Inspection Report
Abbreviated Survey
Census: 104
Deficiencies: 0
Apr 4, 2025
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00248599, GA00252402, and GA00254361.
Findings
The complaints were unsubstantiated and no regulatory violations were cited during the survey.
Complaint Details
Complaints GA00248599, GA00252402, and GA00254361 were investigated and found to be unsubstantiated.
Report Facts
Complaint identifiers: GA00248599, GA00252402, GA00254361
Inspection Report
Deficiencies: 0
Jul 10, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - WEST ATLANTA, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not specify any detailed deficiencies or findings.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Jul 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 5/19/2024 Recertification Survey and to investigate complaint intake #GA00247375.
Findings
All deficiencies from the prior recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake #GA00247375 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 95
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Jul 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 5/19/2024 Recertification Survey and to investigate complaint intake #GA00247375.
Findings
All deficiencies from the previous recertification survey were found to be corrected. The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint intake #GA00247375 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 0
Jul 8, 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
Deficiencies: 9
May 19, 2024
Visit Reason
A State Licensure survey was conducted at Pruitt Health West Atlanta from May 17, 2024 through May 19, 2024 to assess compliance with state health regulations and facility licensure requirements.
Findings
The survey revealed multiple deficiencies including failure to provide required Medicare notices, failure to ensure dignified dining experiences, inadequate physician visits, dietary service failures including serving lactose to an allergic resident, improper medication storage and labeling, unsanitary conditions of ice scoop and beverage dispenser, failure to assess resident medication self-administration ability, incomplete care plans for medications and diet, and failure to maintain proper food temperatures on the steam table.
Deficiencies (9)
| Description |
|---|
| Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to a resident discharged from Medicare Part A coverage. |
| Failed to ensure dignified dining experience including timely meal delivery and respectful staff behavior. |
| Failed to ensure residents were seen by a physician at required intervals. |
| Failed to serve lactose-free diet as ordered, causing allergic exposure. |
| Failed to ensure medications were dated when opened, discarded on discard dates, and stored according to manufacturer recommendations. |
| Failed to ensure ice scoop bin and beverage dispenser were free from buildup, posing contamination risk. |
| Failed to assess resident for ability to self-administer medications prior to leaving medications at bedside. |
| Failed to develop care plan for use of antipsychotic and anti-anxiety medications and failed to implement care plan interventions for diet as ordered. |
| Failed to maintain all food items on steam table at or above 135 degrees Fahrenheit to prevent bacterial growth. |
Report Facts
Residents affected by dignified dining failure: 3
Residents reviewed for physician visits: 10
Residents sampled for dietary service: 40
Medication carts reviewed: 3
Residents affected by ice scoop and beverage dispenser buildup: 1
Residents sampled for medication self-administration assessment: 40
Residents reviewed for care plan adequacy: 5
Residents affected by steam table temperature failure: 9
Total residents receiving oral diet: 99
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Observed pulling resident backwards in geriatric chair and confirmed ice scoop buildup |
| CNA BB | Certified Nursing Aide | Referred to resident as 'feeder' during lunch |
| Director of Health Services | Provided multiple interviews confirming deficiencies and expectations | |
| Dietary Manager | Confirmed serving lactose to allergic resident and ice scoop buildup | |
| LPN FF | Licensed Practical Nurse | Observed medication cart storage and labeling deficiencies |
| LPN DD | Licensed Practical Nurse | Reported resident had medications at bedside without assessment and removed them |
| Corporate Nurse Consultant II | Reported expectations for physician visits | |
| Registered Nurse HH | Registered Nurse | Described care plan responsibilities |
| Case Management Director (CMD) | Responsible for comprehensive care plans, acknowledged care plan oversights | |
| Physician | Reported frequency of resident visits |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 13
May 19, 2024
Visit Reason
A standard survey was conducted from 5/17/2024 through 5/19/2024, including investigations of three complaint intake numbers (GA00246413, GA00244925, GA00241718). Two complaints were substantiated with deficiencies and one was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with multiple deficiencies including failure to ensure dignified resident rights during dining, failure to assess resident ability to self-administer medications, failure to provide required notices, failure to provide specialized psychiatric services, failure to develop and implement comprehensive care plans, failure to ensure proper medication regimen review, improper medication storage and labeling, failure to maintain food temperatures, improper garbage disposal, and inadequate infection control related to ice scoop and beverage dispenser cleanliness.
Complaint Details
Complaint Intake Numbers GA00246413 and GA00244925 were substantiated with deficiencies. GA00241718 was unsubstantiated.
Severity Breakdown
E: 4
D: 7
F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure a dignified dining experience for three residents including timely meal delivery and respectful staff behavior. | E |
| Failed to assess one resident for ability to self-administer medications prior to leaving medications at bedside. | D |
| Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to one resident discharged from Medicare Part A coverage. | D |
| Failed to provide written bed hold notification at time of hospital transfer for three residents. | E |
| Failed to provide specialized psychiatric services as recommended by PASRR for one resident with serious mental illness. | D |
| Failed to develop a care plan for antipsychotic and anti-anxiety medications for one resident and failed to implement diet care plan for another resident. | D |
| Failed to ensure one resident was served a lactose-free diet as ordered, resulting in exposure to lactose-containing foods. | D |
| Failed to ensure residents were seen by a physician at required intervals for four residents. | E |
| Failed to ensure annual Gradual Dose Reduction assessment for antipsychotic medication for one resident. | D |
| Failed to ensure medications and biologicals were dated when opened, discarded on discard dates, and stored according to manufacturer recommendations on one medication cart. | D |
| Failed to ensure all food items on the steam table were held above 135 degrees Fahrenheit, affecting residents on puree diets. | E |
| Failed to prevent two garbage dumpsters from overflowing, preventing lids and doors from closing and lacking a plug to prevent leakage. | F |
| Failed to ensure ice scoop bin and beverage dispenser were free from green and black buildup, risking contamination. | D |
Report Facts
Residents present: 101
Residents ordered puree diet: 9
Residents reviewed for medication self-administration: 40
Residents reviewed for psychiatric services: 40
Residents reviewed for physician visit frequency: 10
Discard dates exceeded: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Acknowledged pulling resident backwards in geriatric chair and education on dignity |
| BB | Certified Nursing Aide | Referred to resident as 'feeder' during lunch |
| DD | Licensed Practical Nurse | Verified resident had not been assessed for self-medication and removed medications from bedside |
| DHS | Director of Health Services | Provided multiple interviews regarding deficiencies, expectations, and policies |
| DM | Dietary Manager | Confirmed food temperature issues and garbage dumpster overflow |
| FF | Licensed Practical Nurse | Verified medication storage and labeling deficiencies on medication cart |
| HH | Registered Nurse | Interviewed regarding care plan and resident behavior |
| UM EE | Licensed Practical Nurse Unit Manager | Reported nursing staff had not been sending out bed hold notices |
| Corporate Nurse Consultant II | Interviewed regarding physician visit frequency requirements |
Inspection Report
Life Safety
Census: 101
Capacity: 120
Deficiencies: 6
May 18, 2024
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including improperly maintained smoke/fire doors, fire alarm system deficiencies, smoking regulation violations, and excessive soiled linen container capacity.
Severity Breakdown
D: 2
E: 4
Deficiencies (6)
| Description | Severity |
|---|---|
| Smoke/fire door at the lobby did not close and seal properly. | D |
| Fire/smoke doors at hallway leading to laundry and kitchen had broken closure devices and doors propped open by carts. | D |
| Fire alarm power circuit was not identified, marked in red, or locked. | E |
| Fire alarm control panel was in trouble mode. | E |
| Smoking area had multiple safety violations including lack of metal safety cans with self-closing lids, absence of ashtrays, cigarette butts in trash cans with combustible materials, and cigarette disposal in no-smoking areas. | E |
| Soiled linen closets exceeded allowable quantities with 4 or more 55-gallon containers stored in two locations. | E |
Report Facts
Census: 101
Total Capacity: 120
Soiled linen containers: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Apr 8, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00245498.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint #GA00245498 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Nov 22, 2023
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in a prior complaint revisit survey concluded on August 23, 2023.
Findings
All deficiencies cited as a result of the complaint revisit survey were found to be corrected.
Complaint Details
This was a complaint revisit survey verifying correction of previously cited deficiencies.
Report Facts
Census: 86
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Nov 22, 2023
Visit Reason
A Revisit Survey was conducted at PruittHealth West Atlanta by a Qualified Survey Team from November 20, 2023, through November 22, 2023 to verify correction of deficiencies cited in a prior complaint revisit survey.
Findings
All deficiencies cited as a result of the complaint revisit survey concluded on August 23, 2023, were found to be corrected.
Complaint Details
This was a complaint revisit survey to verify correction of previously cited deficiencies.
Report Facts
Census: 86
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 0
Nov 22, 2023
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00239548.
Findings
The complaint was unsubstantiated and no federal deficiencies were cited during the survey.
Complaint Details
Complaint number GA00239548 was unsubstantiated without federal deficiency cited.
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Nov 22, 2023
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the complaint survey concluded on September 29, 2023.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected.
Report Facts
Facility census: 86
Inspection Report
Re-Inspection
Census: 86
Deficiencies: 0
Nov 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in a prior complaint revisit survey concluded on August 23, 2023.
Findings
All deficiencies cited as a result of the complaint revisit survey were found to be corrected.
Complaint Details
The visit was a complaint revisit survey verifying correction of previously cited deficiencies.
Report Facts
Facility census: 86
Inspection Report
Follow-Up
Deficiencies: 0
Oct 24, 2023
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 6
Sep 29, 2023
Visit Reason
The inspection was conducted as a Licensure Survey from July 26, 2023 through September 29, 2023 to assess compliance with regulatory requirements for the healthcare facility.
Findings
The facility was found deficient in multiple areas including failure to provide a nutritionally adequate diet affecting 88 of 93 residents on oral diets, inadequate social services support resulting in missed specialty appointments for residents, unresolved water leak problems causing mold growth in resident rooms and common areas, failure to provide nursing care according to resident needs and care plans for three sampled residents, unclean and unsafe environmental conditions in resident rooms and common areas, and failure to maintain the kitchen and dumpster area in a clean and sanitary condition.
Deficiencies (6)
| Description |
|---|
| Facility failed to provide a nutritionally adequate diet affecting 88 of 93 residents on oral diets, including serving meals not on the menu, missing food items, and lack of appropriate substitutes for mechanical soft diets. |
| Facility failed to ensure adequate social services support for two residents, resulting in missed oral surgeries, ophthalmologist, and psychiatry appointments. |
| Facility failed to promptly fix water leak problems resulting in mold in resident rooms and common areas, with mold testing confirming presence in multiple rooms. |
| Facility failed to provide nursing care in accordance with resident needs and care plans for three residents, including inadequate oral care and failure to ensure enteral feeding and hydration orders were followed. |
| Facility failed to maintain cleanliness and safety in resident rooms and common areas, including missing floor tiles, peeling paint, stained curtains, dirty air filters and vents, broken grab bars, rust, stained ceiling tiles, and dirty shower rooms. |
| Facility failed to maintain kitchen and dumpster area in a clean and sanitary condition, with observations of grime, dirt, rust, food debris, damaged equipment, and trash accumulation near dumpsters. |
Report Facts
Residents affected by diet deficiency: 88
Residents on mechanical soft diet: 89
Residents on puree diet: 5
Rooms tested for mold: 49
Residents sampled for nursing care review: 31
Missed psychiatry appointments for R#5: 3
Missed oral surgeries for R#11: 2
Missed ophthalmologist appointments for R#11: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN Restorative Nurse | Licensed Practical Nurse | Confirmed chicken served instead of menu items and discussed meal issues |
| Dietary Manager | Dietary Manager | Discussed diet deficiencies, kitchen cleanliness, and cleaning schedules |
| Administrator | Facility Administrator | Interviewed regarding diet issues, missed appointments, and facility maintenance |
| Registered Dietitian | Registered Dietitian | Provided guidance on mechanical soft diet substitutions and discussed kitchen conditions |
| Maintenance Director | Maintenance Director | Discussed mold, leaks, and facility maintenance issues |
| Certified Nursing Assistant BB | Certified Nursing Assistant | Provided care to resident with oral care deficiencies |
| Unit Manager JJ | Unit Manager | Interviewed about resident care and appointment scheduling |
| Cook NN | Cook | Confirmed kitchen cleanliness issues |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 17
Sep 29, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with a Complaint Investigation was conducted investigating multiple complaint numbers substantiated with deficiencies.
Findings
The facility was found not in compliance with infection control regulations, failed to assess medication self-administration, failed to honor resident trust fund requests timely, failed to provide quarterly trust fund statements, failed to maintain a safe and homelike environment, failed to protect residents from misappropriation of funds, failed to notify the State Agency of an elopement, failed to provide oral care, failed to ensure hydration and enteral feeding per physician orders, failed to ensure water was within reach, failed to coordinate specialty services appointments, failed to follow menu and provide appropriate meals, failed to maintain kitchen cleanliness, failed to promptly fix water leaks resulting in mold, and failed to maintain accurate documentation and provide truthful documentation.
Complaint Details
Complaint numbers GA00233471, GA00233650, GA00237371, GA00237546, GA00237611, GA00237621, GA00237796, GA00237843, GA00237863, GA00238129, GA00238397, and GA00238483 were substantiated with deficiencies related to infection control, resident care, and administrative issues.
Severity Breakdown
Level C: 1
Level D: 7
Level E: 1
Level F: 6
Level G: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to assess one resident for ability to self-administer medications prior to leaving medications at bedside. | Level D |
| Failed to honor two residents' requests for access to their funds within the same day. | Level D |
| Failed to provide resident trust fund account quarterly statements for two residents. | Level F |
| Failed to maintain a safe, clean, and homelike environment with issues including missing floor tile, peeling paint, stained curtains, broken grab bar, rust, stained ceiling tiles, dirty floors, and rusted ceiling in smoking area. | Level F |
| Failed to safely protect two residents from misappropriation of funds; facility used resident's money without consent and unauthorized purchases on resident's credit card. | Level D |
| Failed to have onsite employee files for two employees for 36 days of the survey. | Level E |
| Failed to notify the State Agency within two hours of an incident involving an elopement of one resident. | Level D |
| Failed to provide oral care for one resident dependent on staff for ADL care. | Level D |
| Failed to ensure two residents received appropriate hydration and enteral feeding per physician orders; actual harm occurred with hospitalization and death. | Level G |
| Failed to ensure water was within reach for one resident reviewed for hydration. | Level D |
| Failed to ensure two residents received adequate assistance and support from social services; missed multiple specialty appointments. | Level D |
| Failed to ensure menu was followed to provide appropriate nutrition and notify dietician for substituted food; residents served meals not on menu and missing items such as bacon. | Level F |
| Failed to provide meals prepared by methods that conserve nutritive value, flavor, and appearance; meals served on undivided plates with food items touching. | Level F |
| Failed to maintain kitchen in a clean and sanitary condition; multiple areas dirty, grime, rust, and food debris observed. | Level F |
| Failed to properly maintain dumpster area; trash and debris present with potential for pests and rodents. | Level F |
| Failed to promptly fix water leak problems resulting in mold in resident rooms and common areas; mold testing showed elevated mold in some rooms. | Level F |
| Failed to follow code of conduct by not maintaining accurate documentation and providing false documentation. | Level C |
Report Facts
Resident census: 93
Residents on mechanical soft diet: 89
Residents on puree diet: 5
Employee files missing: 2
Resident trust fund accounts managed: 87
Rooms tested for mold: 17
Rooms tested for mold: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN AAA | Registered Nurse | Provided code of conduct in-service and documentation |
| LPN QQ | Licensed Practical Nurse | Named in medication self-administration deficiency |
| Financial Counselor | Named in resident trust fund and misappropriation findings | |
| Administrator | Facility Administrator | Named in multiple findings including elopement, specialty services, and kitchen maintenance |
| DHS | Director of Health Services | Named in multiple findings including elopement and employee file issues |
| Dietary Manager | Named in findings related to menu substitutions and kitchen cleanliness | |
| Registered Dietitian | Named in findings related to enteral feeding and menu substitutions | |
| Maintenance Director | Named in findings related to mold and maintenance issues | |
| Social Service Director | Named in specialty services and documentation findings |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 23, 2023
Visit Reason
A State Licensure revisit desk review survey was conducted to review deficiencies recited from the original Complaint Investigation on June 23, 2023.
Findings
The facility failed to follow the Plan of Correction and document neurological checks for one of two sampled residents related to notification of change after a witnessed or unwitnessed fall. Interviews revealed the facility does not perform neurological checks on witnessed falls despite prior in-service training indicating otherwise.
Complaint Details
This revisit survey was conducted following an original Complaint Investigation on June 23, 2023. The revisit revealed deficiencies recited from that complaint investigation.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document neurological checks for one of two sampled residents related to notification of change after a witnessed or unwitnessed fall. | SS= D |
Report Facts
Date of witnessed fall: Aug 7, 2023
Date of original complaint investigation: Jun 23, 2023
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 2
Aug 23, 2023
Visit Reason
The revisit desk review survey was conducted to determine if Pruitthealth West Atlanta was in substantial compliance with Medicare/Medicaid regulations following a prior survey.
Findings
The facility was found not in substantial compliance due to failure to follow the Plan of Correction and document neurological checks after a witnessed fall for one sampled resident. The facility also failed to implement effective corrective action plans related to notification of change after falls.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow the Plan of Correction and document neurological checks for one of two sampled residents related to notification of change after a witnessed or unwitnessed fall. | SS= D |
| Failure to implement corrective action plans that effectively addressed notification of change related to falls for one of two sampled residents. | SS= D |
Report Facts
Census: 66
Date of fall incident: Aug 7, 2023
Date of in-service: Jun 23, 2023
Inspection Report
Complaint Investigation
Census: 65
Capacity: 120
Deficiencies: 7
Aug 14, 2023
Visit Reason
A Life Safety Code and Complaint Investigation Survey was conducted on 8/14/23 investigating Complaint Number GA00237796 to assess compliance with Medicare/Medicaid participation requirements and related fire safety codes.
Findings
The facility was found not in substantial compliance with fire safety requirements including missing kitchen suppression system service tags, fire alarm system in trouble mode, loaded sprinklers in the laundry room, resident room doors with holes compromising smoke resistance, drilled holes in smoke/fire barriers, exposed wiring in an electrical box, and failure to document required fire drills for several months.
Complaint Details
Complaint Number GA00237796 was investigated during the survey. The facility was found not in substantial compliance with fire safety and life safety code requirements.
Severity Breakdown
D: 6
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain required service record tags for kitchen suppression system. | D |
| Fire alarm system was in trouble mode and failed to maintain optimum readiness. | E |
| Sprinklers in the laundry room were loaded, potentially delaying activation. | D |
| Resident room doors had holes near door handles compromising smoke resistance. | D |
| Drilled hole through fire/smoke barrier allowing smoke passage between compartments. | D |
| Exposed wiring in electrical box in pantry not secured to protect against shock. | D |
| Facility failed to document required fire drills for several months during the last year. | D |
Report Facts
Smoke Compartments affected: 1
Certified beds: 120
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during the tour and interviews. | |
| Staff A | Confirmed multiple findings during the tour and interviews. |
Inspection Report
Annual Inspection
Deficiencies: 1
Jun 23, 2023
Visit Reason
A State Licensure survey was conducted at Pruitthealth West Atlanta from June 21, 2023 through June 23, 2023 to assess compliance with state health regulations.
Findings
The survey revealed a deficiency where the facility failed to notify the Medical Doctor, Nurse Practitioner, or Responsible Party for one of four residents reviewed for falls, potentially delaying or preventing treatment. Interviews and record reviews confirmed lack of notification despite policy requirements.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify Medical Doctor, Nurse Practitioner, or Responsible Party of a resident's fall. | SS= D |
Report Facts
Residents reviewed for falls: 4
Date of fall incident: Jun 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CC | Unit Manager | Interviewed regarding fall policy and notification failure |
| DD | Licensed Practical Nurse | Interviewed; took vital signs and neurological checks but did not notify MD/NP or RP |
| FF | Licensed Practical Nurse Charge Nurse | Interviewed; had fall policy training but was unsure if MD/NP or RP were notified |
Inspection Report
Abbreviated Survey
Census: 97
Deficiencies: 1
Jun 23, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaints GA00236237 and GA00236414. The survey was initiated on 2023-06-21 and concluded on 2023-06-23.
Findings
Complaint Intake GA00236414 was substantiated with no deficiencies cited. Complaint Intake GA00237236 was substantiated with deficiencies cited related to failure to notify the Medical Doctor, Nurse Practitioner, or Responsible Party for one resident who fell, potentially delaying treatment.
Complaint Details
The survey investigated complaints GA00236237 and GA00236414. GA00236414 was substantiated with no deficiencies cited. GA00237236 was substantiated with deficiencies cited.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to notify the Medical Doctor, Nurse Practitioner, or Responsible Party for one of four residents reviewed for falls, potentially delaying treatment. | SS= D |
Report Facts
Facility census: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DD | Nurse Supervisor | Mentioned in relation to shift medication count and fall notification |
| FF | Licensed Practical Nurse (LPN) Charge Nurse | Mentioned regarding fall policy training and notification procedures |
| CC | Unit Manager, East Wing | Interviewed about fall policy and notification procedures |
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 18, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - WEST ATLANTA, indicating a regulatory inspection was conducted.
Findings
The document contains initial comments but does not provide detailed findings or deficiencies.
Inspection Report
Follow-Up
Census: 88
Deficiencies: 0
Apr 18, 2023
Visit Reason
A revisit survey was conducted on 4/18/2023 to verify correction of deficiencies cited during the COVID-19 Focused Infection Control survey completed on 3/9/2023.
Findings
All deficiencies cited as a result of the COVID-19 Focused Infection Control survey were found to be corrected. The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Report Facts
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 3
Mar 9, 2023
Visit Reason
The inspection was conducted as a complaint survey from 2/21/2023 through 3/9/2023 to investigate multiple complaint numbers related to the facility.
Findings
The facility was found deficient in several areas including failure to complete discharge summaries and post-discharge plans for residents, failure to provide proper notice of involuntary transfer or discharge to residents and their families, failure to notify the Ombudsman of resident discharges and transfers, and failure to promptly investigate and resolve grievances related to missing clothes for residents.
Complaint Details
The visit was complaint-related, investigating complaint numbers GA00226630, GA00227689, GA00227789, GA00228437, and GA00229360. The complaints involved issues with discharge procedures, notification failures, and unresolved grievances about missing resident clothes.
Severity Breakdown
SS= D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to complete discharge summaries including recapitulation of stay, post discharge plan of care, or final summary for two of four residents reviewed for discharge. | SS= D |
| Failure to provide written notice of involuntary transfer or discharge to one of four residents reviewed and failure to notify the Ombudsman of four residents' discharges or transfers. | SS= D |
| Failure to make prompt efforts to investigate and/or resolve grievances of missing clothes for three residents. | SS= D |
Report Facts
Complaint numbers investigated: 5
Residents reviewed for discharge: 4
Residents with missing grievance resolution: 3
Discharge dates: Examples include 7/25/2022 for R#7, 7/28/2022 for R#11, 8/8/2022 for R#13, 9/9/2022 for R#14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| EE | Senior Nurse Consultant | Interviewed regarding discharge planning and failure to complete discharge summaries. |
| BB | Administrator | Interviewed regarding discharge procedures and notification failures. |
| GG | Licensed Practical Nurse (LPN) | Interviewed regarding resident dialysis and admission status. |
| Social Service Director (SSD) | Social Service Director | Interviewed regarding grievance procedures and missing items. |
| Laundry Supervisor | Interviewed regarding missing items grievance process and records. |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 5
Mar 9, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaints related to the facility.
Findings
The facility was found in compliance with infection control regulations but had substantiated deficiencies related to grievance investigations for missing clothes, discharge planning failures including lack of discharge summaries and notices, failure to notify the Ombudsman of discharges/transfers, failure to provide necessary behavioral health services to a resident, and food safety and hygiene violations in the dietary department.
Complaint Details
The complaint investigation involved multiple complaint numbers (GA00226630, GA00227689, GA00227789, GA00228437, GA00229360, GA00233135). Complaints GA00226630 and GA00227689 were substantiated with deficiencies cited. The others were substantiated with no deficiencies cited.
Severity Breakdown
Level D: 4
Level F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to make prompt efforts to investigate and resolve grievances of missing clothes for three residents. | Level D |
| Failed to complete discharge summaries and post discharge plans for two residents. | Level D |
| Failed to issue Notice of Involuntary Transfer or Discharge and notify Ombudsman for four discharged/transferred residents. | Level D |
| Failed to provide necessary behavioral health services to a resident with worsening behaviors and refusal of care. | Level D |
| Failed to maintain proper food temperatures and ensure non-dietary staff wore hair restraints in the kitchen. | Level F |
Report Facts
Resident census: 87
Number of residents with missing clothes grievances: 3
Number of residents reviewed for discharge planning deficiencies: 4
Number of residents affected by Ombudsman notification failure: 4
Number of residents affected by behavioral health service failure: 1
Number of residents affected by food safety deficiencies: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator BB | Administrator | Named in relation to discharge planning and Ombudsman notification deficiencies |
| Social Service Director (SSD) | Social Service Director | Named in relation to grievance investigations and discharge planning |
| Licensed Practical Nurse GG | Licensed Practical Nurse | Interviewed regarding resident R#11's admission and dialysis |
| Cook KK | Cook | Observed taking food temperatures during meal service |
| Dietary Manager (DM) | Dietary Manager | Interviewed regarding food temperature and kitchen hygiene deficiencies |
| Senior Nurse Consultant EE | Senior Nurse Consultant | Interviewed regarding discharge planning deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 28, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - WEST ATLANTA, summarizing deficiencies identified during the inspection completed on 07/28/2022.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies within the provided page.
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Jul 28, 2022
Visit Reason
A revisit survey was conducted on July 27-28, 2022 to verify correction of deficiencies cited during the May 20, 2022 Recertification and Complaint Investigation Survey.
Findings
The deficiency cited in the previous survey was found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jul 28, 2022
Visit Reason
An unannounced complaint survey was conducted from 7/27/22 through 7/28/22 investigating complaint number GA00225617. The survey included a revisit and focused on allegations related to resident care and facility conditions.
Findings
The investigation found all allegations unsubstantiated based on observations, record reviews, and interviews. Residents appeared clean and well cared for, staffing was sufficient, and no odors or pests were observed. The complaint resident had been discharged prior to the survey.
Complaint Details
Complaint number GA00225617 was investigated and found unsubstantiated for all allegations including physical environment, quality of care, nursing services, and supplies.
Deficiencies (5)
| Description |
|---|
| Unsubstantiated findings for physical environment - pets in the facility |
| Unsubstantiated findings for quality of care/treatment - resident wet and soiled |
| Unsubstantiated findings for nursing services - inadequate staffing |
| Unsubstantiated findings for quality of care treatment - ADL care |
| Unsubstantiated findings for physical environment - insufficient supplies of linen |
Inspection Report
Original Licensing
Deficiencies: 0
May 20, 2022
Visit Reason
Licensure survey conducted from May 16, 2022 through May 20, 2022 to determine compliance with State Long Term Care Requirements.
Findings
No State Health Deficiencies were cited during the licensure survey.
Inspection Report
Life Safety
Census: 85
Capacity: 120
Deficiencies: 0
May 19, 2022
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 substantial compliance with the Life Safety Code requirements and the Emergency Preparedness Program was also in substantial compliance with LTC 42 CFR § 483.73.
Report Facts
Census: 85
Certified beds: 120
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 0
Mar 9, 2021
Visit Reason
A COVID-19 Focus Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaint #GA00212562.
Findings
The complaint was unsubstantiated, no regulatory violations were cited, and the facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices.
Complaint Details
Complaint #GA00212562 was investigated and found to be unsubstantiated.
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Feb 11, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations identified by codes GA00207850, GA00207035, GA00211938, GA00201187, GA00206020, GA00206307, GA00206019, and GA00211551.
Findings
Several complaint investigations were unsubstantiated with no deficient practices found, while two were substantiated without deficiencies.
Complaint Details
Investigations for GA00211938, GA00201187, GA00206020, GA00206307, GA00206019, and GA00211551 were unsubstantiated with no deficient practice. Investigations for GA00207035 and GA00207850 were substantiated without deficiencies.
Report Facts
Resident Census: 63
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 24, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints identified by numbers GA00199020, GA00199333, GA00200290, GA00200588, and GA00201185.
Findings
The complaints investigated during the survey were unsubstantiated, and no regulatory violations were found.
Complaint Details
Complaints #GA00199020, GA00199333, GA00200290, GA00200588, and GA00201185 were investigated and found to be unsubstantiated with no regulatory violations.
Inspection Report
Routine
Census: 87
Deficiencies: 0
Sep 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was 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: 93
Deficiencies: 0
Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 101
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Oct 29, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 8/21/19 Complaint Survey.
Findings
All deficiencies cited as a result of the 8/21/19 Complaint Survey were found to be corrected.
Inspection Report
Re-Inspection
Census: 92
Deficiencies: 0
Aug 21, 2019
Visit Reason
A revisit survey was conducted from 8/12/19 to 8/21/19 to verify correction of deficiencies cited in the Abbreviated/Partial Extended Survey conducted on 6/27/19 to 6/28/19.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Abbreviated Survey
Census: 92
Deficiencies: 2
Aug 21, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint numbers GA00198180, GA00198255, and GA00198556.
Findings
The facility failed to develop comprehensive care plans for urinary catheter use for two residents and urinary incontinence for one resident. Additionally, the facility failed to ensure urinary catheters were properly secured to prevent urethral traction for two residents, increasing risk of infection and injury.
Complaint Details
Complaint number GA00198180 was substantiated with no deficiencies cited. Complaint number GA00198556 was unsubstantiated but a related health deficiency was cited. Complaint number GA00198255 was partially substantiated with two related health deficiencies cited.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a care plan for urinary catheter use for two residents (R#7 and R#13) and for urinary incontinence for one resident (R#3). | Level D |
| Failed to ensure urinary catheters were secured to the leg to prevent urethral traction for two residents (R#7 and R#13). | Level D |
Report Facts
Residents reviewed for urinary catheter use: 3
Residents reviewed for urinary incontinence: 3
Urine culture and sensitivity dates: Jul 5, 2019
Urine culture and sensitivity dates: Jun 18, 2019
Urine culture and sensitivity dates: Jul 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) Case Mix Director (CMD) AA | Interviewed regarding lack of catheter and incontinence care plans. | |
| Licensed Practical Nurse (LPN) DD | Verified catheter securement issues for resident R#7. | |
| Certified Nursing Assistant (CNA) BB | Observed performing catheter care for R#7. | |
| Certified Nursing Assistant (CNA) CC | Assisted CNA BB during catheter care for R#7. | |
| Certified Nursing Assistant (CNA) EE | Observed performing catheter care for R#13. | |
| Registered Nurse Clinical Competency Coordinator and Infection Control Nurse | Interviewed regarding catheter care inservice. |
Inspection Report
Routine
Deficiencies: 4
Aug 21, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care requirements, specifically focusing on the development and implementation of care plans for urinary catheter use and urinary incontinence among residents.
Findings
The facility failed to develop care plans for urinary catheter use for two residents and for urinary incontinence for one resident. Additionally, the facility did not ensure that urinary catheters were properly secured to prevent urethral traction, and urinary drainage bags were improperly positioned, increasing the risk of infection.
Deficiencies (4)
| Description |
|---|
| Failed to develop a care plan for urinary catheter use for two residents (R#7 and R#13). |
| Failed to develop a care plan for urinary incontinence for one resident (R#3). |
| Failed to ensure urinary catheters were secured to the leg to prevent urethral traction for two residents (R#7 and R#13). |
| Urinary drainage bags were improperly positioned on the floor, increasing risk of contamination and catheter-associated urinary tract infection (CAUTI). |
Report Facts
Residents reviewed for urinary catheter use: 3
Residents reviewed for urinary incontinence: 3
BIMS score: 6
Date of hospital discharge summary: Jun 30, 2019
Date of urine culture and sensitivity: Jul 5, 2019
Date of nursing progress note: Jul 10, 2019
Date of hospital medical discharge summary: Jul 16, 2019
Date of hospital History and Physical: May 7, 2019
Date of urine culture and sensitivity: Jun 18, 2019
Date of urine culture and sensitivity: Jul 25, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) Case Mix Director (CMD) | Interviewed regarding lack of catheter and incontinence care plans for residents. |
| BB | Certified Nursing Assistant (CNA) | Observed performing catheter care for Resident #7 without securing catheter tubing. |
| CC | Certified Nursing Assistant (CNA) | Assisted CNA BB during catheter care for Resident #7. |
| DD | Licensed Practical Nurse (LPN) | Interviewed and verified catheter securement issues and provided catheter care observations. |
| EE | Certified Nursing Assistant (CNA) | Observed performing catheter care for Resident #13 and acknowledged need for catheter strap. |
| Registered Nurse Clinical Competency Coordinator and Infection Control Nurse | Interviewed about inservice given on catheter care. |
Inspection Report
Complaint Investigation
Deficiencies: 10
Jul 27, 2019
Visit Reason
The inspection was conducted as a Complaint Investigation from July 27 to July 28, 2019, to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to maintain a safe, clean, and comfortable environment, with numerous observations of damaged walls, torn floor mats, stained privacy curtains, broken fixtures, and non-functioning air conditioning units. Communication and reporting processes for maintenance issues were ineffective, with no formal work order system in place and no preventative maintenance policy provided.
Complaint Details
The visit was complaint-related, conducted to investigate compliance with State Long Term Care Requirements. Specific complaints included maintenance issues and environmental sanitation concerns. Substantiation status is not explicitly stated.
Deficiencies (10)
| Description |
|---|
| Floor mat in room 106 had a large tear exposing foam. |
| Resident's window sill in room 108 had a crack; walls were gouged, marred, and scarred; bathroom door wall cracked and rusted; baseboard peeling. |
| Sofa blocking egress door in East Wing common area. |
| Air conditioning unit in room 116 not functioning; no temperature control knobs; resident uncomfortable. |
| Walls in multiple rooms marred, scarred, cracked, or peeling; privacy curtains stained or missing; broken or missing furniture and fixtures throughout various rooms. |
| Electrical outlet without cover and exposed wires in room 121. |
| Bathroom plumbing leaking into resident basin in room 202; basin near overflowing. |
| Light in bathroom not working in room 215 for several days. |
| No effective work order system; maintenance concerns communicated verbally; no documented timeline for repairs. |
| Facility unable to provide policy for preventative maintenance process and schedule. |
Report Facts
BIMS score: 9
BIMS score: 15
BIMS score: 12
Date: May 22, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to maintenance issues and communication failures | |
| East Wing Unit Manager | Confirmed bottle of water should not be on electrical outlet | |
| Administrator | Interviewed regarding maintenance reporting and repair plans | |
| Corporate Representative | Maintenance Services | Interviewed about maintenance rounds and issue resolution |
| Housekeeping Supervisor | Interviewed about cleaning routines and communication of maintenance concerns |
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 2
Jun 28, 2019
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00197698, which was substantiated with deficiencies.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment in 34 out of 52 resident rooms, with issues including torn floor mats, damaged walls, broken furniture, nonfunctioning air conditioning units, stained privacy curtains, and plumbing leaks. Additionally, the facility lacked an effective quality assurance process to address these maintenance concerns, with poor communication and no documented plan or timeline for repairs.
Complaint Details
The survey was initiated based on complaint GA00197698, which was substantiated with deficiencies related to environmental safety and maintenance.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure a safe, clean, comfortable, homelike environment for 34 out of 52 resident rooms, including torn floor mats, damaged walls, broken furniture, stained privacy curtains, and nonfunctioning air conditioning units. | E |
| Facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to address maintenance concerns and repairs throughout the facility. | E |
Report Facts
Resident census: 96
Resident rooms inspected: 52
Rooms with deficiencies: 34
BIMS score: 9
BIMS score: 15
BIMS score: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Maintenance Director | Interviewed regarding maintenance issues, reporting processes, and repair documentation |
| Administrator | Administrator | Interviewed regarding facility maintenance plans and quality assurance processes |
| Corporate Representative | Corporate Representative for Maintenance Services | Interviewed about maintenance rounds, communication, and issue resolution timelines |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning routines and communication of maintenance concerns |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 17, 2019
Visit Reason
A complaint survey was conducted from 2019-06-13 to 2019-06-17 to investigate complaint GA00197406 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA00197406 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 21, 2019
Visit Reason
A desk revisit was conducted to verify correction of deficiencies cited during the Recertification Survey of 2019-01-31.
Findings
All deficiencies cited as a result of the Recertification Survey of 2019-01-31 were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Mar 18, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 99
Capacity: 120
Deficiencies: 5
Jan 31, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements, including deficiencies in fire alarm system installation and maintenance, sprinkler system maintenance, corridor and smoke barrier doors not properly resisting smoke passage, and fire doors not closing properly. These deficiencies could place residents and staff at risk in the event of fire.
Severity Breakdown
F: 3
D: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Fire alarm system had omitted horn/strobe notification devices and two fire alarm pull stations needed relocating to meet code requirements. | F |
| Fire Alarm Control Panel was in a Trouble Condition, beeping and flashing. | F |
| Fire sprinkler system had a loaded sprinkler head in the laundry and a missing sprinkler escutcheon plate in the conference room. | D |
| Several resident room doors would not close to latch, compromising smoke resistance. | F |
| Fire doors on the East wing entrance were not closing properly/completely to resist smoke. | D |
Report Facts
Census: 99
Total Capacity: 120
Residents at risk: 30
Residents at risk: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and inspection |
Inspection Report
Re-Inspection
Census: 90
Deficiencies: 0
Dec 6, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint survey completed on 2018-10-01.
Findings
All deficiencies cited in the prior complaint survey were found to be corrected during this revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey for GA00191451, GA00191471, GA00191079, and GA00191004 completed on 2018-10-01.
Report Facts
Census: 90
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2018
Visit Reason
A complaint survey was conducted on 7/18/2018 through 7/19/2018 to investigate complaints GA00190028, GA00190038, and GA00189472 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
The complaint was unsubstantiated with no deficiencies found during the investigation.
Complaint Details
Complaints GA00190028, GA00190038, and GA00189472 were investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 11, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the April 11, 2018 Complaint Survey GA 00186930.
Findings
All deficiencies cited as a result of the April 11, 2018 Complaint Survey were found to be corrected.
Complaint Details
The revisit survey was conducted following a complaint survey dated April 11, 2018. The deficiencies from that complaint survey were corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 25, 2018
Visit Reason
A follow-up survey was conducted to verify correction of all deficiencies cited during the Standard Survey of 3/1/18.
Findings
It was determined that all deficiencies cited during the Standard Survey of 3/1/18 had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Apr 19, 2018
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
Complaint Investigation
Census: 92
Deficiencies: 2
Mar 1, 2018
Visit Reason
A standard survey was conducted from February 26, 2018 to March 1, 2018, including investigation of Complaint Intake Number GA00185191, to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with regulations related to drug regimen review and psychotropic drug use. Specifically, the facility failed to ensure monthly pharmacist drug regimen reviews for two residents and failed to report antipsychotic drug irregularities, including lack of supporting diagnoses and absence of gradual dose reduction attempts.
Complaint Details
Complaint Intake Number GA00185191 was investigated in conjunction with the standard survey. The complaint involved concerns about medication regimen reviews and psychotropic drug use.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure drug regimens for two of 38 sampled residents were reviewed monthly by a licensed pharmacist with documentation of significant findings. | Level D |
| Failure to report antipsychotic drug regimen irregularities, including lack of supporting diagnoses and failure to attempt gradual dose reduction for one resident. | Level D |
Report Facts
Resident census: 92
Sampled residents: 38
Residents with medication review failures: 2
Medication review dates: 2
PRN psychotropic drug order limit: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| GG | Consultant Pharmacist | Named in relation to failure to conduct monthly medication reviews and report irregularities |
| FF | Nurse Practitioner | Interviewed regarding medication regimen review frequency and psychotropic drug use |
| MM | Licensed Practical Nurse | Provided information on resident behaviors related to medication use |
| HH | Psychiatric Nurse Practitioner | Attempted interview regarding psychotropic medication orders |
Inspection Report
Original Licensing
Deficiencies: 0
Mar 1, 2018
Visit Reason
The inspection was conducted as a licensure survey for the facility.
Findings
No deficiencies were identified during the licensure survey conducted on March 1, 2018.
Inspection Report
Life Safety
Census: 92
Capacity: 120
Deficiencies: 4
Feb 27, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) 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 and resident room door closures, smoke barrier construction, and smoke door functionality, which could place staff and residents at risk in the event of fire.
Severity Breakdown
E: 2
D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Missing sprinkler escutcheon plate in Conference room, painted sprinkler head and escutcheon in Kitchen, loaded sprinkler heads in Kitchen and Kitchen Breakroom, and sprinkler head needing adjusting in dining hall. | E |
| Several resident room doors (#112, 224, 220, 213) would not close to latch as required to resist smoke passage. | E |
| Smoke wall partition above smoke doors near the front entrance were not sealed to resist the passage of smoke. | D |
| Main corridor smoke door would not close properly upon fire alarm activation to resist the passage of smoke. | D |
Report Facts
Staff and residents at risk: 60
Staff and residents at risk: 64
Census: 92
Total licensed beds: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and staff interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 10, 2018
Visit Reason
A complaint survey was conducted on 1/10/18 to investigate complaint GA 00183191 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint GA 00183191 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 18, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00179659 to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00179659 was investigated and found to have no deficiencies.
Inspection Report
Follow-Up
Deficiencies: 0
Aug 15, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags had been corrected.
Inspection Report
Routine
Census: 99
Deficiencies: 0
Jun 29, 2017
Visit Reason
A Standard Survey was conducted at Pruitt Health West, Atlanta Georgia from June 26th, 2017 through June 29th, 2017 to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.
Findings
The Standard survey revealed the facility was in substantial compliance with Medicare/Medicaid regulations.
Inspection Report
Life Safety
Census: 108
Capacity: 124
Deficiencies: 6
Jun 27, 2017
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to multiple fire safety deficiencies including failure to maintain emergency lighting, sprinkler system maintenance issues, corridor doors not latching properly, smoke barrier construction deficiencies, fire/smoke doors not sealing properly, and electrical panel labeling issues.
Severity Breakdown
E: 3
D: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to maintain illuminated egress pathway with emergency lighting; emergency lighting units in kitchen and front entrance did not work properly on test mode. | E |
| Failed to maintain sprinkler system to full readiness; issues included missing sprinkler escutcheon plate, loaded sprinkler head, and a yellow tagged system not addressed. | E |
| Failed to assure limiting of smoke spread; several resident doors failed to completely latch closed. | E |
| Failed to assure limitation of smoke spread through fire/smoke barriers; openings not sealed above main entrance smoke doors and 200 hall fire/smoke doors. | D |
| Failed to assure all fire/smoke doors released and closed to seal against smoke spread; main entrance door did not release properly. | D |
| Failed to maintain all electrical requirements; two electrical panel boxes lacked proper circuit labeling for emergency access and control. | D |
Report Facts
Census: 108
Total Capacity: 124
Residents at risk: 70
Residents at risk: 16
Residents at risk: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 20, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176198 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted at Pruitthealth West Atlanta.
Complaint Details
Complaint #GA00176198 was investigated and found to have no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 27, 2017
Visit Reason
The inspection was conducted to investigate multiple complaints (#GA0017422, GA00168645, GA00165148, GA00164703, and GA00162397) at Pruitt Health - West Atlanta to determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey, indicating compliance with the applicable long term care regulations.
Complaint Details
The survey was conducted in response to complaints identified by their numbers, and the findings showed no deficiencies, implying the complaints were not substantiated.
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