint Survey originally conducted on 10/15/21.
Findings
The revisit found all previously identified deficiencies to be corrected as of 11/05/21.
Complaint Details
The revisit was related to a complaint survey conducted on 10/15/21; all deficiencies were found corrected.
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 3
Oct 15, 2021
Visit Reason
A Focused Infection Control survey was conducted from October 12 through October 15, 2021, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations related to infection control and resident funds.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to convey resident fund account balances within 30 days upon discharge or death for one resident (R#3). The facility withdrew funds from the resident's personal account without documented proper authorization and failed to notify the family regarding remaining funds after the resident's death.
Complaint Details
Complaint Intake Numbers GA00212788 (unsubstantiated), GA00213503 (substantiated without deficiency), GA00215089 (substantiated with deficiency), GA00215722 (unsubstantiated), GA00216002 (unsubstantiated), GA00215053 (unsubstantiated), GA00216407 (unsubstantiated), GA00218233 (unsubstantiated), and GA00214668 (unsubstantiated) were investigated in conjunction with this survey.
Deficiencies (3)
| Description |
|---|
| Failure to convey resident fund account balance within 30 days upon discharge or death for one resident (R#3). |
| Withdrawal of $1000.00 from resident's personal funds without documented verbal or written authorization prior to withdrawal. |
| Failure to notify family of resident's personal fund balance after resident's death and failure to properly manage refund of remaining funds. |
Report Facts
Resident census: 101
COVID stimulus check amount: 1200
Withdrawal amount: 1000
Remaining personal fund balance: 480
Past due balance December 2019: 577
Past due balance January 2020: 423
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Mar 4, 2021
Visit Reason
A Complaint Survey investigating multiple complaints in conjunction with a COVID-19 Focused Infection Control Survey was initiated on February 23, 2021 and concluded on March 4, 2021.
Findings
The complaints were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.
Complaint Details
Complaints GA00212447, GA00209119, GA00209134, GA00208914, GA00210174, and GA00212518 were investigated and found to be unsubstantiated with no regulatory violations cited.
Report Facts
Resident census: 98
Inspection Report
Routine
Census: 107
Deficiencies: 0
Nov 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Georgia Department of Community Health on November 4, 2020.
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 during this survey.
Report Facts
Total census: 107
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 1
Oct 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from October 12-15, 2020, including investigations of multiple complaints, some substantiated with deficiencies, related to resident care and infection control.
Findings
The facility was found in compliance with infection control regulations; however, deficiencies were identified related to resident rights and dignity, specifically the failure to ensure residents were assisted to wear their personal clothing, resulting in 12 residents wearing hospital gowns instead of their own clothing.
Complaint Details
Multiple complaints were investigated, with some substantiated with deficiencies related to resident care and dignity, including complaints GA00203668, GA00203025, and others.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure 12 of 45 residents were treated with respect and dignity by assisting them to wear their personal clothing, resulting in residents wearing hospital gowns in bed and hallways. | E |
Report Facts
Residents wearing hospital gowns: 12
Total census: 106
Residents accepting purchased clothing: 6
Residents offered purchased clothing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA GG | Certified Nursing Assistant | Assigned to residents #1 and #2, provided information about clothing availability and care practices |
| RN II | Registered Nurse Charge Nurse | Interviewed regarding resident #1's clothing and care |
| RN CCC | Registered Nurse Charge Nurse | Provided information about resident #21's care and clothing preferences |
| CNA BBB | Certified Nursing Assistant | Provided information about resident #21's clothing preferences and behaviors |
| CNA DDD | Certified Nursing Assistant | Provided care for resident #21 and information about clothing availability |
| Director of Health Services | Director of Health Services | Provided information about resident #21's behaviors and facility clothing policies |
Inspection Report
Routine
Census: 102
Deficiencies: 0
Aug 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
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
Routine
Census: 100
Deficiencies: 0
Jul 31, 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 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Report Facts
Total census: 100
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 26, 2020
Visit Reason
The visit was conducted as an abbreviated/partial extended survey to investigate infection control related allegations included in complaints #GA00205364 and GA00204505.
Findings
The complaints #GA00205364 and GA00204505 were found to be unsubstantiated and no regulatory violations were cited during the onsite survey.
Complaint Details
The investigation was initiated due to infection control related allegations in complaints #GA00205364 and GA00204505. The complaints were unsubstantiated and no violations were found.
Inspection Report
Abbreviated Survey
Census: 101
Deficiencies: 0
Jun 26, 2020
Visit Reason
A Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted at PruittHealth Virginia Park on June 25-26, 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, including CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Census: 101
Inspection Report
Abbreviated Survey
Census: 106
Deficiencies: 0
Aug 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00198736.
Findings
The complaint was found to be unsubstantiated during the survey.
Complaint Details
Complaint GA00198736 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 4, 2019
Visit Reason
A revisit survey was conducted on 6/3/19 through 6/4/19 to verify correction of deficiencies cited in the 4/11/19 Standard Survey. Additionally, a complaint investigation (Intake Number GA00196568) was conducted in conjunction with this revisit survey.
Findings
All deficiencies cited in the prior 4/11/19 Standard Survey were found to be corrected. The complaint investigation found the complaint to be unsubstantiated.
Complaint Details
Complaint Intake Number GA00196568 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 4, 2019
Visit Reason
A revisit survey was conducted on 6/3/19 through 6/4/19 to verify correction of deficiencies from the 4/11/19 Standard Survey and to investigate Complaint Intake Number GA00196568.
Findings
All deficiencies cited in the 4/11/19 Standard Survey were found to be corrected. The complaint investigation was unsubstantiated.
Complaint Details
Complaint Intake Number GA00196568 was investigated and found to be unsubstantiated.
Inspection Report
Life Safety
Census: 105
Capacity: 125
Deficiencies: 0
Apr 8, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Plan met the necessary standards.
Report Facts
Certified Beds: 125
Census: 105
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2018
Visit Reason
A complaint survey was conducted on 10/10/18 - 10/11/18 to investigate complaints #GA00191814, GA00190999, and GA00191499 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted in response to complaints #GA00191814, GA00190999, and GA00191499 and found no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 10, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00189042, GA00189076, and GA00189703.
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
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 17, 2018
Visit Reason
A complaint survey was conducted to investigate complaints #GA00188547 and GA00188426 to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
The survey was conducted in response to complaints #GA00188547 and GA00188426; no deficiencies were found.
Inspection Report
Re-Inspection
Deficiencies: 0
May 16, 2018
Visit Reason
A Revisit survey was conducted from 5/14/18 through 5/16/18 for the Recertification survey originally conducted from 3/12/18 through 3/15/18.
Findings
The Revisit survey revealed that all previously cited deficiencies had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
May 1, 2018
Visit Reason
A follow-up survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited tags have been corrected as noted by the surveyor during the follow-up visit.
Inspection Report
Routine
Census: 117
Deficiencies: 10
Mar 15, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and long term care facility requirements.
Findings
The survey identified multiple deficiencies including failure to maintain resident council meeting privacy and grievance response, incomplete physician documentation for hospital transfers, failure to implement care plan interventions for fall prevention, failure to invite a resident to care plan meetings, failure to provide hearing aids, inadequate assistance with activities of daily living and bathing, inappropriate use of psychotropic medication without proper documentation, failure to provide adequate assistance with meals leading to weight loss, expired medications stored in medication rooms, poor palatability and appearance of pureed diets, and improper aseptic technique during wound care.
Severity Breakdown
E: 2
D: 8
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident council meetings lacked privacy, were interrupted by staff, and resident grievances were not adequately addressed. | E |
| Physician failed to document rationale for facility-initiated hospital transfer for one resident. | D |
| Care plan interventions for fall prevention, including use of fall mats and bed positioning, were not implemented for two residents. | D |
| Resident cognitively intact was not invited to care plan meetings and care plan was not revised to reflect hearing aid use for another resident. | D |
| Facility failed to provide appropriate self-grooming and bathing for three residents dependent on staff. | D |
| Facility failed to provide resident-centered care and services to address behaviors, including inappropriate administration of injectable antipsychotic without documentation of behaviors or non-pharmacological interventions. | D |
| Resident did not receive assistance with meals as required, resulting in continued weight loss; liquids were not provided in sippy cups as ordered. | D |
| Expired medications and biologicals were stored in medication storage rooms accessible to staff. | D |
| Pureed diets were prepared without conserving flavor, appearance, or palatability, resulting in poor resident satisfaction. | E |
| Facility failed to utilize proper aseptic technique during wound care for two residents, including failure to change gloves between wound sites. | D |
Report Facts
Resident census: 117
Weight loss percentage: 10.73
Weight loss percentage: 12.64
Weight loss percentage: 13.14
Expired medication count: 23
Pureed diet residents: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN MM | Licensed Practical Nurse | Administered Haldol injection to Resident #318 without documentation of behaviors |
| LPN AAA | Licensed Practical Nurse | Primary wound care nurse observed failing to change gloves between wound care steps |
| LPN BBB | Licensed Practical Nurse | Observed failing to change gloves during wound care |
| RN WW | Registered Nurse, MDS Coordinator | Responsible for sending care plan meeting invitations |
| Staff member XX | Receptionist | Sent care plan meeting invitations only to first contact on resident face sheet |
| LPN ZZ | Licensed Practical Nurse, Unit Manager | Unaware of care plan meeting invitation process and care plan details for residents |
| RN JJ | Registered Nurse | Witnessed administration of Haldol injection to compliant resident |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication storage and psychotropic medication use |
| CNA FF | Certified Nursing Assistant | Observed resident behavior prior to Haldol injection |
| Dietician | Interviewed regarding resident weight loss and food quality | |
| Dietary Manager | Interviewed regarding food quality and preparation |
Inspection Report
Routine
Deficiencies: 7
Mar 15, 2018
Visit Reason
The inspection was conducted to assess compliance with state regulations regarding nursing care, resident care plans, hygiene, wound care, and infection control at PruittHealth - Virginia Park.
Findings
The facility was found deficient in multiple areas including failure to invite cognitively intact residents to care plan meetings, inadequate hearing aid provision, improper use of antipsychotic medication without proper documentation, failure to provide or document showers for residents, and lapses in infection control practices during wound care.
Deficiencies (7)
| Description |
|---|
| Failure to invite resident R#46, who was cognitively intact, to care plan meetings as required. |
| Resident R#49 with severe hearing loss did not have hearing aids in place and staff were unaware of their status. |
| Resident R#318 received an intramuscular injection of Haldol for agitation without documented indication or prior non-pharmacological interventions. |
| Resident R#11 had significant facial hair that was not removed for an extended period and had multiple missed baths/showers documented. |
| Resident R#33 had only received one shower since admission despite requesting more, with documentation showing mostly bed baths. |
| Resident R#85, with severely impaired cognition, was not receiving showers as indicated in care plans and mostly received bed baths. |
| Infection control lapses during wound care including failure to change gloves and use hand sanitizer between wound dressing changes. |
Report Facts
Resident reviewed: 24
Haldol dosage: 0.5
Bath documentation gaps: 11
Bed baths received: 42
Sponge baths received: 4
Bed baths received: 75
Whirlpool baths received: 5
Sponge baths received: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN WW | Registered Nurse, MDS Coordinator | Interviewed regarding care plan meeting invitations and resident involvement |
| LPN MM | Licensed Practical Nurse | Signed physician order for Haldol and administered medication to resident R#318 |
| LPN YY | Licensed Practical Nurse | Interviewed about staff interventions for resident behaviors |
| LPN AAA | Licensed Practical Nurse, Primary Wound Care Nurse | Observed providing wound care and training LPN BBB |
| LPN BBB | Licensed Practical Nurse | Observed providing wound care with improper glove use |
| DON | Director of Nursing | Interviewed about care plan meetings, resident hygiene preferences, and documentation |
Inspection Report
Life Safety
Census: 114
Capacity: 125
Deficiencies: 1
Mar 12, 2018
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to failure to maintain multiple doors in the basement area, including two outside exit doors, a laundry door, and a bottom stairwell door, which had detached closers and would not close, latch, or self-close as required by NFPA 101 standards.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain multiple doors in the basement area; two outside exit doors, laundry door, and bottom stairwell door had detached closers and would not close, latch, or self-close. | SS= D |
Report Facts
Census: 114
Total Capacity: 125
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2018
Visit Reason
A complaint survey was conducted to investigate complaints (GA 00185035) by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiency was cited during the complaint investigation survey.
Complaint Details
Complaint investigation related to complaint GA 00185035; no deficiencies were found.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Jan 25, 2018
Visit Reason
An unannounced Complaint Survey was conducted at Pruitt Health Virginia Park on January 24-25, 2018 to investigate a complaint regarding the facility's compliance with Medicare/Medicaid regulations.
Findings
The complaint survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483 for Long Term Care Facilities.
Complaint Details
The survey was complaint-related and revealed substantial compliance with regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 28, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00181185 and #GA00181291.
Findings
No health deficiencies were cited during the complaint survey.
Complaint Details
The survey was complaint-related, investigating two complaints, and no deficiencies were found.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 27, 2017
Visit Reason
A complaint revisit was conducted to determine if the deficiencies from the complaint survey on 9/19/17 had been corrected.
Findings
It was determined that the deficiencies from the complaint survey on 9/19/17 had been corrected.
Complaint Details
This was a complaint revisit following a complaint survey conducted on 9/19/17; deficiencies were found to be corrected.
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 9, 2017
Visit Reason
An abbreviated/partial extended survey was conducted on 9/9/17 to investigate complaint GA00178289. The complaint was substantiated regarding medication administration and self-administration assessment failures.
Findings
The facility failed to ensure medications were not left at the bedside without proper assessment for self-administration and failed to administer medications according to physician orders and facility policies. Medication errors occurred during observed medication passes, resulting in a 20% medication error rate affecting three residents.
Complaint Details
The complaint was substantiated. The facility was found non-compliant with Federal and State Long Term Care regulations related to medication administration and self-administration assessment.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medications were left at the bedside for Resident #1 without assessment or physician order for self-administration. | SS=D |
| Licensed Practical Nurses failed to administer medications according to nursing principles, physician orders, and facility policies for Residents #2, #3, and #4. | SS=D |
| Medication error rate exceeded 5%, with 5 errors out of 25 opportunities (20% error rate) during medication passes affecting Residents #2, #3, and #4. | SS=E |
Report Facts
Medication error rate: 20
Medication errors: 5
Medication pass opportunities: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Failed to administer medications according to orders and policies; prepared excessive medication doses; admitted to forgetting morning medications |
| LPN CC | Licensed Practical Nurse | Failed to administer medications according to orders; omitted narcotic administration; left medications at bedside |
| RN Consultant | Registered Nurse Consultant | Initiated investigation regarding medications left at bedside; confirmed lack of assessment and physician order for self-administration |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 1, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Routine
Census: 114
Deficiencies: 0
Jul 13, 2017
Visit Reason
A standard survey was conducted at Pruitt Health - Virginia Park from July 10, 2017 through July 13, 2017 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 109
Capacity: 125
Deficiencies: 3
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 the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in sprinkler system maintenance, corridor door security, and smoke barrier integrity, which could place residents and staff at risk in the event of fire.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Loaded sprinkler heads found in Laundry areas, no data plate on sprinkler riser, and missing escutcheon plate in the Lobby. | D |
| Several resident room doors (Rooms #317, #418, #423) would not close securely and latch in the closed position. | E |
| Small penetration found over the smoke doors near Room #315 compromising smoke barrier integrity. | D |
Report Facts
Residents at risk: 30
Residents at risk: 40
Census: 109
Total licensed beds: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 2, 2017
Visit Reason
The inspection was conducted as a Complaint Survey on 7/1/17 and 7/2/17 to investigate complaint #GA00176350 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at PruittHealth Virginia Park.
Complaint Details
Complaint investigation #GA00176350 was conducted and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 23, 2017
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint #GA00176100 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted at Pruitthealth Virginia Park.
Complaint Details
Complaint survey conducted to investigate complaint #GA00176100; no deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 26, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175517 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health Virginia Park.
Complaint Details
Complaint #GA00175517 was investigated and found to have no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 24, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175349 and 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
Complaint #GA00175349 was investigated and found to have no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 18, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate multiple complaints identified by their codes.
Findings
The complaints were not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements.
Complaint Details
The complaints GA00170589, GA00172585, GA00170764, GA00166947, GA00169240, and GA00171296 were investigated and found not substantiated.
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