Pruitthealth - Lilburn

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.