Pruitthealth - Austell

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to develop and implement comprehensive, person-centered care plans for two of 47 sampled residents (R) (R62 and R117) related to transfer needs for R62 and accommodation of needs for call light access for R117. This deficient practice resulted in actual harm to R62 on 12/5/2025 when staff improperly transferred the resident without using a gait belt.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled Occurrences, Gait (Transfer) Belts, and Assistance with Transfers, the facility failed to follow established transfer procedures when assisting one of 42 sampled residents (R) (R62). This deficient practice resulted in actual harm to R62 on 12/5/2025 when staff improperly transferred the resident without using a gait belt.

Inspectors wroteBased on staff interviews, resident interviews, record review, and review of the facility's policies titled Care Plans, the facility failed to coordinate a quarterly care plan conference for one of 47 sampled residents (R) (R21).

Inspectors wroteBased on record reviews, observations, resident and staff interviews, and facility policy titled Patient/Resident Rights, Accommodation of Needs, the facility failed to ensure the call light provided was appropriate for the physical condition of one of 47 sampled residents (R) (R117). The facility was unable to ensure that R117 could obtain help when needed using the call light provided. This failure placed R117 at risk of accident, injury, and/or unmet needs related to an inability to use the call light system provided to call for staff assistance.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Physician Orders, the facility failed to ensure timely coordination and follow-up of physician/Nurse Practitioner (NP) recommendations for one of 47 sampled residents (R) (R9). Specifically, the facility failed to schedule or track urology specialist appointments, failed to document completed visits or follow-up outcomes, and failed to act on prior NP recommendations. These deficient practices resulted in prolonged pain, delayed evaluation and treatment of ongoing urinary symptoms, and lack of oversight of the resident's urologic care, placing the resident at risk for worsening complications.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) was administered as ordered for two of 12 residents (R) (R123 and R62) who used oxygen. Specifically, the facility failed to administer oxygen at the correct ordered setting for R123 and failed to ensure oxygen was not administered without a physician's order for R62. These deficient practices placed both residents at increased risk for respiratory complications and adverse clinical outcomes.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policies titled Medication Administration: General Guidelines, the facility failed to ensure accurate administration of medications for two of 28 medication opportunities observed, resulting in a medication error rate of 7.14%. This deficient practice has the potential to negatively impact residents leading to complications of current health status. The facility census was 97.

Inspectors wroteBased on observations, staff interviews, review of manufacturer package inserts, the list titled Expiration Dates for the Following Medications After Opening, and review of the facility policy titled Medication Storage in Healthcare Centers, the facility failed to ensure medications were stored in a safe and secure manner for two of five medication carts (West A and [NAME] B) observed. Specifically, one medication cart contained two expired ophthalmic (eye) drops, one nutritional supplement bottle that was soiled, stored in a bag with a crystallized substance, and had an expiration date that was no longer visible, and a loose unlabeled pill and capsule. In addition, the controlled substance book on that cart contained multiple pages that were torn, loose, and no longer secured within the binder. On a second medication cart, an additional loose unlabeled capsule was found. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Diagnostic and Laboratory Services: Procedure for Processing, the facility failed to notify the physician/ Nurse Practitioner (NP) of abnormal laboratory results for one of 47 sampled residents (R) (R9). This deficient practice had the potential to cause delayed assessment and treatment of abnormal clinical conditions.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure required privacy curtains were in place for one of 47 samples residents (R) (R118). This had the potential to put residents at risk for exposure during care due to the absence of privacy curtains.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure the timely administration of a medication for one of three residents reviewed for medications (Resident (R) 4) out of a total sample of 24 residents. Specifically, R4 had multiple medications, and insulin administered late over six months. This had the potential for a reduction in the effectiveness of the medications. In addition, the late administration of fast acting and long-acting insulin had the potential to control levels of blood sugar.

Inspectors wroteBased on record review, and family member and staff interviews, the facility failed to ensure one of one resident reviewed for billing (Resident (R) 3's) Family Member (F1) was provided with a timely refund for paying for a private room and failed to review the resident's billing for accuracy. As a result of this deficient practice, the resident was billed for excessive charges, and the bill was sent to collections for an unjustified charge.

Inspectors wroteBased on observations, family member and staff interviews, record review, and facility policy review, the facility failed to ensure residents received timely and necessary treatments for their conditions for two of 24 sampled residents (Resident (R) 1 and R4). These failures placed the residents at risk for their conditions to worsen by receiving delayed treatment.

Inspectors wroteBased on record review, resident and staff interviews, and facility policy review, the facility failed to ensure one of three residents reviewed for falls (Resident (R) 12) out 24 sampled residents, had adequate supervision and the resident and/or family had been trained to transfer the resident from her wheelchair to a personal vehicle. The deficient practice had the potential for R12 to sustain a fall and cause harm.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to ensure one of three residents (Resident (R) 12) reviewed for transportation out of a total sample size of 24 residents, was picked up from a medical appointment by the facility's transportation. This failure placed residents at risk for unsafe transportation to a medical appointment from the facility.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure that clinical records were complete and contained accurate documentation for one of 24 residents sampled residents (Resident (R) 4). This failure had the potential for R4 not to receive accurate care.

Inspectors wroteBased on observations, interviews, record review, and the facility's policy titled, Dish Machine- High Temperature, the facility failed to ensure that the dishwashing machine consistently reached the required operating temperature. The deficient practice had the potential to affect 114 out of 117 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations, staff and resident interviews, and record review, the facility failed to ensure a resident's right to dignity for one of 38 sampled residents (R) (R41). Specifically, R41 was left unclothed and uncovered in the middle of care.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide a safe, clean, comfortable, homelike environment for six of 64 rooms on two of four halls. These rooms and hallway contained dirty damaged bathroom ceiling exhaust fan vent covers, dirty damaged Packaged Terminal Air Conditioner (PTAC) units, a bathroom sink with low water pressure, damaged hallway handrails, and pungent odor in the west wing hallways. Initial screening observations on 6/11/2024 at 9:00 am in/near room [ROOM NUMBER] revealed a strong, pungent odor near the doorway. Initial screening observations on 6/11/2024 at 9:15 am in rooms [ROOM NUMBER] revealed PTAC unit filters were dirty with thick, gray, fluffy substances. Further observations revealed the vent in room [ROOM NUMBER] also had black substances scattered on the upper vents. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Grievances: Healthcare Centers, the facility failed to file a grievance on behalf of one of 38 sampled residents (R) (R47) who had concerns with a roommate.

Inspectors wroteBased on observations, resident and staff interviews and record review, the facility failed to provide activities of daily living (ADLs) for two of 38 sampled residents (R) (R 42 and R106). Specifically, showers and assistance with grooming were not provided for R42 and assistance with grooming was not provided for R106.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled, Medication Administration: Oral Medications and Occurrences, the facility failed to document administration of pain medication on the electronic Medication Administration Record (eMAR) and follow up on the assessment related to a fall for one of 38 sampled residents (R) (R97), and to re-order / follow up on delivery of pain medications for one of 38 sampled residents (R23), The deficient practice had the potential to place R97 and R23 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by using appropriate techniques to prevent accidents for one of 38 sampled residents (R) R23. Specifically, the facility did not have the correct size mechanical lift sling, that resulted in breakage of a strap, which caused R23 to fall to the floor.

Inspectors wroteBased on observations, and staff interviews, the facility failed to properly disinfect reusable equipment for five of 38 sampled residents (R) (R35, R9, R87, R109, and R283) during two of five medication administrations, and to properly perform hand hygiene during medication administration by one of five staff. The deficient practice had the potential to spread microorganisms to other residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policies titled, Grievances: Healthcare Centers, and Missing items, the facility failed to ensure prompt and thorough efforts to resolve continued resident grievances regarding missing laundry. The facility census was 121. Findings Include: Review of the facility policy titled Grievances: Healthcare Centers, revised 1/10/2024, the Policy Statement revealed Grievances and complaints should be resolved in a prompt, reasonable, and consistent manner. The Policy continued by revealing All partners shall take an active part in efforts to resolve grievances and complaints without discrimination or retaliation against a person filing a grievance or complaint. [...]

Inspectors wroteBased on resident, resident responsible party, and staff interviews, record review, and review of the facility policy titled, Prevention of patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to protect the residents' right to be free from misappropriation of property by facility staff for one of five sampled residents (R) (R5).

Inspectors wroteBased on resident and staff interviews, record review, and review of facility's policy titled, Occurrence Reduction Program, the facility failed to provide two-person assistance to a resident who required two-person assistance for one of three sampled residents (R) (R5) reviewed for accident hazards. The deficient practice resulted in R5 falling during a shower.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Medication Storage in the Healthcare Centers and Medication Administration: General Guidelines, the facility failed to ensure medication and treatment storage carts were locked when unattended and out of the view of a nurse for two of six medication carts which medications were stored, and one treatment cart in which treatment supplies and medications were stored. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications and potentially hazardous treatment supplies.