PruittHealth - Lithonia, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, record review and review of the facility's policies titled, Foodborne Illness and Labeling, Dating, and Storage facility failed to adequately uphold food safety practices, which could lead to potential foodborne illnesses. Opened food products in the walk-in refrigerator were not appropriately labeled, dated, and discarded. The deficient practices had the potential to place 135 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of facility's policy titled, Foodborne Illnesses reviewed dated 01/8/2021, revealed in Procedure 2. Foods will be used before the expiration date, use by date, and sell by date, indicated on the food item. Foods not used prior to the expiration date, use by date, best by date, or sell by date must be discarded. 3. It is the responsibility of the Dietary Manager to see that dietary employees practice safe and sanitary methods when preparing foods to prevent cross contamination and…

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.

Based on observations, staff interviews, and review of the facility policy titled, Waste Disposal: Dietary Services, the facility failed to ensure the outdoor garbage and refuse area was free of litter by being maintained in a sanitary manner. Findings include:Review of the facility policy titled Waste Disposal: Dietary Services reviewed dated 10/20/2025 revealed under Procedure: 6. Dumpster lids, doors, and plugs should be kept closed at all times. 7. Dumpster and surrounding areas should be kept clean and free of debris. During the initial observation of the dumpster on 03/18/2026 at 11:58 AM the Dietary Manager (DM)PP confirmed the presence of two dumpsters. The dumpster adjacent to the brick wall; left door was observed to be completely open, overflowing with clear trash bags protruding from the left door. Observation indicated the presence of one compressed empty box, purple gloves, remnants of straws, and several white surgical face masks surrounding the two dumpsters. Interview on 03/18/2026, at 11:59 AM was conducted with the DM PP, who acknowledged the presence of trash and…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, staff interviews, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure respiratory equipment was maintained in a clean and sanitary manner by not cleaning the oxygen concentrator filter for one resident (R) (R69) out of 12 residents on respiratory care. This deficient practice had the potential to cause ineffective oxygen delivery, respiratory complications, and increased risk of infection.Findings include:Record review of facility's policy titled Oxygen Administration, reviewed on 11/17/2025, revealed the Policy Statement included, It is the policy of [NAME] Health Hospice and Healthcare Centers/Veterans Homes to provide oxygen safely and accurately to appropriate patients/residents. The policy further revealed The large external, black filter should be washed with soap and water once each week and PRN [as needed]. Dry with towel and reinsert. Clean exterior of concentrators weekly and between each patient/resident use with…

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.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage in Healthcare Centers, the facility failed to ensure that medications and biologicals were stored securely on one of eight hallways. This deficient practice had the potential to place the residents and staff at risk of having unauthorized access to medications. Findings include:A review of the facility's policy titled Medication Storage in Health Care Centers, revised March 12, 2026, revealed that medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, certified medication aides, and pharmacy personnel. Observation on 03/18/2026 at 6:10 AM revealed that a medication cart on the G Hall Corridor was unlocked, unattended, and out of direct sight of a nurse. Observation revealed the cart remained unlocked and unattended for three to five minutes. In an interview on 03/18/2026 at 6:15 AM, Registered Nurse (RN) DD confirmed 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.

Based on observation, interview, and review of the policy titled Food Temperatures the facility failed to ensure that the temperature for cold food (orange juice) was maintained at a temperature of 41 degrees ( ) Fahrenheit (F) or less; This deficient practice had the potential to promote the growth of pathogens that cause foodborne illness. This had the potential to effect 134 of the 141 residents receiving an oral diet.Findings include: Review of the policy titled Food Temperatures revised date of 10/21/2025. Policy: It is the policy of __ that the Dietary Manager or designee be responsible for ensuring that all food has reached and continues to maintain proper temperature prior to tray assembly. Procedure: 2. All potentially hazardous cold foods must be held at 41 degrees or less. 12. Potentially hazardous cold food should be held on the line in an ice bath at 41 degrees or below. Cold foods should not be set up on meal trays longer than 15 minutes prior to meal service and must be kept on ice or chilled during tray line/meal service. An observation on 03/5/2026 at 7:29 am 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.

Based on observation, staff interview, and review of the facility's policies titled, Skilled Nursing Services Storage Areas and Skilled Nursing Services Cleaning and Sanitizing, the facility failed to ensure opened food items in the dry storage and the walk-in refrigerator area were securely wrapped, labeled, dated, and discarded by the expiration date. In addition, the facility failed to maintain sanitary cleanliness of the ice maker and prevent wet nesting by ensuring clean pots, pans and baking trays were properly stacked and stored to dry. The facility census was 147 residents. Findings Include: Review of facility's policy titled, Skilled Nursing Services Storage Areas dated 12/29/2023 under the section titled Guidelines revealed, items should be covered, sealed, labeled, and dated appropriately. Under the subsection titled, Ice machines, revealed, ice chest should be cleaned on a routine basis and as needed. Review of facility's policy titled Skilled Nursing Services Cleaning and Sanitizing, dated 12/29/2023 under the section titled Guidelines revealed, All small ware equipment…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, and review of the facility's policy titled, Bedside Storage of Medications, the facility failed to assess one of eight residents (R) (R88) for self-administration of medication and failed to maintain medication in a secure location for one of three residents (R43). The deficient practice had the potential to allow unauthorized access to unsecured medications to residents and visitors at the facility. Findings Include: 1. A review of the undated facility policy titled, Bedside Storage of Medications revealed under section titled Intent, To support self-administration of medication by appropriate patients within the nursing center while facilitating medication security. Under section titled GUIDELINE revealed, The Pharmacy supports bedside medication storage for patients who are able to self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the nursing center's interdisciplinary patient…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff and resident interviews, record reviews, and review of the facility's policy titled, Best Practice for PASRR, the facility failed to screen one of five residents (R) R43 for Pre-admission Screening and Record Review (PASRR) level two. The deficient practice had the potential to cause R43 not to receive care and services in the most integrated setting appropriate to her needs. Findings include: Review of the facility's undated policy titled, Best Practice for PASRR documented There are two areas a person can be a PASRR patient: Significant Mental Illness (SMI) or Intellectual Disability/Developmental Disability (ID/DD) To be included in the PASARR population, a patient must have a SMI, or an ID/DD as determined on their level two assessment. Review of the Electronic Medical Record (EMR) revealed R43 was admitted to the facility with diagnosis that included but not limited to paranoid schizophrenia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented in Section C…

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.

Based on observations, staff interviews, and review of the policy titled, Cleaning of Shared Equipment, the facility failed to clean and disinfect a shared blood pressure cuff before and after use between residents. The deficient practice had the potential to increase the probability of cross transmission of bacteria that could cause infections for residents that the equipment was utilized for. Findings: Review of the facility policy titled, Cleaning of Shared Equipment with a review date of 12/29/2023, revealed that the purpose was to decrease the risk of cross transmission of bacteria that could colonize or infected patients. It was revealed that medical equipment which is shared between patients shall be cleaned with soap and water or other appropriate cleaner and then disinfected prior to and again after its use on another patient. Sharded equipment include but are not limited to blood pressure cuffs and pulse oximeters. An observation on 9/4/2024 at 9:20 am revealed that Certified Nurses Aid (CNA) JJ, removed an electronic blood pressure cuff out of a room and went across 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.

Based on interviews, record review and review of the facility's policies Skilled Nursing Services Grievance/Concern Guidelines for Patients and Missing Items, the facility failed to appropriately resolve grievances and provide a reasonable expected time frame for completing the review of the grievances related to lost personal items for three of 13 sampled residents (R) (R1, R2, and R8). Findings include: Review of facility's policy titled, Skilled Nursing Services Grievance/Concern Guidelines for Patients dated 12/29/2023, under the Policy Statement revealed, It is also the intent of the center to support each patient's right to voice concerns and to assure that after receiving a concern/grievance, we will actively seek a resolution and keep the patient (or representative) apprised of our progress toward resolution . Under the section titled, Guidelines revealed, Patients will be provided with reasonable expected time frames for completion. lf the concern is not resolved within three business days, the administrator /designee should give a written response to the complainant.…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident and staff interviews, the facility failed to offer one of 13 sampled residents (R) (R2) the choice for showers and to facilitate scheduled shower times that would accommodate the needs of the resident. This failure had the potential to affect the resident's comfort, body image and increase the risk for infections. Findings include: Review of R2's face sheet revealed she admitted with the following diagnoses that included bilateral amputee, end stage renal disease on hemodialysis. Review R2's admission Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Pattern, a Brief Interview of Mental Status (BIMS) score of 13 which indicated she was cognitively intact; Section F-Preferences for Customary Routine and Activities indicated it was somewhat important to her to choose what clothes to wear and choose between a tub bath, shower, bed bath or sponge bath. Section GG-Functional Abilities and Goals revealed she was dependent on ADL care needs; Section H-Bladder…

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.

Based on staff and resident interviews, record review and review of the facility's policy titled, Activity of Daily living (ADL) Plan of Care, the facility failed to develop a person-centered care plan for one of 13 sampled residents (R) (R2) related to bath/shower preferences. Findings Include: Review of facility policy for ADL Plan of Care dated 12/29/2023 Intent statement revealed, Develop and communicate patient needs for assistance with an ADLs. Record review of R2's face sheet revealed diagnoses that included bilateral amputee, end stage renal disease on hemodialysis. Review of the admission Minimum Data Set (MDS) for R2's dated 12/4/2023 revealed Section C-Cognitive Pattern, a Brief Interview of Mental Status (BIMS) score of 13 which indicated she was cognitively intact; Section F-Preferences for Customary Routine and Activities indicated it was somewhat important to her to choose what clothes to wear and choose between a tub bath, shower, bed bath or sponge bath. Section GG-Functional Abilities and Goals revealed she was dependent on ADL care needs. Review of facility's ADL…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to have operating mechanical lifts readily available for use to provide care for one of 13 sampled residents (R) (R13) reviewed. Findings include: Review of R13's Annual Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of nine which indicated moderate cognitive impairment, and dependent for all Activities of Daily Living (ADL) needs with use of a mechanical lift; diagnoses included but not limited to arthritis, Alzheimer's Disease, Cerebrovascular Accident, dementia and hemiplegia or hemiparesis. Observation on 3/20/2024 at 9:40 am revealed multiple items on both sides of hallways on all five halls consisting of mechanical lifts not in use at that time with most of them not plugged into the power socket to keep them charged and readily available for use. Observation and Interview on 3/27/2024 at 12:30 pm on hallway B revealed one mechanical lift near R13's room, who was sitting in his wheelchair 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, the facility failed to ensure that the call light was kept within reach for one resident (R) (R #114), of 23 sampled residents. Findings include: A policy related to call light use was requested from the facility, but the facility did not have a policy. A review of R#114's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and muscle weakness. The admission Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15, which indicated the resident had severe cognitive impairment. The resident required extensive assistance by two staff for bed mobility. The resident was totally dependent on two staff for transfers, dressing, and toilet use. The resident required extensive assistance by one staff member for personal hygiene. The care plan dated 5/25/22,…

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.