Inspection Report Summary
The most recent inspection conducted on March 20, 2025, found that all previously cited deficiencies from the January 30, 2025 survey were corrected. Earlier inspections showed multiple deficiencies related to infection control practices, environmental sanitation, documentation, and life safety issues such as improperly closing doors and outdated equipment tags. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in July 2024 that did not result in deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed prior deficiencies effectively, showing improvement in recent follow-up inspections.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
6.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
121 residents
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - DECATUR, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Follow-Up
Census: 121
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
A health revisit was conducted from March 19, 2025, through March 21, 2025, to verify correction of deficiencies cited in the recertification survey concluded on January 30, 2025.
Findings
All deficiencies cited in the prior recertification survey were found to be corrected during this revisit.
Inspection Report
Routine
Census: 130
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
A standard routine survey was conducted at Pruitthealth-Decatur from January 28, 2025 through January 30, 2025, including investigation of multiple complaint intake numbers.
Complaint Details
The survey included investigation of complaint intake numbers GA00253253, GA00250969, GA00250847, GA00249451, GA00249313, GA00249086, GA00245378, and GA00242291.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to reconcile POLST and physician orders, unsanitary conditions in resident rooms, failure to submit required PASARR Level II for a resident, expired food items in the kitchen, failure to place a resident with wounds on Enhanced Barrier Precautions (EBP), and failure to perform proper hand hygiene during meal service.
Deficiencies (5)
Failure to assure the correct order was on file and medical records reflect the resident's choice per the Physician Orders for Life Sustaining Treatment (POLST) for two residents.
Failure to maintain two resident rooms in a clean, sanitary manner, including unclean PTAC unit and bathroom with bodily fluids.
Failure to submit for a Preadmission Screening and Resident Review (PASARR) Level II after a new mental illness diagnosis was added for one resident.
Failure to dispose of expired food items in the kitchen, including water bottles, donuts, and various spices.
Failure to place one resident with wounds on Enhanced Barrier Precautions (EBP) and failure to perform hand hygiene while serving meals.
Report Facts
Facility census: 130
Sample size: 55
Expired water bottles: 28
Expired food items: 9
Residents with wounds reviewed: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Social Services Director | Confirmed discrepancies in POLST and physician orders; confirmed PASARR Level II not completed for resident |
| DON | Director of Nursing | Confirmed expectations for order reconciliation and hand hygiene; confirmed discrepancies in POLST and physician orders |
| HD | Housekeeping Director | Confirmed PTAC cleaning procedures and debris found |
| MA AA | Maintenance Assistant | Confirmed PTAC cleaning procedures and debris found |
| MD | Maintenance Director | Described PTAC cleaning schedule and noted recent lack of cleaning |
| HA GG | Housekeeping Aide | Confirmed bodily fluids present and cleaning responsibilities |
| CNA HH | Certified Nursing Assistant | Confirmed nursing staff responsibility to clean bodily fluids |
| LPN JJ | Licensed Practical Nurse | Confirmed failure to sanitize hands during meal service |
| DM | Dietary Manager | Confirmed expired food items in kitchen and hand hygiene expectations |
| KK | Dietary Supervisor | Confirmed hand hygiene expectations in dining room |
| CCC | Clinical Competency Coordinator | Confirmed staff received hand hygiene in-service and discussed EBP placement discretion |
| CNA LL | Certified Nursing Assistant | Observed performing wound care without gown; confirmed resident not on EBP |
| WCN DD | Wound Care Nurse | Observed performing wound care without gown; confirmed resident not on EBP |
| ADON | Assistant Director of Nursing | Confirmed resident with pressure ulcer not on EBP and discussed risks |
Inspection Report
Routine
Census: 130
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident rights, environment, infection control, food safety, and care coordination.
Findings
The facility was found deficient in multiple areas including failure to honor residents' advance directives accurately, maintaining a clean and sanitary environment, failure to submit required PASARR Level II for a resident with mental illness, presence of expired food items in the kitchen, failure to implement proper infection prevention and control practices including hand hygiene and enhanced barrier precautions for residents with wounds.
Deficiencies (5)
Failure to assure the correct order was on file and medical records reflect the resident's choice per the Physician Orders for Life Sustaining Treatment (POLST) for two residents.
Failure to maintain two resident rooms in a clean, sanitary manner, including unclean PTAC units and bathrooms with bodily fluids.
Failure to submit for a Preadmission Screening and Resident Review (PASARR) Level II after a new mental illness diagnosis was added for one resident.
Failure to dispose of expired food items in the kitchen.
Failure to place one resident with wounds on Enhanced Barrier Precautions (EBP) and failure to perform hand hygiene while serving meals.
Report Facts
Residents affected: 2
Facility census: 130
Expired water bottles: 28
Expired food packs: 4
Expired seasoning bottles: 7
Residents affected: 1
Residents affected: 19
Residents affected: 124
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Named in hand hygiene deficiency while serving meals |
| SSD CC | Social Services Director | Interviewed regarding POLST order discrepancies and PASARR referral |
| DON | Director of Nursing | Interviewed regarding expectations for advance directives and expired food removal |
| DM | Dietary Manager | Interviewed regarding expired food items in kitchen |
| WCN DD | Wound Care Nurse | Interviewed regarding Enhanced Barrier Precautions for resident with wounds |
| CNA LL | Certified Nursing Assistant | Observed and interviewed regarding wound care and PPE use |
| CCC | Clinical Competency Coordinator | Interviewed regarding hand hygiene and EBP policies |
| ADON | Assistant Director of Nursing | Interviewed regarding EBP placement for residents with wounds |
Inspection Report
Routine
Census: 130
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, infection control, food safety, and care coordination at Pruitthealth - Decatur nursing home.
Findings
The facility was found deficient in multiple areas including failure to honor residents' advance directives, maintaining a clean and sanitary environment, failure to submit required PASARR Level II for a resident, presence of expired food items in the kitchen, failure to implement proper infection prevention and control practices including hand hygiene and enhanced barrier precautions for residents with wounds.
Deficiencies (5)
Failure to assure the correct physician orders reflected residents' choices per POLST for two residents.
Failure to maintain two resident rooms in a clean, sanitary manner including unclean PTAC unit and bathroom surfaces with bodily fluids.
Failure to submit for a PASARR Level II after a new mental illness diagnosis was added for one resident.
Failure to dispose of expired food items in the kitchen, including water bottles, donuts, and various seasonings.
Failure to place one resident with wounds on Enhanced Barrier Precautions and failure to perform hand hygiene while serving meals.
Report Facts
Residents affected: 2
Facility census: 130
Residents affected: 67
Residents affected: 1
Residents affected: 124
Residents affected: 19
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN JJ | Licensed Practical Nurse | Named in hand hygiene deficiency while serving meals |
| SSD CC | Social Services Director | Interviewed regarding advance directives and PASARR referral |
| DON | Director of Nursing | Interviewed regarding advance directives, expired food expectations, and hand hygiene |
| DM | Dietary Manager | Interviewed regarding expired food items and hand hygiene |
| CNA LL | Certified Nursing Assistant | Observed and interviewed regarding wound care and PPE use |
| WCN DD | Wound Care Nurse | Interviewed regarding wound care and Enhanced Barrier Precautions |
| CCC | Clinical Competency Coordinator | Interviewed regarding hand hygiene and Enhanced Barrier Precautions |
| ADON | Assistant Director of Nursing | Interviewed regarding Enhanced Barrier Precautions for residents with wounds |
| Housekeeping Aide GG | Interviewed regarding cleaning responsibilities for bodily fluids | |
| Housekeeping Manager | Interviewed regarding cleaning responsibilities for bodily fluids | |
| Maintenance Director | Interviewed regarding PTAC cleaning schedule | |
| Administrator | Interviewed regarding PTAC cleaning expectations | |
| Dietary Supervisor KK | Interviewed regarding hand hygiene expectations |
Inspection Report
Life Safety
Census: 71
Capacity: 146
Deficiencies: 4
Date: Jan 30, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance with life safety requirements, including improperly tagged hood system, outdated sprinkler system gauge, patient room doors and smoke/fire doors failing to close properly.
Deficiencies (4)
Facility failed to have the hood system properly tagged.
Facility failed to have the Riser Gauge in the north hall stairwell on the third floor changed out and dated 2013.
Facility failed to have the patient room doors properly close for Rooms 115, 121, 247.
Facility failed to have most of the smoke and fire doors closing properly by room 107.
Report Facts
Smoke compartment areas affected: 10
Certified beds: 146
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Participated in facility tour and confirmed findings |
Inspection Report
Annual Inspection
Census: 131
Capacity: 67
Deficiencies: 3
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Pruitthealth-Decatur.
Findings
The facility was found deficient in infection control practices including failure to place a resident with wounds on Enhanced Barrier Precautions and failure to perform hand hygiene while serving meals. Environmental sanitation issues were noted with unclean PTAC units and bodily fluids in resident bathrooms. Additionally, expired food items were found in the kitchen, posing a risk to resident health.
Deficiencies (3)
Failure to place one of 19 residents with wounds on Enhanced Barrier Precautions and failure to perform hand hygiene while serving meals.
Failure to maintain two resident rooms in a clean, sanitary manner including unclean PTAC unit and bathroom surfaces with bodily fluids.
Failure to dispose of expired food items in the kitchen.
Report Facts
Facility census: 131
Resident rooms: 67
Expired water bottles: 28
Expired food packs: 4
Expired seasoning bottles: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Certified Nursing Assistant | Named in deficiency related to wound care and lack of gown use |
| DD | Wound Care Nurse | Named in deficiency related to wound care and lack of gown use |
| JJ | Licensed Practical Nurse | Named in deficiency related to failure to perform hand hygiene while serving meals |
| MM | Certified Nursing Assistant | Interviewed regarding hand hygiene practices |
| KK | Dietary Supervisor | Interviewed regarding hand hygiene and food safety |
| DM | Dietary Manager | Interviewed regarding expired food items and hand hygiene |
| CCC | Clinical Competency Coordinator | Interviewed regarding wound care and hand hygiene policies |
| ADON | Assistant Director of Nursing | Interviewed regarding wound care and Enhanced Barrier Precautions |
| DON | Director of Nursing | Interviewed regarding hand hygiene and food safety expectations |
| DHS | Director of Health Services | Interviewed regarding cleaning of bodily fluids and housekeeping responsibilities |
| HD | Housekeeping Director | Interviewed regarding cleaning of PTAC units |
| MA AA | Maintenance Assistant | Interviewed regarding cleaning of PTAC units |
| MD | Maintenance Director | Interviewed regarding cleaning schedule of PTAC units |
| HA GG | Housekeeping Aide | Interviewed regarding cleaning of bodily fluids |
| HH | Certified Nursing Assistant | Interviewed regarding cleaning of bodily fluids |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00248321.
Complaint Details
Complaint #GA00248321 was substantiated with no deficiency cited.
Findings
The complaint #GA00248321 was substantiated with no deficiency cited.
Report Facts
Census: 128
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for PRUITTHEALTH - DECATUR, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 137
Deficiencies: 0
Date: Sep 21, 2023
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the August 3, 2023 recertification/complaint survey.
Findings
All deficiencies cited as a result of the August 3, 2023 recertification/complaint survey were found to be corrected.
Inspection Report
Life Safety
Census: 140
Capacity: 146
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards during the survey.
Inspection Report
Routine
Deficiencies: 4
Date: Aug 3, 2023
Visit Reason
A State Licensure survey was conducted at Pruitt Health Decatur from July 31, 2023 through August 3, 2023 to assess compliance with state health regulations.
Findings
The survey revealed multiple deficiencies including failure to ensure Skilled Nursing Facility Advance Beneficiary Notices were signed and dated, failure to provide written transfer notices to residents or their representatives for emergent hospital transfers, inadequate infection control measures related to Transmission Based Precautions, improper laundry handling mixing clean and dirty laundry, and failure to assess residents for self-administration of medications before allowing it.
Deficiencies (4)
Failure to ensure Skilled Nursing Facility Advance Beneficiary Notices (SNFABN) were signed and dated for two of three residents reviewed.
Failure to provide written transfer notice containing all required information to four residents or their representatives for facility initiated emergent hospital transfers.
Failure to ensure infection control measures were appropriately implemented related to Transmission Based Precautions for two residents and failure to keep clean laundry separated from dirty laundry.
Failure to ensure one resident reviewed for self-administration of medications was assessed by the facility to determine if the practice was clinically appropriate.
Report Facts
Residents reviewed for SNFABN: 3
Residents reviewed for emergent hospital transfer: 4
Residents reviewed for Transmission Based Precautions: 2
Total residents in facility: 131
Resident reviewed for self-administration of medications: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Financial Counselor | Interviewed regarding lack of signatures and dates on SNFABN forms and mailing of bed hold notices. | |
| Unit Manager (UM1) | Interviewed about infection control practices and medication self-administration. | |
| Certified Nursing Assistant (CNA8) | Observed entering TBP room without full PPE and interviewed about PPE use. | |
| Director of Health Services (DHS) | Interviewed about staff PPE use and medication self-administration policies. | |
| Housekeeping Supervisor (HKS) | Interviewed about laundry room conditions and mixing of clean and dirty laundry. | |
| Licensed Practical Nurse (LPN9) | Interviewed about transfer forms given to residents or representatives. | |
| Assistant Director of Nursing (ADON) | Interviewed about medication administration and policies against leaving meds at bedside. |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication administration, resident assessments, transfer notifications, respiratory care, infection control, and care planning at Pruitthealth - Decatur nursing home.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, incomplete and untimely Minimum Data Set (MDS) assessments and transmissions, inadequate notification for resident transfers, improper PASARR screening, incomplete care plans, insufficient staffing during resident care leading to a fall, inadequate respiratory equipment maintenance, and lapses in infection control practices including improper use of PPE and laundry handling.
Deficiencies (11)
Failure to ensure one resident was assessed for self-administration of medications before allowing self-administration.
Failure to ensure Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms were signed and dated for two residents.
Failure to provide timely written transfer notices to residents or their representatives for emergent hospital transfers.
Failure to complete comprehensive admission/annual Minimum Data Set (MDS) assessments within required time frames for five residents.
Failure to transmit Minimum Data Set (MDS) assessments within required time frames for nine residents.
Failure to complete and transmit a significant change in status MDS assessment timely for one resident.
Failure to complete PASARR Level I screening correctly for two residents with mental disorders.
Failure to update care plan to reflect required two-person assist for one resident, resulting in a fall.
Failure to provide adequate supervision and staffing during care, resulting in a resident fall.
Failure to clean oxygen concentrator filters and casing and failure to document weekly oxygen tubing changes for five residents.
Failure to ensure proper infection control measures including appropriate use of PPE for residents on Transmission Based Precautions and failure to keep clean laundry separated from dirty laundry.
Report Facts
Residents reviewed for MDS assessments: 16
Residents affected by transfer notice deficiency: 4
Residents affected by respiratory care deficiency: 5
Residents affected by infection control deficiency: 2
Residents affected by PASARR screening deficiency: 2
Residents affected by care plan deficiency: 1
Residents affected by fall due to inadequate staffing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA4 | Certified Nursing Assistant | Named in fall incident where resident R111 fell due to being assisted by one staff instead of two. |
| RN2 | Registered Nurse | Responded to resident R111 fall and confirmed CNA4 was providing care alone. |
| CNA8 | Certified Nursing Assistant | Entered TBP room without full PPE including N95 mask. |
| UM1 | Unit Manager | Interviewed regarding medication self-administration and infection control PPE use. |
| ADON | Assistant Director of Nursing | Interviewed regarding medication self-administration, respiratory care, and infection control. |
| DHS | Director of Health Services | Interviewed regarding medication self-administration, MDS assessments, respiratory care, and infection control. |
| CMD | Case Mix Director | Interviewed regarding incomplete and untransmitted MDS assessments. |
| SSD | Social Services Director | Interviewed regarding PASARR screening deficiencies. |
| DON | Director of Nursing | Interviewed regarding expectations for staff to follow care plans. |
| LPN3 | Licensed Practical Nurse | Interviewed regarding dusty oxygen concentrator. |
| FC | Financial Counselor | Interviewed regarding missing signatures and dates on SNFABN forms and transfer notices. |
| Administrator | Facility Administrator | Interviewed regarding laundry room conditions and staff training. |
| HKS | Housekeeping Supervisor | Interviewed regarding laundry room conditions and mixing of clean and dirty laundry. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 3, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to update a resident's care plan and provide adequate staff assistance, which resulted in a resident fall.
Complaint Details
The complaint investigation found that Resident 111 fell out of bed on 7/22/2023 when a Certified Nursing Assistant provided care alone despite the care plan requiring two-person assistance. The fall was confirmed by staff and family interviews and resulted in minimal harm.
Findings
The facility failed to update the care plan for Resident 111 to reflect the required two-person assist for care, leading to the resident falling when a single staff member provided care. Interviews and record reviews confirmed the care plan was not updated timely and staff did not follow the care plan, resulting in minimal harm to the resident.
Deficiencies (2)
Failed to ensure a Care Plan was updated related to the required number of staff necessary to provide care safely for Resident 111.
Failed to ensure appropriate number of staff members assisted Resident 111 during care, resulting in a fall.
Report Facts
Residents reviewed: 30
Residents affected: 1
Date of fall: Jul 22, 2023
Assessment Reference Date: May 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 4 | CNA | Provided care alone to Resident 111 when fall occurred |
| Registered Nurse 2 | RN | Responded to fall incident and provided assessment |
| Director of Nursing | DON | Interviewed regarding staff expectations to follow care plans |
| Director of Health Services | DHS | Interviewed regarding staff expectations to follow care plans |
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 11
Date: Aug 3, 2023
Visit Reason
A standard survey was conducted at Pruitt Health Decatur from July 31, 2023, through August 3, 2023, including investigation of two complaint intake numbers GA00237451 and GA00236438. The visit was to assess compliance with Medicare/Medicaid regulations and investigate complaints.
Complaint Details
Complaint Intake number GA00237451 was substantiated with deficiencies cited. Complaint Intake number GA00236438 was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies cited including failure to assess residents for self-administration of medications, incomplete Skilled Nursing Facility Advance Beneficiary Notices, failure to provide written transfer notices for hospital transfers, incomplete Minimum Data Set (MDS) assessments, failure to complete Pre-Admission Screening Resident Reviews correctly, failure to update care plans related to staffing for resident safety, failure to ensure appropriate staff assistance during care resulting in a resident fall, failure to clean oxygen concentrators and change tubing weekly, and failure to maintain proper infection control measures related to transmission-based precautions and laundry separation.
Deficiencies (11)
Facility failed to ensure resident R109 was assessed before self-administration of medications.
Facility failed to ensure Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms were signed and dated for residents R132 and R133.
Facility failed to provide written transfer notices for hospital transfers for residents R24, R78, R115, and R119.
Facility failed to complete comprehensive admission/annual Minimum Data Set (MDS) assessments within required timeframes for residents R19, R45, R66, R78, and R120.
Facility failed to transmit significant change in status MDS assessment timely for resident R59.
Facility failed to transmit MDS assessments timely for residents R2, R8, R35, R37, R72, R76, R77, R80, and R91.
Facility failed to complete Level I Pre-Admission Screening Resident Review (PASSAR) correctly for residents R6 and R8 diagnosed with mental disorders.
Facility failed to update care plan to reflect required two-person assist for resident R111 prior to fall incident.
Facility failed to ensure appropriate staff assistance during care for resident R111, resulting in a fall.
Facility failed to clean oxygen concentrators and change oxygen tubing weekly for residents R8, R34, R43, R118, and R120.
Facility failed to ensure proper infection control measures for transmission-based precautions for residents R44 and R84 and failed to keep clean laundry separated from dirty laundry.
Report Facts
Resident census: 131
Deficiencies cited: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA4 | Certified Nursing Assistant | Named in fall incident involving resident R111 |
| RN2 | Registered Nurse | Named in fall incident involving resident R111 |
| UM1 | Unit Manager | Interviewed regarding medication self-administration and infection control |
| ADON | Assistant Director of Nursing | Interviewed regarding medication self-administration and oxygen equipment care |
| DHS | Director of Health Services | Interviewed regarding medication self-administration, MDS assessments, oxygen equipment care, and infection control |
| CMD | Case Mix Director | Interviewed regarding MDS assessments |
| FC | Financial Counselor | Interviewed regarding Skilled Nursing Facility Advance Beneficiary Notice forms and transfer notices |
| SSD | Social Services Director | Interviewed regarding PASSAR forms |
| CNA8 | Certified Nursing Assistant | Interviewed regarding transmission-based precautions breach |
| HKS | Housekeeping Supervisor | Interviewed regarding laundry room conditions |
| Administrator | Interviewed regarding laundry room and staff training | |
| LPN3 | Licensed Practical Nurse | Interviewed regarding oxygen concentrator care |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
A State Licensure survey was conducted at PH Decatur from June 5, 2023 through June 8, 2023 to assess compliance with state health regulations.
Findings
The survey revealed that the facility failed to provide requested medical records within two days to the attorney of one of three residents, violating resident care and treatment requirements.
Deficiencies (1)
Failure to provide requested medical records within two days to the attorney of resident #4.
Report Facts
Number of residents referenced: 3
Days to provide medical records: 2
Survey dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding medical records request process | |
| Nurse Consultant | Interviewed regarding facility's 48-hour requirement to provide medical records |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intakes initiated on June 5, 2023, and concluded on June 8, 2023.
Complaint Details
Multiple complaints were investigated; several were unsubstantiated, some substantiated with no deficiencies cited, and one complaint (GA00231797) was substantiated with a deficiency cited related to failure to provide medical records timely.
Findings
The facility failed to provide requested medical records within two days as required to the attorney of one of three residents (Resident #4). Several complaints were unsubstantiated or substantiated with no deficiencies, but one complaint was substantiated with a deficiency cited related to delayed medical records provision.
Deficiencies (1)
Failure to provide requested medical records within two days to the attorney of Resident #4 as required by facility policy.
Report Facts
Complaint intakes investigated: 16
Days to provide medical records: 2
Dates of medical record requests: Requests made on August 22, 2022, October 4, 2022, and December 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding medical records request process | |
| Nurse Consultant | Interviewed and confirmed 48-hour requirement for medical records provision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 8, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide requested medical records within the required two-day timeframe to the attorney of one resident (R#4).
Complaint Details
The complaint was substantiated based on record review, staff interviews, and policy review. The attorney for resident #4 had requested medical records multiple times starting August 22, 2022, but had not received all requested documents as of the inspection date.
Findings
The facility failed to provide requested medical records within two days as required, despite multiple requests from the resident's attorney. The delay was attributed to the medical records clerk who handled the request no longer being with the facility and no clear reason for the continued delay.
Deficiencies (1)
Failure to provide requested medical records within two days to the resident's legal representative as required.
Report Facts
Days to provide medical records: 2
Date of initial medical records request: Aug 22, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding the process of forwarding medical records requests. |
| Nurse Consultant | Nurse Consultant | Interviewed regarding the 48-hour requirement to provide medical records and the status of the request. |
Inspection Report
Re-Inspection
Census: 94
Deficiencies: 0
Date: Mar 29, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 2/4/2022 Recertification Survey.
Findings
All deficiencies cited as a result of the 2/4/2022 Recertification Survey were found to be corrected.
Inspection Report
Deficiencies: 0
Date: Mar 29, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for PRUITTHEALTH - DECATUR, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 4, 2022
Visit Reason
The inspection was conducted to assess compliance with care standards, specifically focusing on the facility's provision of personal hygiene and grooming assistance to residents.
Findings
The facility failed to provide adequate personal hygiene and grooming assistance to Resident #15, who required limited staff assistance but was observed to have an unshaved beard over several days. Staff interviews revealed inconsistent shaving practices and lack of specific interventions for shaving in the care plan.
Deficiencies (1)
Failure to provide personal hygiene and grooming assistance for Resident #15, specifically failure to shave the resident as needed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Stated shaving should be done as needed and automatically on shower days; not responsible for Resident #15's care usually. |
| EE | CNA | Stated he was supposed to shave residents when needed, especially after showers or bed baths. |
| BB | Licensed Practical Nurse (LPN) | Monitored skin assessments after showers; stated shaving should be done during daily ADL care by CNA. |
| GG | Certified Nursing Assistant (CNA) | Observed Resident #15 needed shaving and stated resident could not shave herself and needed staff assistance. |
| Director of Nursing (DON) | Director of Nursing | Stated staff are supposed to shave residents during ADL care unless refused; noted no intervention for shaving in ADL care plan. |
Inspection Report
Renewal
Deficiencies: 1
Date: Feb 4, 2022
Visit Reason
The inspection was conducted as a Licensure survey to assess compliance with nursing care requirements and other regulatory standards for the facility.
Findings
The facility failed to provide personal hygiene and grooming assistance for Resident #15, who required limited staff assistance according to care plans and assessments. Observations and interviews revealed the resident had not been shaved as needed, and staff did not consistently provide or document shaving care.
Deficiencies (1)
Failure to provide personal hygiene and grooming assistance for Resident #15 as required by the care plan.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Described nursing and CNA responsibilities related to bathing and shaving residents. |
| EE | Certified Nursing Assistant (CNA) | Stated responsibility to shave residents when needed, especially after showers or bed baths. |
| BB | Licensed Practical Nurse (LPN) | Monitored skin assessments and described shaving responsibilities during medication pass. |
| GG | Certified Nursing Assistant (CNA) | Reported resident was independent with grooming but acknowledged resident needed shaving and staff should provide it. |
| Director of Nursing (DON) | Director of Nursing | Explained expectations for shaving during ADL care and acknowledged lack of shaving intervention in care plan. |
Inspection Report
Routine
Census: 109
Deficiencies: 1
Date: Feb 4, 2022
Visit Reason
A standard survey was conducted from January 11, 2022 through January 14, 2022, including investigation of multiple complaint intakes. Further investigation was needed for one complaint but it was not substantiated.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. One complaint required additional document requests but was not substantiated. No regulatory violations were cited related to the complaints.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to provide personal hygiene and grooming assistance for Resident #15, who required limited staff assistance. No regulatory violations were cited related to the complaint investigations.
Deficiencies (1)
Failure to provide personal hygiene and grooming assistance for Resident #15, including failure to shave the resident as needed.
Report Facts
Resident census: 109
Complaint intake numbers: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Provided information about shower assignments and Body Audit Forms |
| EE | Certified Nursing Assistant (CNA) | Stated responsibility for shaving residents when needed |
| BB | Licensed Practical Nurse (LPN) | Monitored skin assessments and discussed shaving responsibilities |
| GG | Certified Nursing Assistant (CNA) | Observed resident and stated shaving was needed but not done |
| Director of Nursing | Director of Nursing (DON) | Explained shaving procedures and responsibilities for ADL care |
Inspection Report
Life Safety
Census: 109
Capacity: 146
Deficiencies: 0
Date: Jan 12, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and related standards at Pruitt Health Decatur.
Findings
The facility was found in compliance with the requirements for participation in Medicare/Medicaid regarding life safety from fire. The first floor was not surveyed due to COVID-19 patient occupancy, but all smoke compartments and doors were fully functional on surveyed floors.
Report Facts
Stories: 4
Construction Type: 2
Certified Beds: 146
Census: 109
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00214267, with an additional complaint #GA00214929 added during the survey process.
Complaint Details
Complaints #GA00214267 and #GA00214929 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
Both complaints #GA00214267 and #GA00214929 were found to be unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Abbreviated Survey
Census: 124
Deficiencies: 0
Date: Mar 10, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint #GA00212577.
Complaint Details
Complaint #GA00212577 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint was unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Routine
Census: 125
Deficiencies: 0
Date: Mar 2, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Census: 129
Deficiencies: 0
Date: Jan 28, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Extended Survey to investigate multiple complaints.
Complaint Details
Complaints GA00209582, GA00209822, and GA00210655 were unsubstantiated. Complaint GA00209178 was substantiated but no Federal citations were issued.
Findings
The facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices. Three complaints were unsubstantiated with no deficiencies cited, and one complaint was substantiated but with no Federal citations written.
Report Facts
Complaints investigated: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2021
Visit Reason
An Abbreviated Partial Extended Survey was conducted from January 4, 2021 to January 7, 2021 to investigate multiple complaints identified by their numbers.
Complaint Details
Complaints #GA 00202779 and #GA 00207530 were substantiated with no regulatory violations. Complaints #GA 00203578, #GA 00208881, #GA 00209008, #GA 00208017, and #GA 00210869 were unsubstantiated with no regulatory violations.
Findings
Complaints #GA 00202779 and #GA 00207530 were substantiated with no regulatory violations found. Complaints #GA 00203578, #GA 00208881, #GA 00209008, #GA 00208017, and #GA 00210869 were unsubstantiated with no regulatory violations.
Inspection Report
Routine
Census: 125
Deficiencies: 0
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations for COVID-19.
Report Facts
Total census: 125
Inspection Report
Re-Inspection
Census: 132
Deficiencies: 0
Date: Feb 10, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the 12/12/2019 Standard Survey.
Findings
All deficiencies cited in the previous survey were found to be corrected during this revisit survey.
Inspection Report
Annual Inspection
Census: 120
Deficiencies: 3
Date: Dec 12, 2019
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with healthcare facility regulations, including dietary services, nursing care, dialysis communication, and physical plant standards.
Findings
The facility failed to consistently offer bedtime snacks to residents, did not follow the plan of care for range-of-motion services for one resident, and failed to maintain effective communication with the dialysis center for another resident. Additionally, the facility did not ensure sanitary trash disposal and proper maintenance of the trash compactor area.
Deficiencies (3)
Facility failed to ensure bedtime snacks were consistently offered to 6 residents out of 108 on an oral diet.
Facility failed to follow the plan of care related to range-of-motion services for one resident and failed to maintain effective communication system between dialysis and facility for another resident.
Facility failed to ensure trash was disposed of in a sanitary manner and failed to ensure areas surrounding the trash compactor were free of debris.
Report Facts
Residents on oral diet not consistently offered bedtime snacks: 6
Facility census: 120
Restorative services provided to resident R#22: 0
Restorative services provided to resident R#22: 3
Restorative services provided to resident R#22: 11
Restorative services provided to resident R#22: 9
Restorative services provided to resident R#22: 5
Dialysis center communication forms found: 7
Dialysis center communication forms completed: 1
Dialysis visits scheduled: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PP | Registered Nurse (RN) | Interviewed about snack distribution process |
| OO | Certified Nursing Assistant (CNA)/Restorative Aide | Provides restorative services to resident R#22 and documents care |
| BB | Licensed Practical Nurse (LPN) | Confirmed dialysis schedule and resident memory issues for resident R#65 |
| CC | Licensed Practical Nurse (LPN) | Confirmed dialysis communication forms kept in binder |
| DD | Licensed Practical Nurse (LPN) | Responsible for preparing residents for dialysis and filling dialysis communication forms |
| Director of Nursing (DON) | Confirmed issues with dialysis communication forms and follow-up with dialysis center | |
| Dietary Manager (DM) | Interviewed about snack delivery and stocking | |
| Maintenance Assistant | Confirmed damage to trash compactor door and repair attempts |
Inspection Report
Life Safety
Census: 121
Capacity: 146
Deficiencies: 0
Date: Dec 10, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in compliance with the Life Safety Code requirements and the Emergency Preparedness Program met the regulatory standards.
Report Facts
Certified Beds: 146
Census: 121
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 16, 2019
Visit Reason
A complaint survey was conducted to investigate a complaint by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 16, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple GA complaint numbers to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The survey investigated complaints GA00193740, GA0019359, GA00192574, and GA00193111. The allegations of deficient practice related to Quality of Care/Treatment were substantiated for GA00193740 and GA00192574 with no deficiencies, unsubstantiated for GA0019359, and the allegation of injury of unknown origin was substantiated with no deficiencies for GA00193111.
Findings
The allegations related to Quality of Care/Treatment and injury of unknown origin were substantiated with no deficiencies found, while one allegation related to Quality of Care/Treatment was unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 24, 2018
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate GA complaint number GA00192098 and to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
The complaint investigation was substantiated with no deficiencies.
Findings
The allegation of deficient practice related to Quality of Care/Treatment was substantiated with no deficiencies found.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 10, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00190598.
Complaint Details
Complaint GA00190598 was investigated and found to be unsubstantiated.
Findings
The complaint was found to be unsubstantiated during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 9, 2018
Visit Reason
A follow-up to the Recertification survey of August 2, 2018 was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of September 16, 2018.
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 1, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Plan requirements and Life Safety Code standards.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2018
Visit Reason
A complaint survey was conducted to investigate complaint #GA00185818 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint #GA00185818 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2018
Visit Reason
An unannounced complaint survey was conducted to investigate Complaint #GA00183084 and #GA00183749.
Complaint Details
Investigation of Complaint #GA00183084 and #GA00183749 resulted in no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 15, 2017
Visit Reason
A standard survey was conducted in conjunction with complaint GA00180955.
Complaint Details
Complaint GA00180955 was investigated and found to be unsubstantiated.
Findings
The complaint GA00180955 was found to be unsubstantiated.
Inspection Report
Life Safety
Census: 136
Capacity: 146
Deficiencies: 0
Date: Dec 12, 2017
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found to be in substantial compliance with the emergency preparedness plan requirements and Life Safety Code standards during the survey.
Report Facts
Census: 136
Certified Beds: 146
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 8, 2017
Visit Reason
A revisit survey was conducted on 12/8/17 to follow up on the Complaint survey of 10/6/17.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 10/6/17. All deficiencies were corrected and the facility was in compliance as of 10/30/17.
Findings
All deficiencies identified in the prior complaint survey were corrected, and the facility was found to be in compliance as of 10/30/17.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00173847 and #GA00175384 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The survey was complaint-related, investigating two specific complaints, and no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey at Pruitt Health Decatur.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 24, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00172833 and #GA00171249 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The visit was complaint-related to investigate two complaints, and no deficiencies were found, indicating no substantiated issues.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 20, 2017
Visit Reason
A Health Revisit was conducted from 1/17/17 through 1/20/17 to verify correction of previous deficiencies and to investigate complaints GA00167208, GA00168914, GA00161677, and GA00167543.
Complaint Details
Complaints GA00161677 and GA00167543 were not substantiated. Complaints GA00168914 and GA00167208 were substantiated with no regulatory deficiencies cited.
Findings
All previous deficiencies had been corrected. Complaints GA00161677 and GA00167543 were not substantiated. Complaints GA00168914 and GA00167208 were substantiated but no regulatory deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 20, 2017
Visit Reason
A Health Revisit was conducted from 1/17/17 through 1/20/17 to determine correction of previous deficiencies and to investigate complaints GA00167208, GA00168914, GA00161677, and GA00167543.
Complaint Details
Complaints GA00161677 and GA00167543 were not substantiated. Complaints GA00168914 and GA00167208 were substantiated with no regulatory deficiencies cited.
Findings
All previous deficiencies had been corrected. Complaints GA00161677 and GA00167543 were not substantiated. Complaints GA00168914 and GA00167208 were substantiated but no regulatory deficiencies were cited.
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