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PruittHealth - Lilburn

788 Indian Trail Road, Lilburn, GA 30047 · For profit - Limited Liability company · 152 certified beds · (770) 923-2020 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0610) — most recent Sep 20233 immediate-jeopardy citations$59,423 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0610) — most recent Sep 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 3 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $59,423 in federal fines (most recent 2023-09-18)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • about 20% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
656 Indian Trail Lilburn Rd NW · (770) 925-2559 · Call to confirm hours
Pharmacy
1190 Indian Trail Lilburn Rd NW · (770) 638-8958 · Call to confirm hours
Grocery
895 Indian Trail-Lilburn Rd NW · (770) 381-2006 · Call to confirm hours
Park
5075 Lawrenceville Hwy NW · (678) 277-0860 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased1.4%15.3%15.4%better
Long-stay residents who lose too much weight1.3%5.6%5.4%better
Long-stay residents with a catheter left in their bladder0.5%0.9%0.9%better
Long-stay residents with a urinary tract infection1.4%2.5%2.0%better
Long-stay residents with depressive symptoms28.0%11.3%6.5%check this — see note marked dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.2%3.2%3.3%better
Long-stay residents whose ability to walk worsened4.0%15.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.4%20.5%18.9%better
Long-stay residents given the seasonal flu vaccine99.1%95.0%95.3%typical
Long-stay residents with pressure ulcers2.8%5.6%4.7%better
Long-stay residents with worsening bladder/bowel control3.4%15.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.4%19.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.9%2.6%1.4%worse
Short-stay residents given the seasonal flu vaccine95.5%78.4%79.4%better
Short-stay residents rehospitalized after admission33.9%25.0%22.6%worse
Short-stay residents with an outpatient ER visit4.2%11.6%12.0%better

This value is several times the typical-state benchmark. It can be real, or it can be a coding artifact in what the facility submitted. Weigh it against the inspection record above.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

45.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 63 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.9%U.S. median 51.5%
Got home and stayed home
12.7%U.S. median 10.7%
Went back to hospital
0.13U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.9%CMS range 36.0–57.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.7%CMS range 8.4–20.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.54
RN hours/ resident / day
0.62
LPN hours/ resident / day
1.86
Aide hours/ resident / day
3.02
Total nurse hours/ resident / day
0.41
RN hoursweekends
48.9%
Total nursing turnover
56.3%
RN turnover

How full it usually is: this home is certified for 152 beds and averages 118.8 residents a day — about 78% occupied, or roughly 33 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.02 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.54 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.86 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.56 hrs/resident/day on weekends vs 3.21 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.60 to 0.41 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 49% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

7
deficiencies at the latest standard inspection (2025-05-15)
4
at the previous standard inspection (2024-01-18)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

23 citations, most serious first. The 13 most serious are shown; the remaining 10 are one tap away and print in full.

  • Immediate jeopardy · K2023-09-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the facility policy, the facility failed to ensure residents were free from abuse. Specifically, the facility failed to ensure four residents (R) (residents (R9, R14, R25, and one unknown resident) were free from sexual abuse by R10; and eight residents (R15, R11, R19, R20, R16, R17, and R18) were free from physical abuse in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the facility policy titled Prevention of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2023-09-18 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and review of the facility policy, the facility failed to thoroughly report and investigate incidents of abuse. Specifically, the facility failed to report and/or thoroughly investigate incidents of sexual abuse for four residents (R) (residents (R9, R14, R25, and one unknown resident); and of physical abuse for eight residents (R15, R11, R19, R20, R16, R17, R10, R18) in a sample of 35 residents. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · K2023-09-18 · tag F0835 — failed to run the facility competently — pattern
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record review, and review of the Administrator position description, facility Administration failed to effectively oversee an abuse prevention program to promote, foster and maintain an abuse free environment. The facility census was 113. On 9/13/2023 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Facility Administrator was informed of the Immediate Jeopardy (IJ) on 9/13/2023 at 10:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/23/2022. At the time of exit on 9/18/2023, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the IJ remained ongoing. Findings include: Review of the Administrator's position description signed by the Administrator on 2/6/2022 revealed the job purpose is to direct the day-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers .…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-05-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews, record review, and review of the facility's policies titled, Infection Prevention-Hand Hygiene, Infection Control: Glucometer Cleaning and Disinfecting, and Infection Control Prevention and Control Activities, the facility failed to perform hand hygiene and sanitize shared medical equipment while providing care to four residents during medication pass. The facility sample was 63 residents. This failure had the potential to increase the risk of infection transmission among residents and staff. Findings include: Review of the facility's policy titled, Infection Prevention-Hand Hygiene, updated 10/15/2024 revealed the Policy section included D. Indications Requiring Hand Wash or Hand Rub. 1. Before and after contact with the resident. 2. Before donning gloves, including sterile gloves 4. After contact with a resident's intact skin, (i.e., taking blood pressure, pulse, and lifting/turning a resident) .7. Immediately after removal of personal protective equipment (e.g., gloves, gown, facemasks). Review of the facility's policy titled Infection…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility policy, titled, Clean air filters, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters for one room [ROOM NUMBER] out of 18 rooms in B Hall. This deficient practice had the potential to compromise the health and safety of the residents by increasing the risk of infections. Findings Include: 1. A review of the facility's policy, titled Clean air filters, revealed the Steps section was, 2. Remove air filter and inspect for cleanliness. If filter is dirty either wash or replace depending on type of filter. If clean, reinstall filter. An observation on 5/12/2025 at 3:04 pm and 5/14/2025 at 4:42 pm, observed in room [ROOM NUMBER], PTAC filters with grey, fuzzy debris. Interview walking rounds on 5/15/2025 at 9:45 am with the Maintenance Director (MD) confirmed dirty PTAC unit. MD revealed the maintenance staff clean the filters monthly and they keep a log of this; however, they didn't get a chance due…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews the facility failed to document behavior monitoring for two resident(s) (R) (R10 and R56) of 63 sampled residents who required behavior monitoring for psychotropic medication use. Findings include: 1. admission Date: 10/28/2016 with the following pertinent diagnoses: primary generalized (osteo)arthritis, type 2 diabetes mellitus without complications, essential (primary) hypertension, depression, unspecified, anxiety disorder, unspecified, active acute embolism and thrombosis of unspecified deep veins of left lower extremity, other idiopathic peripheral autonomic neuropathy, insomnia, unspecified, pain in left knee, pain in left hand, pain in unspecified knee, pain in left wrist, abrasion, left knee, sequela, and rheumatoid arthritis, unspecified. A review of the quarterly minimum data set (MDS) dated [DATE] revealed Section C - Brief Interview of Mental Status (BIMS) 12, indicating mild cognitive impairment. Section D: indicating mild depressive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-15 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and a review of the facility's policy titled, Care Plans, the facility failed to follow care plan related to (r/t) allergy restrictions concerning chocolate for one resident (R) (R56) out of 63 sample residents. This failure had the potential to result in an adverse allergic reaction. Findings included: Review of the policy titled, Care Plans, dated 2022, indicated, admission Comprehensive Plan of Care - 3. The comprehensive person -centered care plan is developed to include measurable goals and time frames to meet a patient/resident's medical, nursing and psychosocial needs the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. A review of the Electronic Health Record (EHR) for R56 revealed she was admitted on [DATE] and has the following diagnosis but not limited to schizophrenia, dementia, post-traumatic stress syndrome…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and a review of the facility's policy titled, Care Plan the facility failed to update the care plan for resident (R) R30 to accurately reflect the resident's code status for one of 63 sampled residents. This failure had the potential to result in the provision of care that was not aligned with the resident's end-of-life wishes, potentially causing physical and emotional harm. Findings include: Review of the facility policy titled Care Plans, updated 7/27/2023 reveals under Policy .section 7 .Update care plan electronically. When applicable, write a new goal, discontinue approaches and /or add approaches Care Plan Review and Update: 1 .Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals, or approaches should be indicated directly on the care plan .Updates to the care plans should be made with any changes in condition at the time…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, Medication Administration: General Guidelines, the facility failed to administer medications as per physician's orders for two residents of 63 sampled residents. This deficient practice may result in residents not receiving necessary treatment, posing a risk to their health and safety. Findings include: Review of the facility's policy titled: Medication Administration: General Guideline, reveals the Policy statement, Medications are administered as prescribed, in accordance with good nursing principles and practices an only by persons legally authorized to do so .Procedure: .2. Medications are administered in accordance with written orders of the attending physician .9 . The individual records the administration on the patient/resident's MAR at the time the medication is given. At the end of each medication pass, the person administering the medications review the paper MAR or the electronic version…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-15 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews with residents and staff, the facility failed to adhere to documented food preferences and allergy-related restrictions concerning chocolate for one resident (R56) out of 63 sample residents. The facility census was 86. This failure had the potential to result in an adverse allergic reaction, decline in the residents' trust in the facility's ability to meet their dietary needs, thereby impacting overall quality of care and resident safety Findings Include: The facility did not provide a policy related to (r/t) adhering to food preferences and allergy-related restrictions. A review of the Electronic Health Record (EHR) for R56 revealed she was admitted on [DATE] and has the following diagnosis but not limited to schizophrenia, dementia, post-traumatic stress syndrome (PTSD), bipolar disorder and depression. Furthermore, R56's EHR documented a food allergy to chocolate dated 12/8/2020. A review of R56's admission Minimum Data Set (MDS) dated [DATE] documented in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-01-18 · tag F0947 — failed to train nurse aides adequately — pattern
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interviews, record review, and review of the facility's policy and procedures titled Required Training - Partner Education and Tracking and the Alliant Health Solutions Staff development, the facility failed to ensure seven out of 37 Certified Nursing Assistants (CNA) completed the required 12 hours of annual in-service training. Findings include: Review of the facility's policy titled Required Training - Partner Education and Tracking dated 7/15/2016 under section titled, Curriculum(s) and sub-section title Annual revealed, based on job roles, all partners are assigned an annual training curriculum designed to meet federal standards and company expectations. Review of the Alliant CNA Annual Report dated 12/18/2023 for review period 8/1/2022 - 7/31/2023 revealed a staff development review was conducted on 12/18/2023 and problems identified were seven full time Certified Nursing Assistants (CNA) without the required 12 in-service hours per the code of Federal Regulations (42CFR483.35/483.95). Recommendations included, please submit a plan of correction on how the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-18 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record reviews, the facility failed to refer a Level II PASRR (Preadmission Screening and Resident Review) to the appropriate state-designated authority for evaluation and determination of specialized services for one of 43 sampled Residents (R) (R47) reviewed with serious mental illness. This deficient practice has the potential to delay specialized care and treatment for the resident. Findings include: Review of R47's Georgia Department of Medical Assistance PASRR Level 1 Application (DMA-613) Resident Identification Screening Instrument dated 6/3/2022 revealed, the resident did not have a primary diagnosis of Dementia, Serious Mental Illness, or Mental Disorder. Review of R47's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, for Section A: Identification Information, indicated the resident admitted on [DATE], Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment, Section N:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-01-18 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility's policy and procedures titled Specialty [NAME]: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health, the facility failed to assist one of 43 sampled Residents (R) (R101) in gaining access to vision services by making an appointment and arranging transportation. Findings include: Review of the facility's policy titled Specialty [NAME]: Dental Services, Vision Services, Podiatry Services, Hearing Services, and Mental Health dated 12/6/2022, Policy Statement revealed, It shall be the responsibility of this healthcare center to obtain regular and emergency specialty services for each patient/resident to ensure the highest well-being of the residents. The healthcare center has specialty service providers who provides consultation, participates in in-service education, and is available in case of emergency. Interview on 1/16/2024 at 3:54 pm with R101 revealed that he had reported to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 10 citations
  • Potential for harm · Dcited before2024-01-18 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's procedure titled Small Volume Nebulizer, the facility failed to follow infection control measures during the storage of nebulizer equipment for one of two Residents (R) (R9) who receive nebulized medications. Findings include: Review of the facility's procedure titled Small Volume Nebulizer dated 2019 revealed under the section titled, Supplies listed a plastic bag for storing the mouthpiece and tubing when not in use. Under the section titled, Procedure revealed, .17. Dissemble and rinse the SVN (small volume nebulizer) and mouthpiece, shaking out excess moisture. Store the setup in the bag at the bedside. Change the nebulizer cup and tubing according to the facility policy. Observation on 1/16/2024 at 11:40 am of nebulizer set up/mask not in use on R9's nightstand uncovered and unbagged. Observation on 1/16/2024 at 2:08 pm of nebulizer set up/mask not in use on R9's nightstand uncovered and unbagged. Observation on 11/17/2024…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, family interview, and staff interview, the facility failed to notify the resident's representative timely of a fall with injury and hospitalization for one resident (R) (9) of three residents reviewed for change in condition. Findings include: R9 was admitted to the facility on [DATE] with the following diagnoses: vascular dementia, dysphagia, aphasia, and adult failure to thrive. Review of the 4/28/2023 admission Minimum Data Set (MDS) Assessment revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. Review of the 4/29/2023 Progress Note revealed, Resident was found on the floor away from her room and was observed with swelling and blood on her mouth. Prior to the fall, resident was observed wandering on the hall. NP (Nurse Practitioner) .was called and ordered for resident to be sent to the hospital. Resident was transferred to the hospital. No contact listed on the face sheet to be notified. During an interview on 9/12/2023 at 4:19…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-18 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to develop a care plan for two residents (R) (R9 and R10) from a total sample of 35 residents. Specifically, the facility failed to develop a care plan that addressed R9 and R10's wandering behavior that led to elopements from the facility. Findings include: Review of facility policy titled, Elopement Prevention, revised 6/2/2017, revealed, Prior to or at the admission each resident shall be assessed for risk factors for unsafe wandering. An appropriate care plan shall be implemented to address each resident's needs. 1. R9 was admitted to the facility on [DATE] with the following diagnoses: vascular dementia, dysphagia, aphasia, and adult failure to thrive. Review of Progress Notes dated 5/29/2023 and 6/22/2023 revealed R9 had eloped from the facility on these dates. Review of R9's Elopement Risk Observation dated 5/12/2023 revealed an elopement score of 15, indicating high risk for elopement. Review of R9's clinical record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure that audiology orders were implemented, as ordered by the physician, for one resident (R7) from a total sample of 35 residents. Findings include: R7 was admitted to the facility on [DATE] with the following diagnoses: Parkinson's disease and adult failure to thrive. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating R7 was cognitively intact. During an interview on 9/11/2023 at 12:31 p.m., R7 stated, I can't hear because of all the wax in my ear. They got it out one ear but not the other. R7 indicated the facility was supposed to follow up with a different physician but had not. Review of audiology report dated 5/31/2023 revealed, Cerumen was successfully removed from the right ear canal, however, cerumen in the left ear canal could not be removed completely. Recommend Debrox drops and follow up with ENT (ear, nose, throat) physician to remove cerumen…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure adequate supervision for two residents (R) (R9 and R10) from a total sample of 35 residents. Specifically, R9 eloped twice from the facility and R10 eloped twice from the facility and was once found in a neighborhood near the facility. Findings include: 1. R9 was admitted to the facility on [DATE] with the following diagnoses: vascular dementia, dysphagia, aphasia, and adult failure to thrive. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. During an interview on 9/12/2023 at 4:19 p.m., Family of R9 stated R9 had eloped from the facility in May 2023. Review of R9's Elopement Risk Observation dated 5/12/2023, revealed an elopement score of 15, indicating high risk for elopement. Review of the 5/29/2023 Progress Note revealed, Resident was noted wandering outside of the back door of the A Hall, wander guard in place. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-09-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and record review, it was determined that the facility staff failed to maintain infection control during incontinence care for two residents (R29 and R31) of the 35 sampled residents. Findings include: 1. Observation on 9/12/2023 at 6:09 am revealed incontinence care being provided for R31. Certified Nursing Assistant (CNA) HH wiped R31's peri area with the wipes and cleansed the area. CNA HH did not clean the resident from front to back. CNA HH cleaned the front of the peri area in circular motions and cleaned the buttock up and down. The surveyor confirmed with CNA HH the failure to provide incontinent care properly. 2. Observation on 9/11/2023 at 1:32 pm revealed incontinence care being provided for R29. CNA II failed to properly provide incontinent care to R29. Surveyor observed CNA II cleanse the resident with soiled brief. CNA II failed to wash her hands after handling soiled briefs. An interview with CNA II revealed she had not realized she had forgotten to cleanse hands between dirty and clean care. An interview on 9/18/2023 at 9:50 am…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-04-01 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and the manufacturer's recommendations, the facility failed to ensure the proper storage and labeling of four containers of blood glucometer testing strips on four of four medication carts on four of four hallways. The census was 100. Findings include: Review of the manufacturer's recommendations for the Even Care G2 Blood Glucose Test Strips revised 11/2018, revealed under storage and handling, the test strips should be used within six months after opening the container. During an observation of a glucometer check on [DATE] at 8:30 a.m., for R#13 by Licensed Practical Nurse (LPN) AA, the bottle of Even Care G3 blood glucose test strips (Lot 16821093002, Expiration Date [DATE]) on the D hallway medication cart had not been dated or labeled when initially opened, to determine when to discard. Observation of the medication cart on the B hallway on [DATE] at 8:45 a.m., revealed the bottle of Even Care G3 blood glucose strips (Lot 16821128006, Expiration [DATE]) had not been dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-01 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the policy titled, Transfer Policy dated 10/3/19, the facility failed to ensure that the resident, resident representative, and the Ombudsman were provided written notification of transfer for one of two residents (R) (#97) reviewed for hospital transfers. Findings include: Review of the facility policy titled Transfer Policy, dated 10/3/19, revealed the policy did not specify hospital transfers. The policy did not address providing written notification to the resident and/or a resident's legal representative, or the Ombudsman of a transfer or discharge. Review the undated Resident Face Sheet, (resident demographic information), located in the electronic medical record (EMR) revealed that R#97 was admitted to the facility on [DATE] with diagnoses to include poly-osteoarthritis, unspecified acute lower respiratory infection, type 2 diabetes mellitus, muscle weakness, lack of coordination, difficulty walking, pneumonia due to coronavirus disease 2019, COVID-19,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-04-01 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy titled, Bed Hold Acknowledgement Form: Georgia dated 4/23/18, the facility failed to provide one of two residents (R) # 97 a written copy of bed hold notices prior to or within 24-hours of transfer to the hospital. Findings include: Review of the facility policy titled Bed Hold Acknowledgment Form: Georgia dated 4/23/18 revealed, Policy: Bed Holds. Any patient/resident who is transferred or discharged from the healthcare center to be readmitted , in accordance with applicable regulations, including determining that there are no medical care issues that the medical staff believes the healthcare center will be unable to treat. Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. ln cases of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-04-01 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, the facility failed to ensure that staffing information was posted daily and assessable to residents and visitors for two days during the survey 3/29/22 and 3/30/22. The census was 100. Findings include: Observation on 3/29/22 at 1:54 p.m. revealed a plastic holder on the wall at the nurses' station, which held the daily staffing information was empty. Interview conducted on 3/29/22 at 1:54 p.m. with the Human Resources Coordinator (HRC) revealed that she is responsible for posting the daily nurses staffing information but had not had time to complete it today due to providing orientation to new employees. Observation on 3/30/22 at 8:33 a.m. revealed the same plastic holder on the wall at the nurses' station was empty revealing the staffing information was not posted. Interview on 4/1/22 at 2:15 p.m. with the Administrator revealed the HRC had worked in the position for a couple of months and did not know the importance of posting the nurse staffing information daily. The Administrator stated the facility did not have a policy on posting the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$59,423 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $59,423 — penalty dated 2023-09-18
  • Medicare payment denial — starting 2023-09-22 for 56 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to PRUITTHEALTH — 95 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.9-1.9 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 1 of 52.5-1.5 vs chain
Quality measures 4 of 53.6+0.4 vs chain
The other 94 homes this chain runs (chain average 2.9★, per CMS)
1 of 5Oaks - Athens Skilled Nursing, TheAthens, GA 1 of 5PruittHealth - Holly Hill, LLCValdosta, GA 1 of 5PruittHealth- AikenAiken, SC 1 of 5PruittHealth- ColumbiaColumbia, SC 1 of 5PruittHealth- Rock HillRock Hill, SC 1 of 5PruittHealth-Carolina PointDurham, NC 1 of 5PruittHealth-DurhamDurham, NC 1 of 5PruittHealth-TrentNew Bern, NC 1 of 5PruittHealth-Union PointeMonroe, NC 1 of 5Pruitthealth - AustellAustell, GA 1 of 5Pruitthealth - Lakehaven, LLCValdosta, GA 1 of 5Pruitthealth - MaconMacon, GA 1 of 5Pruitthealth - Magnolia ManorMoultrie, GA 1 of 5Pruitthealth - Old CapitolLouisville, GA 1 of 5Pruitthealth - PalmyraAlbany, GA 1 of 5Pruitthealth - SwainsboroSwainsboro, GA 1 of 5Pruitthealth - ToccoaToccoa, GA 1 of 5Pruitthealth - West AtlantaAtlanta, GA 2 of 5NC State Veterans Home-KinstonKinston, NC 2 of 5PruittHealth - AugustaAugusta, GA 2 of 5PruittHealth- BambergBamberg, SC 2 of 5PruittHealth- DillonDillon, SC 2 of 5PruittHealth- EstillEstill, SC 2 of 5PruittHealth- Moncks CornerMoncks Corner, SC 2 of 5PruittHealth- RidgewayRidgeway, SC 2 of 5PruittHealth-NeuseNew Bern, NC 2 of 5Pruitthealth - BrookhavenAtlanta, GA 2 of 5Pruitthealth - CreeksideAugusta, GA 2 of 5Pruitthealth - DecaturDecatur, GA 2 of 5Pruitthealth - FairburnFairburn, GA 2 of 5Pruitthealth - Fleming IslandFleming Island, FL 2 of 5Pruitthealth - ForsythForsyth, GA 2 of 5Pruitthealth - GriffinGriffin, GA 2 of 5Pruitthealth - Richmond, LLCAugusta, GA 2 of 5Pruitthealth - RomeRome, GA 2 of 5Pruitthealth - SavannahSavannah, GA 2 of 5Pruitthealth - Valdosta, LLCValdosta, GA 2 of 5Pruitthealth-North Tampa, LLCLutz, FL 2 of 5The Oaks-BrevardBrevard, NC 3 of 5Christian City Rehabilitation CenterUnion City, GA

Showing 40 of 94; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
SMITH, TONIIndividualW-2 MANAGING EMPLOYEEsince 02/03/2022
PRUITT, NEILIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/24/2007

CMS files one row per role, so the 4 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$11.9M
Net patient revenuemost recent cost report
-4.1%
Operating marginrevenue minus expenses
$2.4M
Related-party expense20% of expenses
Who pays — share of resident-days
Medicaid 71%Medicare 2%Other / private 27%

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 20% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$302per resident / day
operating cost
$9,166per month
≈ monthly operating cost
$290per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in GA

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Georgia Medicaid page.

Typical monthly cost in Georgia
$8,821/mo
Nursing home (semi-private)
$9,429/mo
Nursing home (private)
$5,300/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 115516. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-05-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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